Does a Case Completion Curriculum Influence Dental Students’ Clinical Productivity? Sang E. Park, D.D.S., M.M.Sc.; Harlyn K. Susarla, B.A.; Romesh Nalliah, B.D.S.; Peggy Timothé, D.D.S., M.P.H.; T. Howard Howell, D.D.S., M.M.Sc.; Nadeem Y. Karimbux, D.M.D., M.M.Sc. Abstract: The purpose of this study was to evaluate the effects of a new clinical curriculum on dental student productivity as measured by number of procedures performed in the student teaching practice. Harvard School of Dental Medicine adopted a new clinical education model for the predoctoral program in summer 2009 based upon a Case Completion Curriculum (CCC) rather than a discipline-based numeric threshold system. The two study groups (threshold group and case completion group) consisted of students who graduated in 2009 and 2010. Clinical performance was assessed by clinical productivity across five major discipline areas: periodontics, operative dentistry, removable prosthodontics, fixed prosthodontics, and endodontics. The relationships between the two study groups with regard to number of procedures performed by category revealed that the case completion group performed a significantly higher number of operative and removable prosthodontic procedures, but fewer periodontal and endodontic procedures (p≤0.03). No statistically significant difference in number of procedures was observed with fixed prosthodontic procedures between the two groups. Clinical productivity as a result of redesigning the clinical component of the curriculum varied in selected disciplines. The CCC, in which the comprehensive management of the patient was the priority, contributed to achieving a patient-based comprehensive care practice. Dr. Park is Senior Tutor and Assistant Professor, Harvard School of Dental Medicine; Ms. Susarla is a D.M.D. candidate, Harvard School of Dental Medicine; Dr. Nalliah is Senior Tutor, Harvard School of Dental Medicine; Dr. Timothé is Senior Tutor, Harvard School of Dental Medicine; Dr. Howell is Dean for Dental Education and Professor, Harvard School of Dental Medicine; and Dr. Karimbux is Assistant Dean for Dental Education and Associate Professor, Harvard School of Dental Medicine. Direct correspondence and requests for reprints to Dr. Sang Park, Harvard School of Dental Medicine, 188 Longwood Ave., Boston, MA 02115;
[email protected]. Keywords: clinical education, curriculum, dental education, case completion curriculum, comprehensive care, student productivity Submitted for publication 3/26/11; accepted 8/29/11
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his retrospective study analyzed the impact of a new Case Completion Curriculum (CCC) on dental student clinical productivity in various patient care disciplines. The CCC was developed and implemented in summer 2009 at the Harvard School of Dental Medicine (HSDM) for the class of 2010. In our previous article, we discussed the design and implementation of this new clinical education curriculum.1 We envisioned that this change would redirect predoctoral clinical learning from a student requirement-driven educational model to a patientcentered and patient-driven care model. The traditional clinical curriculum resulted in a lack of motivation among the dental students after their discipline-specific numeric requirements had been met. This resulted in poor attendance, decreased productivity, and missed learning opportunities. Another institution attempted to overcome such challenges by setting monetary production targets and providing incentives for student providers,2 602
while other studies that explored the effect of not having numerical thresholds found either a similar or improved level of student productivity.3-5 This form of change in clinical education could improve the quality of comprehensive care to patients by student providers, especially since two studies found that repetitive clinical procedures did not correlate with clinical competence and students performed equally well when the requirements were reduced.6,7 The CCC places a strong emphasis on treatment planning and the delivery of comprehensive care. In it, students place the treatment needs of the patients first, rather than students’ discipline-specific numeric procedural requirements, by performing quality patient care and learning the importance of patient management. A significant finding in our previous study1 was that the number of transfers that took place from the graduating class to the third-year class decreased with the CCC. This allowed for smoother transitions when student providers graduated. A Journal of Dental Education ■ Volume 76, Number 5
reduction in the number of shared patient cases and of patients who are in between treatments due to neglect was also noted since the implementation of the new curriculum. The objective of this retrospective study was to compare the new CCC education system to the traditional numeric procedural requirement clinical curriculum as measured by student productivity in five major discipline areas: periodontics, operative dentistry, removable prosthodontics, fixed prosthodontics, and endodontics. The null hypothesis was that there would be no difference in the number of discipline-specific procedures performed by students upon implementation of the CCC compared to the previous numeric procedural requirement curriculum.
Materials and Methods The pilot study sample consisted of all fourthyear dental students in the graduating classes of 2009 and 2010 at HSDM who met the following criteria: sequential completion of years three and four of dental education, timely completion of all graduation requirements, and fulfillment of expected graduation date. The new CCC guidelines and explicit details were introduced and explained to the students, faculty members, and staff members. Each class of students is randomly divided into four Treatment Teams, each with a senior tutor. Senior tutors balance caseloads among students and assigned patients, provide formal approval of treatment plans, and track the progress and completion of treatment. In the baseline year of 2008–09, the four senior tutors were two general dentists and two prosthodontists. In 2009–10, when the new system was implemented, two general dentists, one prosthodontist, and one pediatric dentist served as senior tutors. The senior tutors met with students individually for case review in the third year prior to their promotion to the fourth year to review and assess the cases on a preliminary basis. In addition to their existing patient pool of twenty to thirty cases, the senior tutors assigned four or more transfer patients from the previous graduating class to students. During the fourth year of their dental education, new patients who required comprehensive care were randomly assigned to students through new patient intake, recall rotations, emergency rotations, and personal referrals. Students were expected to complete all of the sequential treatment plans in their patient lists.
May 2012 ■ Journal of Dental Education
The senior tutors used their discretion to redistribute cases to balance students’ exposures to various disciplines, procedures, and experiences. The senior tutors monitored the students closely and continued to meet with them individually and in teams during the fourth academic year to discuss patient care. Students met with their senior tutors prior to graduation for a final case review of all cases received during their third and fourth years of clinical education to verify that all care was completed as described in the treatment plan. During these sessions, any outstanding or pending treatment needs were further discussed, and needs for transfer, inactivation, or placement on the recall system were determined. Cases were determined according to the difficulty and duration of treatment required using Park’s Case Classification System,1 which was distributed as a tool for identifying the complexity and involvement of multidisciplinary learning. Type 1 procedures include preventive therapies, simple operative procedures, prophylaxis, and scaling and root planing. Type 2 procedures include interdisciplinary management (endodontics, periodontal surgery, oral surgery, etc.) and complex restorative procedures, not including prosthodontic treatment. Type 3 procedures include interdisciplinary management and restorative procedures, including prosthodontic treatment (fewer than three fixed prosthodontic units). Type 4 procedures include complex interdisciplinary management (four or more disciplines) and restorative procedures including prosthodontic treatment (three or more fixed prosthodontic units) or difficult patient management. Type 5 procedures involve removable partial dentures (metal and resin). Type 6 procedures include complete dentures, immediate complete dentures, overdentures, and implant-supported overdentures. Requisite numbers of completed cases encompassing the specified case compositions were identified using the Case Selection Criteria according to Park et al.1 To meet the minimum requirements, students were required to complete a minimum of fifteen cases encompassing the following case compositions: maximum of seven Type 1 and 2 cases; minimum of four Type 3 and 4 cases (one of which must be Type 4); and minimum of four Type 5 and 6 cases (must consist of both types). To receive a grade of Honors, students must have completed a minimum of twenty cases consisting of the following case compositions: maximum of nine Type 1 and 2 cases; minimum of six Type 3 and 4 cases (two of which must be Type 4); and minimum of five Type 5 and 6 cases (must consist of both types).
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Students were required to turn in an approved absence form in case of a planned absence from their clinic sessions. In the event of patient cancellation or failing to show at the last minute, students were expected to utilize the clinic session most efficiently by engaging in productive activities, such as assisting their classmates, doing lab work, or being available to see emergency patients. Outcome variables consisted of the average discipline-based procedures completed by students during the clinical years prior to and after the change. Students’ clinical performance and productivity were evaluated in five disciplines: periodontics, operative dentistry, removable and fixed prosthodontics, and endodontics. The periodontal categories included prophylaxis, scaling and root planing, maintenance, and periodontal surgery procedures. The students’ performance on all operative treatments involving direct restorative materials (e.g., composite/amalgam restorations) was included as outcome measures. Removable prosthodontic procedures included complete dentures, immediate complete dentures, and removable partial dentures (RPDs; metal and resin). Fixed prosthodontic procedures included ceramometal crowns, full cast gold crowns, onlays, implant abutment crowns, and fixed partial dentures (FPDs; e.g., multi-unit bridges). Endodontic procedures were classified as single-canal and multi-canal root canal therapies. Clinical productivity was evaluated by examining the average number of procedures completed by each student within a given category. The study was approved by the Institutional Review Board at Harvard Medical School and Harvard School of Dental Medicine (HMS IRB Docket #M20952-101). Data were obtained from the senior tutor’s office at the Harvard School of Dental Medicine and coded to ensure anonymity and confidentiality. The data were entered into a statistical database (SPSS v.13.0, SPSS Inc., Chicago, IL), and all were encoded with numeric identifiers to ensure confidentiality with regard to individual student records. Descriptive statistics were computed (mean±standard
deviation). Bivariate statistics were computed to compare the two study groups. Given the lack of confirmed normality within the dataset, as well as the relatively small sample sizes, non-parametric methods were used to compare the two groups. The null hypothesis that there was no difference in the number of treatment procedures completed was tested using the Mann-Whitney U test. For all analyses, a p-value of ≤0.05 was considered significant.
Results During the study period, thirty students were evaluated from the class of 2009 and thirty-three students from the class of 2010. All students from both groups met the inclusion criteria for the study. The bivariate relationship among the five major categories assessed (periodontics, operative dentistry, removable prosthodontics, fixed prosthodontics, and endodontics) was summarized by study group (Class of 2010: case completion; Class of 2009: threshold) (Table 1). The case completion group performed a greater number of operative and removable prosthodontic procedures, but fewer periodontal and endodontic procedures (p≤0.03). With regard to periodontal procedures, the case completion group performed statistically significantly fewer procedures (51.5±7.8 procedures) than the threshold group (56.4±9.1 procedures; p=0.03). The mean number of operative procedures performed was 47.0±13.5 procedures in the case completion group and 39.1±9.8 procedures in the threshold group (p=0.01), which indicated a statistically significant increase in number of procedures since the implementation of the CCC. With regard to removable prosthodontic procedures, the case completion group performed a greater number of procedures (6.5±2.4 procedures) relative to the threshold group (5.2±1.8 procedures; p=0.03). No statistically significant difference in number of procedures was observed with fixed prosthodontic procedures between the two study groups (19.8±10.0
Table 1. Descriptive statistics (mean and standard deviation) for study population by discipline Procedure Category Periodontics Operative Dentistry Removable Prosthodontics Fixed Prosthodontics Endodontics
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Class of 2009
Class of 2010
56.4±9.1 39.1±9.8 5.2±1.8 21.3±5.4 7.7±3.2
p-value
51.5±7.8 0.03 47.0±13.5 0.01 6.5±2.4 0.03 19.8±10.0 0.50 4.5±1.7
