The basic program of undergraduate education

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1 Comparing Integrated and Disciplinary Clinical Training Patterns for Dental Interns: Advantages, Disadvantages, and Effect on Students Self-Confidence Junrong Wu, BDS; Xiaoli Feng, BDS; Aijie Chen, BDS; Yanli Zhang, MDS; Qi Liu, MDS; Longquan Shao, DDS Abstract: In China, the five-year program of undergraduate education for stomatology consists of four years of lecture courses and one year of internship focused on clinical training. Dental schools provide this clinical training either in their own clinics (referred to as the one-stage pattern because all forms of practice are completed together) or by placing students in external clinics usually at non-affiliated hospitals (referred to as the three-stage program because the three primary areas are taught separately). The aims of this study were to investigate differences in teaching effect between the one-stage and the three-stage patterns and to evaluate advantages and disadvantages of the two patterns. A three-section, 31-item questionnaire was designed to assess basic and clinic information about the interns training and their self-confidence in performing clinical procedures. The survey was administered to graduates who finished the fifth-year internship in Of the 356 individuals invited to participate, 303 graduates who spent their intern years in 43 academic dental institutions returned completed surveys (response rate of 85%). The one-stage group (n=121) reported longer independent operation time than the three-stage group (n=182) (p<0.01). No significant difference was found between the groups for assessment of clinic infrastructure (p=0.121). The interns were most confident in oral hygiene instruction and scale and polish (overall median=5), but showed low confidence in rubber dam placement and four other procedures (overall median=2). The one-stage group rated their confidence level higher than the three-stage group on comprehensive skills such as arranging appointments and managing patients and procedures needing long treatment periods such as molar endodontics. The three-stage group showed higher confidence on more specialized procedures such as surgical extractions and suturing. This study found that both of the two intern patterns had advantages and shortcomings in clinical training in various procedures. Combining the two could be a way to improve clinical education in China. Dr. Wu is a Master s student, Nanfang Hospital, Southern Medical University, Guangzhou, China; Dr. Feng is a Master s student, Nanfang Hospital, Southern Medical University, Guangzhou, China; Dr. Chen is a Master s student, Nanfang Hospital, Southern Medical University, Guangzhou, China; Dr. Zhang is a Master s student, Nanfang Hospital, Southern Medical University, Guangzhou, China; Dr. Liu is Lecturer, Nanfang Hospital, Southern Medical University, Guangzhou, China; and Dr. Shao is Professor, Nanfang Hospital, Southern Medical University, Guangzhou, China. Direct correspondence and requests for reprints to Dr. Longquan Shao, Nanfang Hospital, Southern Medical University, Guangzhou Avenue North 1838, Guangzhou , PR China; ; shaolongquan@smu.edu.cn. Keywords: dental education, clinical education, clinical skills, curriculum, clinic environment, self-confidence, China Submitted for publication 6/5/15; accepted 9/3/15 The basic program of undergraduate education for stomatology in China requires five years of study consisting of four years of lecture courses and one year of internship. For the first four years, students take basic courses, clinical medical courses, and stomatological courses. The fifth year of dental school is defined as an intern year, which focuses on clinical practice training. Total clinical practice time should be no less than 45 weeks, according to educational standards in China. 1 The undergraduate education program for stomatology in China has long focused on the areas of oral medicine (including endodontics and periodontics), prosthodontics, and maxillofacial surgery. Thus, clinical practice training in these three branches is the focus of intern training. 1 Procedures in some subjects are mainly taught in graduate education programs, such as pediatric dentistry, public health, and orthodontics. According to program requirements, 1-3 interns should master basic procedures in the three branches, such as composite restorations, endodontic treatments, scale and polish, bridge preparation, and complete denture construction. For intern training, dental procedures of maxillofacial surgery focus on simple extractions, surgical extractions, and simple suturing. Two types of intern training patterns exist in most dental institutions providing clinical practice opportunities in China: one-stage patterns and 318 Journal of Dental Education Volume 80, Number 3

2 three-stage patterns. The most significant difference between them is whether a clinic is established for interns. The one-stage pattern is used in dental institutions with an intern clinic, while the three-stage pattern exists in institutions without intern clinics, such as non-affiliated hospitals of universities. Under the one-stage pattern, interns practice clinical skills in all three branches in one room simultaneously for several months, without separation into three stages and are supervised by at least three instructors in different specialties. Under the three-stage pattern, interns rotate through various departments of the three branches and normally receive supervision from one clinical instructor in one specialty at a time. The main features of the two patterns are shown in Table 1 and Figure 1. Dental schools arrange intern patterns according to their own requirements. About the same number have one-stage and three-stage patterns. China is not the only country with different intern training patterns. UK dental schools also have approached clinical teaching in differing ways. 4 Some schools disperse their students across a number of selected dental practices, while others have developed a purpose-built unit where patients are treated in a primary care setting. 5 This latter method in the UK and the one-stage pattern in China have some points in common. Lynch et al. introduced a 12-chair purpose-built unit at Cardiff Dental School dedicated to dental undergraduate interns for outreach teaching; 4 this system is similar to the intern clinic in China. Clinical practice is important not only as a link to dental education, but also an approach that greatly enhances dental students ability for practical work and professional quality. 1 Feelings of preparedness are important in the successful transition from being a student to a practicing dentist. 6 To transit from the preclinical to clinical year successfully, dental students must develop self-confidence in their abilities. 7 However, there is a lack of research regarding the most beneficial type of intern training pattern in terms of developing confidence in the last year of dental school in Mainland China and the advantages and disadvantages of the two types of intern patterns. To address these gaps, the aims of our study were to measure interns self-confidence levels regarding several clinical procedures based on their respective intern experiences and to collect data about the two training patterns. These findings will aid in program revisions and possibly suggest which pattern is superior for clinical dental education in China. Methods Exemption from the Ethics Committee of the Nanfang Hospital, Guangzhou, China, was obtained for our study. The survey was administered to graduates of multiple dental schools who had finished the fifth-year mandatory internship. With our goal of involving graduates who still retained a fresh memory about their intern experience, the ideal candidates were subjects who graduated from 2012 to The questionnaires were conducted using SO JUMP (a professional online survey platform in China). The study was conducted by faculty members at Southern Medical University, Guangzhou, China. A snowball sampling method was used. Snowball sampling is a non-probability sampling technique that uses a small pool of initial informants to nominate other participants who meet the eligibility criteria and could potentially contribute to a study. 8 We chose snowball sampling for two reasons. First, because of the general intern arrangement in China, dental students graduate soon after they finish their internship and may not be easily contacted after graduation. As a result, reaching our target subjects was difficult unless we used the snowball sampling method. Second, we hoped to obtain information about a large number of dental institutions in China to reduce bias caused by restricted inclusion of districts and schools. The snowball sampling method is a feasible way to achieve the goals. For the first step of the sampling stage, we contacted eligible graduates using information from an address list of attendees at a dental summer camp. A total of 128 potential participants from 30 dental institutions were recruited via with a link to the questionnaire. Respondents in the first round were encouraged to share the addresses of other contacts who graduated from 2012 to 2014 and were willing to participant in our study. Subsequently, we asked the next round of contacts to participate. As such, diversity of the subjects was ensured by the snowball sampling method. As we used snowball instead of random sampling, we estimated the sampling size by the following method. We had designed a total of 39 questions for the survey, and the sample size should be five-fold to ten-fold greater than the quantity of the total questions. Thus, a sample size of was considered adequate. By the end of the recruitment process, questionnaires had been distributed to 356 graduates. March 2016 Journal of Dental Education 319

3 Table 1. Main differences between one-stage pattern and three-stage pattern in clinical education in China One-Stage Pattern: Three-Stage Pattern: Characteristic With an Intern Clinic Without an Intern Clinic Clinic/s for internship Integrated intern clinic Departmental clinics of specialties Educational method Interns practice procedures of three branches Interns practice procedures of one branch (oral medicine, prosthodontics, and at a time maxillofacial surgery) simultaneously Rotation times Seldom (interns spend approximately nine Frequent (interns spend approximately three months in the intern clinic) months in one clinic and then rotate to another) Instructors At least three instructors specializing in the One instructor of one branch in each clinic three branches in an intern clinic Teaching features Instructors from different branches work Instructors in separate branches provide interns together in one intern clinic; thus, they not with professional instruction about diagnosis, only provide instructions in their own treatment planning, and practical skills; access specialty, but also give comprehensive to specialty expertise is abundant suggestions about treatment planning in consultation with all instructors Instruments Interns can access dental instruments from Instruments in each clinic are limited and the three branches, which are classified and dedicated to a single branch placed in the public area Figure 1. Illustration of the one-stage pattern and the three-stage pattern Note: Top half of image shows the one-stage pattern, and bottom half shows the three-stage pattern. 320 Journal of Dental Education Volume 80, Number 3

4 We designed the questionnaire on the basis of relevant articles found in a literature review focused on intern training patterns and graduates confidence in their clinical skills. 4,5,9-15 The questionnaire had three parts. The first section consisted of a series of basic information questions, including graduation year and intern institution. The second section contained basic questions about the intern training pattern, such as whether there was an independent dental clinic specifically dedicated to interns. Respondents who answered yes to this question were classified as belonging to the one-stage intern pattern group, and two subsequent questions were asked to determine number of clinical chairs and instructors in the intern clinic. Respondents who chose no were classified as belonging to the threestage intern pattern group. Questions concerning total independent operation time and assessment of clinic infrastructures were also included. 12 The third section asked respondents to rate their clinical confidence level after finishing the intern year. Based on practice requirements in the three branches and previous research findings, 1-3,10,11 we chose 31 items covering basic dental procedures. Respondents rated their self-confidence level for each item (to evaluate the training effect) on a five-point scale with 1=very little confidence, 2=little confidence, 3=neutral, 4=confident, and 5=very confident. The median was determined to describe the central tendency of each item. A Wilcoxon test was used to identify differences between the two groups in independent operation time, assessment of clinic infrastructure, and confidence level for the 31 items. All data were analyzed using SPSS, Version 20.0 (IBM Corp., New York, NY, USA). The significance level was set at Results At the end of the survey period (August 15 to December 5, 2014), 356 graduates had been contacted by to invite them to participate. Of these, 303 responded to all questions with adequate answers (response rate of 85%). The number of respondents in each graduation year was 76 in 2012, 48 in 2013, and 179 in These interns had graduated from 28 universities and finished their intern year in 43 academic dental institutions, distributed across 22 provinces of Mainland China. The distribution by district of dental institutions represented is shown in Figure 2. The maximum number from one institution was 20, while the minimum was three. Of the 303 respondents, 121 (39.9%) made up the one-stage pattern group, while 182 (60.1%) made up the three-stage pattern group. Of the 121 one-stage participants, 43.8% (53) reported having six to ten dental chairs in their intern clinics, and 80.2% (97) reported having three or four clinical teachers in their intern clinics. The number of dental chairs and clinical teachers in the intern clinics is shown in Figure 3. The independent operation time and assessment of clinic infrastructure of the two patterns are shown in Figure 4. Less than half (41.8%) of the three-stage respondents rated their independent operation time as accounting for total intern time at 50% or above, while the one-stage respondents reported percentages as high as 86.8%. A Wilcoxon test showed there was a significant difference in independent operation time between the two patterns (p<0.01). This result indicated that the one-stage pattern provided more independent operation opportunities than the threestage pattern. No one from either group gave very poor ratings for assessment of clinic infrastructure. Most interns assessments were positive (one-stage pattern: 45.5% good, 27.3% excellent; three-stage pattern: 47.3% good, 19.2% excellent). A Wilcoxon test showed there was no significant difference in assessments of clinic infrastructures between the two groups (p=0.121). In terms of confidence levels, Table 2 presents data including the overall medians (n=303) on 31 items and the medians of the one-stage group (n=121) and three-stage group (n=182) separately. There were five items on which the graduates rated themselves as having little confidence (overall median=2); 11 items the graduates rated neutral (overall median=3); 13 items the graduates rated confident (overall median=4); and two items the graduates rated very confident (overall median=5). Results of the Wilcoxon test (mean rank and p-values) between the two groups are also shown in Table 2. Part A shows eight items for which the Wilcoxon test showed no significant differences between the two patterns. Part B shows 14 items for which the one-stage group rated confidence levels higher than did the three-stage group. Part C shows nine items for which the three-stage group rated higher confidence levels than the one-stage group. There were significant differences for these items between the two groups (p<0.05). March 2016 Journal of Dental Education 321

5 Figure 2. Distribution of dental institutions in which respondents conducted their internships, by district Discussion We studied interns self-confidence regarding clinical procedures rather than competence in this study. Self-confidence is a psychological characteristic that reflects a person s trust in his or her ability to successfully complete an activity. In general, selfconfidence is not equal to competence. Mattheos et al. found that students tended to overestimate their competence in relation to the judgments of their instructors on diagnostic skills, but not on skills relevant to treatment. 16 However, the role of studying self-confidence in dental education cannot be underestimated. First, as Cowpe et al. noted, one of the most desirable characteristics of newly graduated dentists is their ability to perform a variety of clinical procedures with confidence. 17 The final year in dental school is vital for students to practice clinical skills and acquire self-confidence in dealing with patients and oral disease. Sufficient confidence is the foundation of working as an independent dentist. Second, self-confidence comes from achievements and successful experience. A high confidence level means an intern has successfully worked with a certain number of clinical cases and gained approval from instructors, which is a reflection of competence to some extent. Third, it is important for educators to assess students confidence in every subject. Honey et al. reported that dental schools should monitor the confidence of their students in completing clinical tasks, thereby give them an opportunity to address these deficits in confidence before graduation. 3 Their study indicated that confidence levels could largely reflect imperfections in dental education. In light of this, we studied the interns self-confidence level on 31 dental procedures to see where should we pay more attention and make improvements on dental education in China. Overall Self-Confidence Level Murray et al. noted that one of the limits to developing confidence in performing clinical procedures has been identified as insufficient clinical 322 Journal of Dental Education Volume 80, Number 3

6 Figure 3. Number of dental chairs and clinical instructors in the intern clinics Figure 4. Independent operation time and assessment of clinic infrastructure of the two patterns ing the internship. Besides, such a procedure could reduce stress and enhance confidence especially during the initial internship stage. Our study thus agreed with Honey et al. s research, which also found that simple procedures such as scale and polish were the areas in which students at Cardiff and Cork dental schools had the most confidence. 3 In contrast, there were five procedures in our study for which the interns showed relatively low confidence (overall median=2): rubber dam placement, vital tooth bleaching, pulpotomy, veneer preparation, and complete denture construction. Alexposure during undergraduate education. 18 It is generally accepted that practice and repetition are essential elements in the achievement of confidence and competence. It was not surprising that students in our study showed more self-confidence on two items: oral hygiene instruction and scale and polish (overall median=5). Oral hygiene instruction is the most common procedure, which is not only given to patients in clinics but also given to friends and families in daily life. Given that scale and polish is a non-invasive, simple, and practical procedure, the interns have many opportunities to practice it dur- March 2016 Journal of Dental Education 323

7 Table 2. Medians of self-confidence level and mean ranks of 31 items for one-stage group and three-stage group One-Stage Pattern Three-Stage Pattern Procedure (Overall Median) Median Mean Rank Median Mean Rank p-value A. Items with no significant differences in ratings of self-confidence between the two patterns Rubber dam placement (2) History and exam (4) Radiography (4) Fissure sealants (4) Preventive resin restorations (4) Wedge-shaped defects treatment (4) Oral hygiene instruction (5) Scale and polish (5) B. Items for which the one-stage pattern group rated confidence levels higher than the three-stage pattern group Complete denture construction (2) <0.05 Treatment planning (3) Comprehensive diagnosis (3) Appointment setting and patient management (3) Molar endodontics (3) Acrylic partial denture design and construction (3) Metal partial dentures design and construction (3) Bridge preparation (3) Communication with patients (4) Anterior composite restorations (4) Posterior composite restorations (4) Anterior endodontics (4) Premolar endodontics (4) Simple extractions (4) C. Items for which the three-stage pattern group rated confidence levels higher than the one-stage pattern group Vital tooth bleaching (2) <0.05 Pulpotomy (2) Veneer preparation (2) Surgical extractions (3) Simple suturing (3) Subgingival scaling (3) Treatment of pediatric patients (3) Indirect pulp capping (4) Single crown preparation (4) Note: Respondents rated their self-confidence on a five-point scale with 1=very little confidence, 2=little confidence, 3=neutral, 4=confident, and 5=very confident. though the necessity of the rubber dam must always take precedence over convenience and expediency, previous studies have reported that the rubber dam was seldom or never used during endodontic procedures The most likely reason for low confidence in rubber dam placement among our respondents is the infrequency of using it. As for the other four procedures, three studies found that these procedures were difficult for undergraduates and needed special attention during clinical training In fact, interns training in these procedures is relatively limited for various reasons. The technical difficulty and lack of cases can be obstacles for interns to master these procedures and gain confidence. Indications of vital tooth bleaching and veneer are relatively limited. Plus, the main concerns of patients visiting educational clinics in China are pain problems rather than esthetic problems. Demonstrations and professional instructions are deficient as a result of few suitable cases. Thus, the interns lack of practice and low confidence are inevitable. Pulpotomy is more often used on primary teeth when the coronal pulp is infected and the root pulp 324 Journal of Dental Education Volume 80, Number 3

8 is still healthy enough. However, a large portion of pediatric patients who need endodontic treatment come to see the dentist with serious pulp problems. As pulpal infection is not limited in coronal pulp, pulpotomy is inappropriate in such condition. Besides, many parents would ask the dentist to guarantee painlessness after treatment. Considering the risk of failure that will result in pain and a second treatment, dentists and parents prefer pulpectomy than pulpotomy to treat primary teeth. As a result of lack of demonstrations and practice, interns low confidence in pulpotomy is not surprising. The technical difficulty of complete denture design and construction is probably the most important reason for interns low confidence. Although implantology is widely used around the world, complete denture care is still needed due to the increasing life expectancy among the elderly 25 and bad oral condition of senior citizens in China. This context indicates that skill in treating patients with complete dentures should not be neglected. Comparing One-Stage and Three- Stage Patterns The one-stage group in our study showed more confidence on procedures requiring long treatment and repeated appointments such as bridge preparation, anterior endodontics, and premolar endodontics. Differences in confidence levels for these items could be explained by different rotation arrangement of clinical practice between the two patterns. Interns in the three-stage pattern rotate from one department to another at intervals of approximately three months, which makes it difficult for them to follow a complicated case from the first visit to the end of treatment. Plus, time is needed to adapt to new equipment, new instructors, and new subjects when interns in the three-stage pattern rotate into new departments; this process may reduce independent operation time to some extent. Discontinuous and incomplete experience practicing complex procedures may also reduce the confidence of the three-stage group. In contrast, those in the one-stage pattern spend less time rotating and adapting to new clinic environments. Remaining in an intern clinic for about nine months provides interns with more operation time to accomplish entire complex procedures independently, which plays an important role in improving their self-confidence. 26 Besides treatment procedures, the one-stage pattern contributed greatly to interns confidence in comprehensive skills such as communicating with patients, arranging appointments, and managing patients. In the three-stage pattern, by contrast, the instructor leans toward taking the dominant role in a specialized department, which provides less opportunity for interns to practice talking to patients as independent dentists. However, the one-stage pattern provides an open environment for interns to communicate with patients, in which interns are in charge of talking to patients, explaining treatment procedures, arranging appointments, and managing patients. Thus, interns in the one-stage group showed more confidence in these items. Treatment planning is another comprehensive skill in which the one-stage group showed more confidence. Formulating a rational sequence of treatment steps designed to eliminate disease, avoid discomfort, and restore esthetic and masticatory function to a patient is a very important capacity for young dentists. 27 Instructors in the three-stage pattern tend to solve problems belonging to their own specialties and sometimes neglect to comprehensively guide interns. Specialties may differ greatly in terms of the sequence of treatment and choice of method. When multiple and sometimes even incompatible plans are available, it is hard for interns to distinguish which is better when facing the patient; uncertainty increases their confusion and decreases their self-confidence. In contrast, interns in the one-stage pattern group were less puzzled under such circumstances. Instructors of the three areas in an intern clinic held thorough discussions on complicated cases that needed more than one kind of treatment procedure and then provided interns with the unified recommendation. Meanwhile, they would explain the reasons, so that interns could learn and sum up their own experience. This process contributed to interns self-confidence when they faced patients independently. Compared with the one-stage group, the threestage group showed more confidence on procedures that needed a short treatment period and simpler protocols such as indirect pulp capping and single crown preparation. Usually, these procedures are easy to master compared with molar endodontics or bridge preparation and could be done in once or two appointments. Within a three-month period, interns have sufficient repetition in dealing with multiple patients with similar problems who need these same sorts of treatments. Abundance in clinical cases allows interns to repeat related procedures over time; thus, they become more skilled and gain more confidence. March 2016 Journal of Dental Education 325

9 In addition, the three-stage group showed relatively more confidence on some more specialized procedures such as surgical extractions, simple suturing, subgingival scaling, and treatment of pediatric patients. Surgical extractions and simple suturing are surgical procedures that require a set of operating instruments and various types of dental elevators and forceps. Subgingival scaling requires a special ultrasonic scaling device. With respect to the treatment of pediatric patients, it is likely that pedodontics departments provide equipment that is suitable for children. Since the intern clinic must have instruments from all three branches, the diversity of instruments for each specialty cannot compare with that of a specialist clinic. Availability of needed instruments is an essential condition for interns to treat problems like impacted teeth in bone or severe periodontitis and become familiar with the use of various specialized instruments, so that is an advantage of the three-stage pattern. Besides this reason, patients with impacted teeth or facial trauma tend to go to a surgical clinic rather than an intern clinic and thus provide interns in the three-stage pattern with sufficient practice on specialized treatments like surgical extractions and suturing. As the sample size of 303 participants represented only a small percentage of all new dentists in China, a larger sample size is needed in further studies to confirm our findings. Although self-confidence is a representative indicator, it is a subjective reflection of interns performance. Including a more objective assessment indicator such as GPA or medical licensing examination performance could be a good complement to our study. Interns in the two patterns showed different levels in self-confidence on several items, which we classified by procedures needing a long/short treatment period or procedures that were more comprehensive/specialized. Overall, this study demonstrated that the two intern patterns have somewhat different effects on interns self-confidence. Each pattern has its own advantages and shortcomings. One possible direction for improvements could be to arrange more clinical practice time to address the weaknesses of each pattern. Another direction is to adapt Chinese patterns to make them more like those in other countries. Clinical dental training in North America, for example, offers a combination of one-year comprehensive patient care and one year of more specialized training. 28 Such a structure suggests that combining our two patterns could be a way to improve clinical practice education in China. 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