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Dental Student Community Clinic Placement in Australia and the United States: Systematic Review and Case Study
Anna Duan Bowers, MS, DDS, is a first-year postgraduate endodontics resident at the University of the Pacific, Arthur A. Dugoni School of Dentistry where she also obtained her dental degree with honors. She is a member of the American Association of Endodontists and the Northern California Academy of Endodontics. Conflict of Interest Disclosure: None reported.
Ove A. Peters, DMD, MS, PhD, is the discipline lead and a professor of endodontics as well as the academic director of the Oral Health Alliance at the University of Queensland, School of Dentistry. He has held faculty positions in Heidelberg, Germany, Zurich, Switzerland at the University of California and the University of the Pacific. He was the founding director of the postgraduate endodontic program at the UOP. Conflict of Interest Disclosure: None reported.
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Paul Subar, DDS, EdD, is a professor, and the chair of the department of diagnostic sciences and director of the special care clinic/hospital dentistry program at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. He also holds a faculty appointment as a clinical professor, department of family medicine, University of California, San Francisco, School of Medicine. Conflict of Interest Disclosure: None reported.
Sandra March, BDSc, is a lecturer in the University of Queensland School of Dentistry where she received her dental degree. Dr March’s practice interests are centered on prevention and endodontics. Conflict of Interest Disclosure: None reported.
Christine I. Peters, DMD, is a senior lecturer in endodontics at the University of Queensland School of Dentistry. She was an assistant professor in the department of prosthetic dentistry and in the division of endodontics at the University of Zurich Dental School and an assistant professor and professor of endodontology at the University of the Pacific, Arthur A. Dugoni Dental School in San Francisco. Conflict of Interest Disclosure: None reported.
ABSTRACT
Background: Community-based dental education is increasingly integrated in dental school curricula to promote educational enrichment, to accommodate larger class sizes and to expose students to a broader patient demographic. This review examined community clinic rotations and their impact on dental students’ level of competence in Australia and the United States.
Methods: A systematic review identified pertinent literature between 2005 and 2021 from databases including PubMed, SCOPUS and the Cochrane Library. It was limited to studies involving dental student placement at community-based dental clinics and the impact of the community-based dental rotation on clinical competency. Two case studies present data from identical surveys addressing final-year dental students.
Results: Nineteen articles met the inclusion criteria out of an initial 51 titles identified. Eleven articles addressed community-based dental education (CBDE) in the U.S and five related to Australia. Overall, there was a positive effect following students’ rotation across all outcomes, including treatment planning, diagnosis, time management, clinical skills, productivity and communication/interpersonal skills. In addition, students were found to be more likely to consider employment in rural/underserved areas following these clinic outplacements. These findings were in line with feelings and observation by the selected cohorts of students in Australia and the U.S.
Conclusion: Community clinic rotations resulted in evident gains in competency for students across multiple competencies. The current literature suggests that a longer outplacement program with more patient encounters offers increased benefits. Moreover, placement to clinics in underserved regions may encourage students to practice in these locations, mitigating the maldistribution of the dental workforce in rural areas.
Keywords: Dental health education, community clinic, clinical competence, U.S. dental education, Australian dental education
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Community-based dental education (CBDE) is increasingly incorporated in dental education.[1–3] Placement of dental students at community clinics allows interfacing with and caring for a diverse patient pool and varied populations and enriches and improves clinical learning. Furthermore, educators and public health officials hope that this experience will promote a life-long participation in community service, especially in underserved geographic areas.[1,3]
In Australia, dental students typically rotate through urban and rural community clinics, as determined by the dental curriculum of each university. At the University of Queensland School of Dentistry (UQ) in Brisbane, Australia, rotations are integrated within the final year of the curriculum, where students spend four days per week performing clinical practice activities either at an external placement or internally at the dental school clinic. In the U.S., the Commission on Dental Accreditation (CODA) requires that dental education programs provide opportunities and assist students in engaging in servicelearning experiences and/or communitybased learning experiences.[4]
Student-centered teaching in outreach clinics enhances confidence and clinical competency and may be more effective than dental school training alone in teaching treatment planning.[5–8] Community clinic stays increase the number of student-patient encounters and are rewarding and encouraging for the students involved.[5,9]
Recently, Formica et al.[10] published a strategic analysis and recommendations for future dental education. The authors emphasize a changing practice environment, with graduates choosing larger group clinics rather than solo practices. To avoid preparing dental students for a single-practice scenario that many new dentists will not work in, they advise moving clinical education to community-based clinics. Patients benefit from affordable dental treatment rendered by a larger number of clinicians. Students, on the other hand, learn to manage adult and pediatric patients with more complex health and dental needs.[10]
Challenges for dental students include balancing and reconciling their private lives with high tuition fees, full study schedules and demanding academic assessments. International students leave their family support and navigate a new culture.[11,12] In CBDE, students describe increased comfort, better time management and an enjoyable and positive experience.[8,13,14] For example, participants in a survey by Johnson and colleagues[1] reported their time spent in a community clinic as the best part of their dental education.
In this study, the change in students’ overarching competence before and after community clinic rotations at particular dental schools in the United States and Australia is systematically reviewed in the literature. The selfreported impact of CBDE in terms of component competencies on students at the University of Queensland (UQ) and at the University of the Pacific (Dugoni) are compared and evaluated.
Materials and Methods
The review section of this article is based on a search for suitable literature between 2005 and 2021 from databases including PubMed, SCOPUS and the Cochrane Library by one independent reviewer. The following terms and their various combinations were used in the initial search strategy: dental education, dental community clinic, clinical competency, dental students, community clinic rotation and rural placement (TABLE 1). An evaluation of the titles and abstracts was undertaken for all identified articles. Duplicates and articles nonpertinent to the review topic were removed, leaving 51 articles for further review (FIGURE 1).
The following inclusion criteria were used to identify appropriate literature: dental education studies in the United States or Australia and placement at community dental clinics and its impact on clinical competency (self-reported or evaluated). Excluded were studies conducted outside of the United States or Australia, editorials, abstracts, news and policy briefs and studies not investigating change in competencies before and after rotation. The final sample included 16 publications, five of which addressed CBDE in Australia[1,15–17,32] and the remaining 11 dealt with CBDE in the U.S.[2,18–25,30,31]
Results
Details for the characteristic and data collected from the studies included in the systematic review are in TABLE 1. There was a high degree of heterogeneity among the type of placement as well as the approach to collecting the information. The following describes the findings for both locations.
Data Collection Methods
Twelve of the 16 studies collected data with questionnaires or surveys.[1,2,15–18,21–23,30–32] Others employed reflective journaling and open-ended questions,[16,17] interviews,[1,20] assessment of productivity[24,25] and direct performance assessments,[19] such as licensing exam performance scores. Five studies used pre- and postrotation evaluations,[2,15,16, 25,30] while others gathered postrotation metrics only.[1,17–22,24,31,32]
Sample sizes varied among the studies, from less than 50 to more than 200 (TABLE 2). Key outcomes assessed in the studies included treatment planning, diagnosis, time management, clinical skills, productivity, provider confidence, critical thinking, professionalism and interpersonal and communication skills.
Duration of Placement
The placement length reported in the Australian studies was in the one month or less range[1,15–17] in all studies except one.[32] In contrast, the studies conducted at schools in the U.S. tended to cover a longer placement duration, with the majority of the studies describing an assignment of longer than five weeks and three studies lasting longer than 12 weeks.[18–20]
Impact on Treatment Planning CBDE rotation enhanced students’ ability to treatment plan. On a scale of 1 to 5, with 5 being the highest score, Berg et al.[18] reported a post-rotation change from 74.6% to 82.5% in students who gave themselves self-assessment scores of 4 to 5 in treatment planning and associated competencies. Likewise, Johnson et al.[15] noted that pre-rotation self-assessed treatment planning skills improved from a mean score of 3.4 ± 0.5 to 3.8 ± 0.3, compared to no improvement in students who did not attend a rural placement rotation. Simon et al.[2] found that students agreed significantly more with the statement “I feel competent in developing different treatment plans for my patient.” McFarland et al.[21] saw improved assessment, diagnosis and treatment planning in two investigated cohorts.
Impact on Diagnosis
Self-reported diagnostic ability improved after CBDE. Berg et al.[18] described 77.6% versus 83.1% of 4 to 5 grades in students’ ability to “identify and record patient’s oral problems.” Examination and evaluation of patients improved from 79.1% to 86.4%. Coe et al.[22] found that 61% of their students became more confident in providing exams, prophylaxis and fluoride treatments to pediatric patients following their CBDE rotation. DeCastro et al.[19] saw returning students produced almost three times the clinical points compared to students who did not attend that rotation. Johnson et al.[15] stated that post-rotation, students reported their diagnostic ability as a strength compared to pre-placement where it was reported as a weakness. McFarland et al.[21] saw improvement in assessment, diagnosis and treatment planning following rotations.
Impact on Time Management
While time management and clinical efficiency was a common self-reported weakness of students prior to their rotation through a rural placement program, a four-week placement window turned speed and clinical adeptness into strengths of the students.[16] Students were “pleased with the clinical experience provided, with increased time management skills and clinical confidence emphasized.”[16] In a separate study, Johnson et al.[15] noted that students perceived an increase in self-reported time management skills from 3.2 ± 0.7 to 3.6 ± 0.6 postplacement, compared to students who did not attend and noted no improvement (3.6 ± 0.6 to 3.6 ± 0.7). Koedyk et al.[32] noted “improved time management” mentioned by students. All studies were conducted at an Australian dental school. None of the U.S. studies reported metrics on time management.
Impact on Clinical Skills
The highest impact (13 of 16 studies) of CBDE rotations was noted relative to clinical skills. All included Australian studies[1,15–17,32] and eight out of the 11 U.S. studies described improvements in this metric.[2,18–20,22,23,30,31]
Prior to the rotation, students listed extractions, restorations and scaling as strengths, while postrotation, detecting caries and crown preparations were also listed as strengths, indicating improved skills in these areas.[16] Treatment skills and clinical ability improved in participating versus nonparticipating students.[15] Similarly, Lalloo et al.[17] described “clinical skills improved” alongside “social and life skills,” with 32% strongly agreeing and 52% agreeing that they “developed clinical operative skills in a primary care environment.” However, due to poor patient flow, some locations were found to be “not very beneficial to learn clinical skills.”[17]
Berg et al.,[18] in a study conducted at a United States dental school, noted a moderate or large enhancement of confidence in students’ clinical skills. Prior to their rotation, 74.6% of students rated their ability to “treatment plan and be able to provide majority of required care” as a 4 to 5 compared to 86.4% of students postrotation. Coe et al.[22] found that 78% of students became more confident giving local anesthesia, 69% in providing simple restorative treatments, 100% in performing stainless steel crown procedures, 89% in delivery of pulp therapy treatment and 69% in performing extractions. Mathieson et al.[20] noted that higher patient volume on clinical placement brought a “substantial increase in their speed and technical skill.” Northeast Regional Board restorative exam pass rates improved after CBDE, as did scores with simulated patients.[19] Highly significant increases in confidence “as a clinician in terms of efficiency, clinical skills and competence” were noted in another study;[2] specifically, rotations advanced the students’ ability to “manage dental emergencies.” Rohra et al.[31] reported that 80% of their respondents agreed or strongly agreed with improving their clinical skills through the community-based education, and Habibian et al.[30] found a high level of satisfaction with clinical experience and students stating an increase in confidence as well as becoming “more independent and working autonomously.” Indeed, it was described that the proportions of students perceiving excellent skill levels in treating underserved patients more than doubled.[23]
Impact on Productivity
Three U.S. studies directly assessed productivity as a metric. Students who were placed on rotation scored an average of 1,946.54 ± 472 clinical points compared to a significantly lower mean in nonparticipating students who scored 1,082.45 ± 187.58 points.[19] In these combined points across oral diagnosis, endodontics, prevention, periodontics, general dentistry, fixed prosthodontics, removable prosthodontics and oral surgery, CBDE resulted in nearly doubling student productivity. Mascarenhas et al.[24] noted that longer clinical externships resulted in even greater productivity. Students who were placed on a 10-week rotation performed 35% more procedures than those on the six-week rotation over the course of the rotation.[24] Clinical revenue increased by more than onethird, and students accomplished more procedures per month postexternship compared to preexternship.[25]
Impact on Communication/ Interpersonal Skills
The second most commonly assessed CBDE metric was on students’ communication and interpersonal skills. The proportion of students’ self-grading of 4 or 5 in “utilizing patient management and interpersonal skills” rose from 91.0% to 96.5%.[18] Students’ ability to “educate patients on etiology and control of oral diseases/conditions” improved from 83.6% to 91.2% postrotation.[18] Students initially noted “patient communication” as both a strength and also an area where they hoped to improve.[16] Postplacement, “patient management” and “communication skills” were commonly reported strengths with many students indicating improvement. Students receiving CBDE saw their communication ability improve from 3.9 ± 0.7 to 4.3 ± 0.4 compared to students who did not receive CBDE, whose ability only changed from 4.3 ± 0.5 to 4.4 ± 0.5.15 Lalloo et al.[17] found a strong agreement or agreement with the statement “I developed skills of patient management including communication skills” 32% and 49% of the time. Interpersonal factors remained a common theme, with students experiencing positive interactions with dental patients from various socioeconomic statuses, but no numerical metric was assigned to improvements.[20] McFarland et al.[21] reported increased communication and interpersonal skills in two consecutive student cohorts. Finally, students were more likely to “feel comfortable in presenting and discussing sequence of treatment, estimated fees, payment plans, timetable and patients’ responsibilities for treatment” and 27 out of 35 students reported that “building meaningful relationships with patients” was the most rewarding part of their rotation.[2]
Impact on Intent To Practice in a Rural/Underserved Area
A hope in CBDE is that students develop an intent to practice in a rural/ underserved area after their rotations. All three Johnson et al.[1,15,16] studies found that students were more likely to practice in a rural setting after their rotation experience. Initially, only 57% of students were “likely to work in a rural setting after graduation” compared with 97% postrotation.[16] A second study[15] found that prior to their placement, 54.8% of students considered working in a rural location, compared to 96.9% postrotation. Students not on rotation considered rural work only 35.5% of the time. One of the top 15 graduate feedback responses was that rural clinical placement rotation “influenced me to work rurally.”[1] Lalloo et al.[17] noted after rotations, 8% of students strongly agreed and 25% of students agreed with the statement “I am now more likely to choose a career in the public sector,” and 15% of students strongly agreed and 25% of students agreed with the statement “I am now more likely to work in a rural and remote setting” after their rotations. Koedyk et al.[32] reported that following rural placement, most students would consider rural practice after graduation.
It appears choosing to work in community clinics is a function of how many weeks students spent on rotations in community clinics.[23] In 2005, where the rotations were three weeks in length, 6.1% wanted to work in a rural area versus 16.5% in 2010, where rotations were eight weeks in length.[23] Simon et al.[2] found that students increasingly agreed with the statement “I am interested in incorporating community health and outreach work into my practice to be a provider for the underserved” following rotations.
In conclusion, practical implications for teaching institutions with limited clinic capacity include easing space constraints by transferring students into extramural sites. This might allow admission of a higher number of students. From the standpoint of dental education providers, learning in public health clinics teaches real-life dentistry, participation in community service, genuine public health, applied professional ethics and communication with populations outside of the known setting of their dental school.[13] Interestingly, while studies demonstrate similar revenue generated in community sites and in dental school clinics,[14] production increases postexternship.[13] The benefits of CBDE appear to increase as rotation time lengthens, allowing multiple appointments for more complex clinical procedures.[26]
Thus, placing dental students into community-based clinic rotations or community-based dental education (CBDE) has various advantages, not only students, but also to patients, public health organizations and dental schools.[17]
Case Study
To our knowledge, no direct comparison exists between a U.S. and an Australian dental school regarding the benefits of community-based dental education for students’ competencies.
The aim of this case report addressed the following questions: (i) what were the similarities and differences in observations and self-reported impact of community clinic rotation on clinical treatment self-confidence between dental students at the two participating schools; and (ii) what were the self-rated levels of competency before and after rotation.
The UQ Health and Behavioral Sciences Faculty Ethics Committee granted approval for the survey (HABS approval # 2017001568), and the Institutional Review Board (IRB) at Dugoni permitted a cooperative research agreement (IRB protocol review # 2017001568).
The study was conducted at the University of Queensland, School of Dentistry, a public dental school in Herston, Qld, Australia, and at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco.
At both universities, senior students in their final year of dental education and students who had graduated the previous year were invited to participate. A total of 36 out of 132 eligible UQ students or graduates and 38 out of 290 eligible Dugoni students or graduates responded to a survey (27% and 13% response rates, respectively), with a distribution of 44% female respondents at UQ and 56% female respondents at Dugoni. The average participant age was 26 at UQ and 27.5 at Dugoni. Of the responding students, 76% at Dugoni and 54% at UQ were recent graduates, and 24% at Dugoni and 46% of the students at UQ were current students; 73% of UQ students were situated in rural community clinics, while only 21.4% of Dugoni students were placed in nonurban clinic rotations.
Data Collection
Students at both universities were invited to take identical online surveys related to their community clinic rotation experiences, influence of rotations on self-reported confidence in clinical treatment and self-reported levels of component competencies and overall clinical competency after rotations. The survey consisted of 11 questions starting with demographics such as gender, age and whether respondents were recent graduates or current students (SURVEY QUESTIONS).
The second section of the survey questioned students about their experiences in community clinic rotation. This part of the survey included a set of 5-point Likert-scale items that asked students to report whether the rotation resulted in increased self-confidence in clinical treatment.
The last survey segment asked students to rate their skill levels prior to and after community clinic rotations by assigning themselves “before” and “after” grades for several component competencies in the Competencies for the New General Dentist by the American Dental Education Association (ADEA).[27] In addition to these component competencies, students were asked to rate their overall clinical competency on a sliding scale of 0–100, with 100 representing a personal optimum.
Data Analysis
The underlying hypothesis was that there would be differences in skills acquisition between the two dental schools evidenced by community clinic rotation experiences, self-reported changes in clinician confidence, component competencies and overall competency before and after rotation. Data were either continuous (timeframes, numbers of patients or self-reported competency) or proportions. Continuous data were consistent with normal distributions. Hence, students’ t-tests and chi square tests were used; the level of significance was set at 0.05.
Community Clinic Rotation Experiences
The setting in dissimilar clinic locations, such as urban versus rural sites, caused no significant difference in the learning experience in outplacement programs. Students at UQ, however, consistently rated their experience significantly better than those at Dugoni (TABLE 3).
Students at UQ worked 21.2 ± 6.5 (mean ± SD) weeks. This was a significantly (p < 0.0001) longer time in the outplacement program than for students at Dugoni, who spent 3.2 ± 1.9 weeks in community clinics. Consequently, students at UQ had a higher overall number of patient encounters (UQ 373.4 ± 130.5 versus Dugoni 41.3 ± 23.8). If calculated by week, however, the difference was not statistically significant: 19 weekly patient treatments took place at Dugoni venues and 17 patients were treated at UQ-associated clinics per week. The percentage of students somewhat or strongly agreeing that the time spent was sufficient varied from 93.9% of the students at UQ versus 74.3% of students at Dugoni.
All responding students at UQ agreed that patient care was relevant; it resulted in better understanding of treatment needs and ethical considerations of the served population. This percentage was significantly higher (p = 0.002) than the 80% of students at Dugoni feeling the same way. Students´ perception on calibration regarding treatment methods between the dental school and community clinic showed no significant differences between both institutions.
Overall, the mentor/student relationship was constructive and encouraging. No student at UQ disagreed; however, 20% of students at Dugoni did not think the collaboration between mentor and student worked well (p < 0.0001). In the same line of perception, 23% of students at Dugoni were not satisfied with the mixture of patients and treatments and only 3% of students at UQ (p = 0.018) voiced this concern. In fact, 67% of students at UQ strongly agreed that the number of treatments rendered was appropriate as opposed to 37% of students at Dugoni (p = 0.014).
Self-Reported Confidence in Clinical Treatment After Rotation
In terms of self-confidence, all surveyed students at UQ reported that they felt more confident in both the interaction with patients and in diagnosis and treatment planning after the rotation, a significantly higher percentage than the approximately 70% of Dugoni students (TABLE 3).
Furthermore, students at UQ felt they had learned better time management, a greater number of procedures rendered or being more productive in clinical treatment.
Self-Reported Changes in Component Competencies
Before outplacement rotations, perception among students on their component competencies before CBDE contrasted significantly between the two institutions. In general, students at Dugoni rated their prerotation level of competency significantly higher than students at UQ.
Concerning critical thinking, 77.1% of students at Dugoni felt reasonably or strongly competent before the rotation. No student at UQ felt strongly competent and only 33.3% felt reasonably competent (p < 0.0001).
In patient care, assessment, diagnosis and treatment planning before the rotation at UQ, no student felt strongly competent, but 33.3% of the cohort felt reasonably competent. Meanwhile, 20% and 57.1%, respectively, felt strongly and reasonably competent at Dugoni (p = 0.001).
Spending time in communitybased education considerably changed opinions among students in both institutions regarding their component competencies. Participants from both institutions recorded improvement in all ADEA competencies, including health promotion and practice management, and perceived their abilities as similarly high after the outplacements in all competencies tested.
Self-Reported Overall Competency Before and After Rotation
A sliding scale from 0–100, with 100 reflecting the personal best, provided overarching self-reflective grades. In this respect, self-assigned grades before placement were significantly higher (p = 0.005) for students at Dugoni (65.7 ± 18.1) than for those at UQ (53.9 ± 14.7). The increase in the self-grade after the placement was significantly higher (p < 0.0001) for students at UQ (22.4 ± 10.6) than for those at Dugoni (5.4 ± 20.3).
Discussion
This study reviewed community clinic rotations and their impact on dental students’ level of competence in Australian and U.S. dental schools and reported two cases aimed to compare community clinic rotations and their impact on student clinical competency and self-perceived confidence. There were a limited number of studies limited to the U.S. and Australia that assessed students’ competency in relation to community clinic rotations. Ultimately, 16 studies were identified with five addressing community clinic rotations in Australia and 11 addressing them in the U.S.
In all the key outcomes identified for review in this study, there was an improvement when comparing prerotation to postrotation metrics. In terms of treatment planning, four of the 13 studies addressed that there was an improvement in students’ ability to treatment plan following their participation on rotation. Five of the 13 studies noted an improvement in diagnosis ability of students following rotation and three studies directly addressed improvement in time management. Of the studies that directly addressed time management, all were conducted at schools in Australia, although the three studies addressing improvement in productivity were from the U.S. One can ascertain that if there is improvement in productivity, consequently there is also likely improvement in time management of students during their procedures. The two categories that were most studied were those addressing improvement in clinical skill and communication/ interpersonal skills. Thirteen of the studies saw that students improved in their clinical skills, whether self-assessed or assessed through other metrics such as regional clinical exam performances, and seven studies found that students saw an improvement in communication/ interpersonal skills. It seemed that more of the Australian studies were interested in students’ future employment plans, with all five of the Australian studies having some metric on whether there was a positive correlation with rotation placement and consideration of the rural working locations postgraduation. All of the Australian studies found that postrotation, students were more likely to choose a rural location for employment. As Australia continues to struggle with poor distribution of dental professionals in rural locations, exposing students to a rural setting through these rural placement programs in the hopes of encouraging students to eventually practice in a rural setting can help address this rural shortage.[1]
In U.S. dental schools, a period of at least four weeks is the norm.23 It was found that augmenting CBDE time to eight weeks increased the graduates’ willingness to serve in community clinics after graduation.[23] In addition, rotation length is critical in allowing conclusion of multiple-appointment treatments. Procedures that require several appointments necessitate a suitable length of clinic presence to bring a treatment to completion. In a study on CBDE practices in 33 U.S. dental schools, Mays et al.[26] stated that “shorter rotations will limit the type of patient encounters and impact the student’s experience.” Rotation times in U.S. schools was found to generally be longer than those in Australian schools with the majority of the U.S. rotations lasting five weeks or longer and Australian rotations generally being about four weeks in length.
A survey of recent graduates and current students at UQ and Dugoni before and after community clinic rotations investigated differences and similarities between the schools. The self-reported impact of community clinic rotation on clinical confidence was assessed, as were self-graded component competencies and overall competency.
In the first section of this survey on demographics, there were no significant differences between Dugoni or UQ dental schools concerning age, gender or whether participants had already graduated or were still enrolled. About three times as many students at UQ worked in rural community clinics, in comparison to Dugoni students, who mainly completed rotations in urban clinics. Differences in setting did not however impact the students’ learning experience in outplacement programs in either rural or urban clinics. Students at UQ consistently rated their experience significantly better than those at Dugoni.
One possible reason for the positive results with UQ students could be the significant difference in time spent on clinical learning on rotation. Students at UQ spent about 21 weeks in the outplacement program while Dugoni students spent much less time, about three weeks, on rotation. As a result, UQ students treated nine times as many patients as Dugoni students; almost 94% of students at UQ somewhat or strongly agreed that their community clinic time spent was adequate, while a quarter of students at Dugoni felt the time given for rotations was not sufficient. If calculated by week, however, this difference did not lead to significantly less studentpatient encounters for Dugoni students.
The survey results show that component competencies students felt lacking in improved more for students at UQ, leading to a similar self-reported final achievement in both institutions. Perceived changes were not as evident in students at Dugoni, as demonstrated by student ratings on the overall outplacement experience itself.
At both dental schools, survey participants were asked to grade themselves in ADEA competencies.[27] A “competency” encompasses an indispensable set of behaviors or skills that sustain unsupervised, selfregulated dental practice. Further, competencies include comprehension, critical thinking and problem- solving skills, professional behavior, experience, ethics and hand skills.[27]
Populations outside the dental school differ from the more closely defined patient pool inside an education institution. In a community clinic, dental education gains aspects of private practice, such as engagement with realistic dentistry, community service, exposure to the public health system, applied ethics and interpersonal and interprofessional communication with populations outside of the known environment of their dental school.[13] Perhaps as important, studies point out similar revenue in community sites and in dental school clinics and an increase of production postexternship.[14,25]
In this survey, students at Dugoni felt more self-confident before the outplacement and gave themselves significantly better initial grades for seven ADEA competencies than survey participants at UQ. This difference leveled out to similar scores for both institutions after CBDE.
In terms of critical thinking, there was a significant difference, with more than three-quarters of students at Dugoni feeling reasonably or strongly competent before the rotation. No student at UQ felt strongly competent and only a third felt reasonably competent.
None of the Dugoni students or new graduates thought they were still developing competence at professionalism before CBDE. All Dugoni students felt strongly, reasonably or at least just competent, while significantly more students at UQ felt they were still developing professionalism. Students at Dugoni also felt significantly more accomplished and strongly competent in communication and interpersonal skills than students at UQ. The disparity could be based in the different programs, UQ accepting some undergraduate students straight out of high school, as opposed to college graduates, with potentially more mature life skills at Dugoni.
In patient care, assessment, diagnosis and treatment planning before the rotation, more than three-quarters of Dugoni students felt strongly competent, while slightly more than a third felt reasonably competent at UQ. These differences among students in both institutions in competency lost significance after community-clinic rotation. The results seem to indicate that a longer stay in CBDE programs and the higher number of patients available for UQ students compensated any previous lack of self-confidence and resulted in the same final perception on competency and similar self-grades as students at Dugoni.
Lastly, students assigned themselves an overarching grade on a sliding scale from 1–100. These final, self-reflective grades started out significantly higher for Dugoni than UQ students. The end results were similar, with a significantly higher increase in grades after CBDE for students taking the survey at UQ.
This study had certain limitations; for example, only one university per country was assessed and the results represent survey data only, not institutional grading. Despite multiple efforts to remind participants, it accomplished a comparatively low response rate. The latter finding mirrors research on survey response rates. In a randomized trial on effects and costs of different modes of survey administration, Scott et al.[28] noted an online response rate of 12.95% in medical GPs. Cook et al.[29] conducted a randomized experiment with a physician survey that included low-cost nonmonetary incentives, a formal reminder letter and a postcard and only 8.5% of practitioners completed the questionnaire. To the contrary, Pit at al.[13] stated in their systematic review that postal surveys were costly but more effective than telephone or email surveys and that monetary or non-monetary incentives increased participation. In this survey, three email reminders were sent, but no compensation or reward was offered, which may have influenced the response rate.
Another potential limitation of the review is that the protocol was not registered with the PROSPERO database. While not mandatory, such registration is beneficial to avoid duplication and to enable comparison of already reported review methods with what is planned. However, due to the sequencing of the survey and review portions, this was not done in the present study.
Regardless, collectively the reviewed studies demonstrated that studentcentered teaching in outplacement clinics enhances confidence and clinical competency. Likewise, CBDE can lead to better treatment-planning skills.[5–7,9] The number of treated patients increases and in turn provides a greater quantity of rendered clinical work. Spending part of their dental training outside of the routine and familiarity of their dental school considerably changed students’ perceptions in a positive way, in both institutions. Participants from Dugoni and UQ recorded noticeable improvement in all ADEA competencies. Patient treatments in community clinics are a fulfilling and confidence- building experience for participating students.[5–7,9] With enhanced clinical learning outcomes in CBDE and future directions in dentistry indicating mostly large group practices rather that individual practices, dental education might take steps to decrease dental school clinic presence and increase time spent in community clinics. Therefore, it may be recommended to not only make CBDE a significant component of dental education but also to enhance it in the final year of education specifically at Dugoni.
Conclusions
Collectively, literature suggests that community-clinic rotations lead to gains in competency for students across multiple metrics including treatment planning, diagnosis, time management, clinical skill, productivity and communication/interpersonal skills. Similarly, our case report regarding UQ and Dugoni shows improved clinical confidence and self-reported skills in the ADEA competencies of critical thinking, professionalism, communication and interpersonal skills, health promotion, practice management and informatics as well as patient care in assessment, diagnosis, treatment planning and establishment and maintenance of oral health. Students gained higher selfreflective grades. Positive changes after rotations suggest increased benefits of longer outplacement programs with considerably more patient encounters. In addition, exposure to rural clinic placements/clinics in underserved regions can help expose students to other career possibilities following graduation and hopefully encourage them to consider practicing in areas where there is a dental health professional shortage, mitigating the maldistribution of the dental workforce in rural or underserved areas.
REFERENCES
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THE CORRESPONDING AUTHOR, Christine I. Peters, DMD, can be reached at c.peters@uq.edu.au.
