VI. Competencies and Proficiencies

Introduction

Postdoctoral General Dentistry (PGD) programs play an important and expanding role in the education of the nation's primary health care providers in dentistry. These programs build on and complement predoctoral dental education. In these postdoctoral programs, dental school graduates: learn new techniques; become proficient in previously learned techniques; become capable of providing dental care for patients with complex medical, dental, and social conditions; and learn to integrate professional values with various aspects of dental treatment in order to provide long term comprehensive care to individuals and communities of patients.

There is a growing trend in dental education to describe curricula in terms of their impact on students (expressed as competencies) rather than on discipline-based content (expressed as behavioral objectives).3 Such a description focuses attention on the outcome, in terms of graduate’s abilities, of educational experiences, rather than on the process of education. This focus is more likely to create a graduate with the desired skills and to encourage program directors to choose and provide educational experiences that will lead to the development of graduates with those skills.

The director and faculty of the Advanced Education Program in General Dentistry (AEGD) at the University of Maryland, Dental School are committed to incorporating competency and proficiency concepts and evaluation methodologies into the program. This document presents a method for describing graduates of University of Maryland Dental School AEGD program in terms of their abilities and methodologies for assessing those abilities. It is anticipated that this document will be useful for: applicants to the program desiring to know what skills they can expect to gain in the program; residents in the program who will be able to measure their progress and document their accomplishments in the areas of competency and proficiency described; and for the program director and faculty who will be able to use these measures for outcomes assessment and continuous improvement of the program.

Competency and Proficiency Statements

University of Maryland, Dental School's Advanced Education in General Dentistry Program:

The following statements describe the graduates of University of Maryland, Dental School's AEGD program. They are intended to communicate the expectations of the faculty to the resident and serve as the basis for evaluation of resident's satisfactory completion of the program.

Definitions

In order to facilitate reading this list of statements, certain terms have been predefined so they could be used in the manual without repetitive definition. These definitions are listed in the next section of this manual. In general, the definitions proposed by Chambers and Gerrow5 have been followed, although some new definitions have been added and some definitions modified. In situations where it is expected that the PGD program graduate will be able to, and likely to, actually perform the necessary procedures, the terms "perform", "provide", "restore", or "treat" have been used. In circumstances where the graduate may perform some treatment but is more likely to oversee treatment or refer, the term "manage" is used. The term "appropriate" is not used in these statements to eliminate repetitive verbiage. It is assumed that all knowledge, skills, and procedures described will be performed for appropriate reasons, in appropriate circumstances, and in an appropriate manner. In this manual each statement is designated as either an area of competency (C) in which graduates are expected to have little experience at the beginning of their programs, or as an area of proficiency (P) in which graduates are expected to be competent at the beginning of their programs and gain further experience, skill, and judgment as the program progresses.

A graduate of the University of Maryland, Dental School's AEGD program will:

In regard to planning and providing comprehensive multidisciplinary oral health care

1. Function as a patient's primary, and comprehensive, oral health care provider. (P)
2. Explain and discuss with patients, or parents or guardians of patients, findings, diagnoses, treatment options, realistic treatment expectations, patient responsibilities, time requirements, sequence of treatment, estimated fees and payment responsibilities in order to establish a therapeutic alliance between the patient and care provider. (C)
3. Integrate multiple disciplines into an individualized, comprehensive, sequenced treatment plan using diagnostic and prognostic information for patients with complex needs. (P)
4. Modify the treatment plan, if indicated, based on unexpected circumstances or patient's individual needs. (P)
5. Diagnose and manage a patient's occlusion. (C)
6. Manage uncomplicated diseases and abnormalities of the pediatric patient. (C)

In regard to health care delivery:

1. Treat patients efficiently in a dental practice setting. (C)
2. Use scheduling systems and insurance and financial arrangements to maximize production in dental practice. (C)
3. Support the program's mission statement by acting in a manner to maximize patient satisfaction in a dental practice. (C)
4. Use and implement accepted sterilization, disinfection, universal precautions and occupational hazard prevention procedures in the practice of dentistry. (C)
5. Provide patient care by working effectively with allied dental personnel, including performing sit down, four-handed dentistry. (C)
6. Provide dental care as a part of an interprofessional health care team such as that found in a hospital, institution, or community health care environment. (C)
7. Demonstrate the application of the principles of ethical reasoning, ethical decision making and professional responsibility as they pertain to the academic environment, research, patient care and practice management. (C)
8. Participate in organized dentistry. (C)

In regard to information management and analysis:

1. Evaluate scientific literature and other sources of information to determine the safety and effectiveness of medications and diagnostic, preventive, and treatment modalities, and make decisions regarding the use of new and existing medications, procedures, materials, and concepts. (P)
2. Maintain a patient record system that facilitates the retrieval and analysis of the process and outcomes of patient treatment. (C)
3. Analyze the outcomes of patient treatment to improve that treatment. (C)
4. Understand and use a system for continuous quality improvement in a dental practice. (P)
5. Use selected business systems in dental practice including marketing, scheduling patient flow, record keeping, insurance financial arrangement, and continuing care systems. (C)

In regard to oral disease detection and diagnosis:

1. Select and use assessment techniques to arrive at a differential, provisional and definitive diagnosis for patients with complex needs. (C)
2. Obtain and interpret the patient's chief complaint, medical, dental, and social history, and review of systems. (P)
3. Obtain and interpret clinical and radiographic data and additional diagnostic information from other health care providers or other diagnostic resources. (P)
4. Use the services of clinical, medical, and pathology laboratories and refer to other health professionals for the utilization of these services. (P)
5. Perform a limited history and physical evaluation and collect other data in order to establish a risk assessment for dental treatment and use that risk assessment in the development of a dental treatment plan. (P)
6. Diagnose and manage common oral pathological abnormalities including soft tissue lesions. (P)

In regard to promoting oral and systemic health and disease prevention:

1. Participate in community programs to prevent and reduce the incidence of oral disease. (C)
2. Use accepted prevention strategies such as oral hygiene instruction, nutritional education, and pharmacologic intervention to help patients maintain and improve their oral and systemic health. (P)

In regard to assessment of medical risk:

1. Treat patients with a broad variety of acute and chronic systemic disorders and social difficulties including patients with special needs. (C)
2. Develop and carry out dental treatment plans for patients with special needs in a manner that considers and integrates those patient's medical, psychological, and social needs. (C)
3. Perform dental and medical consultations for patients in a health care setting.

In regard to sedation, pain, and anxiety control:

1. Use pharmacologic agents in the treatment of dental patients. (P)
2. Provide control of pain and anxiety in the conscious patient through the use of psychological interventions, behavior management techniques, local anesthesia, and oral and nitrous oxide conscious sedation techniques. (C)
3. Prevent, recognize, and manage complications related to use and interactions of drugs, local anesthesia, and conscious sedation. (C)

In regard to restoration of teeth:

1. Restore single teeth with a wide range of materials and methods. (P)
2. Place restorations and perform techniques to enhance patient's facial esthetics. (P)
3. Restore endodontically treated teeth. (P)

In regard to replacement of teeth using fixed and removable appliances:

1. Treat patients with missing teeth requiring removable restorations. (P)
2. Treat patients with missing teeth requiring uncomplicated fixed restorations. (P)
3. Communicate case design with laboratory technicians and evaluate the resultant prostheses. (P)
4. Manage uncomplicated endosseous implant restorations. (C)

In regard to periodontal therapy

1. Diagnose and treat early and moderate periodontal disease using non-surgical and surgical procedures. (C)
2. Manage advanced periodontal disease. (C)
3. Evaluate the results of periodontal treatment and establish and monitor a periodontal maintenance program. (C)

In regard to pulpal therapy:

1. Diagnose and treat pain of pulpal origin. (P)
2. Perform uncomplicated non-surgical anterior endodontic therapy. (P)
3. Perform uncomplicated non-surgical posterior endodontic therapy. (C)
4. Treat uncomplicated endodontic complications. (P)
5. Manage complex endodontic complications. (C)

In regard to hard and soft tissue surgery:

1. Perform surgical and nonsurgical extraction of teeth. (P)
2. Extract uncomplicated soft tissue impacted wisdom teeth. (C)
3. Perform uncomplicated pre-prosthetic surgery. (C)
4. Perform biopsies of oral tissues. (C)
5. Treat patients with complications related to intra-oral surgical procedures. (C)

In regard to treatment of dental and medical emergencies

1. Treat patients with intra-oral dental emergencies and infections. (P)
2. Anticipate, diagnose and provide initial treatment and follow-up management for medical emergencies that may occur during dental treatment. (C)
3. Treat intraoral hard and soft tissue lesions of traumatic origin. (C)
4. Recognized and manage facial pain of TMJ origin. (C)

Second Year Competency and Proficiency Statements

The following are competency and proficiency statements that describe the additional areas beyond those of the first year program, that apply to residents completing the second year program.

1. Integrate all aspects of dentistry in the treatment of patients with complex dental, medical and social situations. (P)
2. Perform advanced procedures in the selected clinical Area of Concentration. (P)
3. Use proper dental school protocol when treating and managing patients in a health center environment. (P)
4. Participate in the management of a system of continuous quality improvement in a dental practice. (P)
5. Supervise and chair the literature review seminars for AEGD first year residents. (P)
6. Develop and participate in the second year curriculum that is customized for their particular interests. (P)
7. Perform and maintain uncomplicated endosseous implant restorations.  (C)

Definitions

adapted from Chambers and Gerrow ¹

Assess. Evaluation of physical, written, and psychological data in a systematic and comprehensive fashion to detect entities or patterns that would initiate or modify treatment, referral, or additional assessment. Assessment entails understanding of relevant theory, and may also entail skill in using specialized equipment or techniques. But assessment is always controlled by an understanding of the purpose for which it is made and its appropriateness under the present circumstances. Recognition is a more limited term that does not subsume the notion of evaluating findings. Diagnosis is a more inclusive term, which relates evaluated findings to treatment alternatives.

Competency. Behavior expected of the beginning practitioner. This behavior incorporates understanding, skill, and values in an integrated response to the full range of requirements presenting in practice. The level of performance requires some degree of speed and accuracy consistent with patient well being but not performance at the highest level possible. It also requires an awareness of what constitutes acceptable performance under the circumstances and desire for self-improvement.

Diagnose. Diagnosing means systematically comparing a comprehensive database on the patient with an understanding of dental and related medical theory to identify recognized disease entities or treatable conditions. The concept of diagnosis subsumes an understanding of disease etiology and natural history.

Discuss (communicate, consult, explain, present). A two-way exchange that serves both the practitioner's needs and those of patients, staff, colleagues, and others with whom the practitioner communicates. The conversation, writing, or other means of exchange must be free of emotional or other distorting factors and the practitioner must be capable of expressing and listening in terms the other party understands. [Caution should be exercised with using these verbs to ensure that the communication is between the practitioner and the patient. Communication between the student and faculty is language reminiscent of the old instructional objectives and is not evidence of competency.]

Document. Making, organizing, and preserving information in standardized, usable, and legally required format.

Manage. Management refers to the selection of treatment including: no intervention; choice of specific care providers-including hygienists, and medical and dental specialists; timing and evaluation of treatment success; proper handling of sequel; and insurance of patient comprehension of and appropriate participation in the process. In circumstances where the graduate may perform some treatment but is more likely to oversee treatment or refer, the term "manage" is used. In situations where it is expected that practitioners will be capable of and likely to provide treatment as well as oversee it, the terms "treat", "provide", or "perform", will be used.

Monitor. Systematic vigilance to potentially important conditions with an intention to intervene should critical changes occur. Normally monitoring is part of the process of management.

Obtain (collect, acquire). Making data available through inspection, questioning (patients, physicians, relatives), review of records etc., or capturing data by using diagnostic procedures. Health histories, radiographs, casts, and consults are obtained. It is always assumed that the procedures for obtaining data are performed accurately so that no bias is introduced, are appropriate to the circumstances, and no more invasive than necessary, and are legal.

Patients With Special Needs. Those patients whose medical, physical, psychological, or social situations make it necessary to modify normal dental routines in order to provide dental treatment for that individual. These individuals include, but are not limited to, people with developmental disabilities, complex medical problems, and significant physical limitations.

Perform (conduct, restore, treat). When a procedure is performed, it is assumed that it will be done with reasonable speed and without negative unforeseen consequences. Quality will be such that the function for which the procedure was undertaken is satisfied consistent with the prevailing standard of care and that the practitioner accurately evaluates the results and takes needed corrective action. All preparatory and collateral procedures are assumed to be a part of the performance.

Practice. Used to describe a general habit of practice, such as "practice consistent with applicable laws and regulations."

Prepare (see perform).

Present (see discuss).

Prevent [the effects of]. The negative effects of known or anticipated risks can be prevented through reasonable precautions. This includes understanding and being able to discuss the risk and necessary precautions and skill in carrying out the precaution. Because preventing future damage is of necessity a response to an internalized stimulus rather than a present one, additional emphasis is placed on supportive values.

Proficiency. A level of practice that exceeds competency. Proficiency entails slightly greater speed and accuracy of performance, ability to handle more complicated and unusual problems, and problems presenting under less than ideal circumstances, and greater internalization and integration of professional standards.

Provide care (see perform).

Recognize (differentiate, identify). Identify the presence of an entity or pattern that appears to have significance for patient management. Recognition is not as broad as assessment -- assessment requires systematic collection and evaluation of data. Recognition does not involve the degree of judgment entailed by diagnosis. [Caution is necessary with these terms. They are often use in the old instructional objectives literature to refer to behavior students perform for instructors. They can only be used for competencies when practitioners recognize, differentiate, or identify for patients or staff.]

Refer. A referral includes determination that assessment, diagnosis, or treatment is required which is beyond the practitioner's competency. It also includes discussion of the necessity for the referral and of alternatives with the patient, discussion and cooperation with the professionals to whom the patient is referred, and follow-up evaluation.

Restore (see perform).

Skill. The residual performance patterns of foundation skills that is incorporated into competency. The importance of the skill is more than speed and accuracy: it is the coordination of performance patterns into an organized competency whole.

Treat (see perform).

Use. This term refers to a collateral performance. In the course of providing care, precautions and specialized routines may be required. For example, infection control and rapport building communication are used. Understanding the collateral procedure and its relation to overall care is assumed. It is often the case that supporting values are especially important for procedures that are needed -- they are usually mentioned specifically because their value requires reinforcement. ["Utilize" is a stylistic affectation that should be avoided.]

Understanding. The residual cognitive foundation knowledge that is incorporated into competency. Understanding is more than broad knowledge of details: it is organized knowledge that is useful in performing the competency. [Caution should be used with this term. Understanding alone is not a competency; it must be blended with skill and values.]

Values. Preferences for professional appropriate behavior in the absence of compelling or constraining forces. Values can only be inferred from practitioner's behavior when alternatives are available. "Talking about" values reflects a foundation knowledge; valuing can be inferred by observing the practitioner's attempts to persuade others. [Caution should be used with this term. Valuing alone is not a competency; it must be blended with skill and understanding.]

References

1. Chambers DW, Gerrow JD, Manual for developing and formatting competency statements. J Dent Educ 1994;58:361-6.