Approaching Training-Practice Gaps After the Transition: A Practice Proposal for Supervision After Training

Evaluation of dental students and alumni's confidence level in orthodontic diagnosis and treatment-planning: A qualitative study

BACKGROUND

Orthodontic education, besides some other factors, influences the confidence level of recently graduated dentists to diagnose subjects seeking orthodontic treatment and provide treatment plans. This study aims to explore the factors that influence the confidence level of undergraduate dental students to diagnose subjects seeking orthodontic treatment and provide treatment plans after graduation.

METHODS

A qualitative study was undertaken using focus groups and interviews. Purposive sampling was used, focus groups and face to face semi-structured interviews were adopted as the method of data collection. Three focus groups were evaluated including fifth-year undergraduate, postgraduate orthodontic students, and recently graduated general dentists. In addition, eleven interviews were performed with the fifth-year undergraduate students. Data collection ceased upon reaching data saturation, with thematic analysis employed for qualitative data analysis.

RESULTS

Six themes and two sub-themes were extracted from the data. More focus on the theory was highly noticed, and most of the participants exhibited a low level of self confidence in extrapolating orthodontic diagnosis and establishing treatment plans after graduation. In addition, they believed that practical teaching sessions mostly deal with wire bending and demanded to expand the clinical orthodontic knowledge to be able to indicate the right diagnosis and initiate proper treatment plans.

CONCLUSIONS

Clinical and practical training alongside theoretical foundation represent key factors in orthodontic education required to obtain confidence in orthodontic practice among dental undergraduate students and alumni. The findings help in enhancing undergraduate programs via providing a clinically oriented orthodontic education from student perceptions.

Towards a flexible and personalised development of veterinarians and veterinary nurses working in a companion animal referral care setting

In the Netherlands, the demand for veterinarians and veterinary nurses (VNs) working within referral care is rapidly growing and currently exceeds the amount of available board-certified specialists. Simultaneously, a transparent structure to guide training and development and to assess quality of non-specialist veterinarians and VNs working in a referral setting is lacking. In response, we developed learning pathways guided by an entrustable professional activity (EPA) framework and programmatic assessment to support personalised development and competence of veterinarians and VNs working in referral settings. Between 4 and 35 EPAs varying per discipline (n = 11) were developed. To date, 20 trainees across five disciplines have been entrusted. Trainees from these learning pathways have proceeded to acquire new EPAs in addition to their already entrusted set of EPAs or progressed to specialist training during (n = 3) or after successfully completing (n = 1) the learning pathway. Due to their outcome-based approach, the learning pathways support flexible ways of development.

Medical competence as a multilayered construct

BACKGROUND

The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment.

THE MODEL

Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different.

IMPLICATIONS

The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.

Transdisciplinary entrustable professional activities

Healthcare has become highly specialized. Specialists, in medicine as well as in nursing, determine much of the high quality of current health care. But healthcare has also become increasingly fragmented, with professionals trained in separate postgraduate silos, with boundaries often difficult to cross. While a century ago, generalists dominated patient care provision, now specialists prevail and risk becoming alienated from each other, losing the ability to adapt to neighboring professional domains. Current health care requires a flexible workforce, ready to serve in multiple contexts, as the COVID-19 crisis has shown.The new concept of transdisciplinary entrustable professional activities, EPAs applicable in more than one specialty, was recently conceived to enhance collaboration and transfer between educational programs in postgraduate nursing in the Netherlands.In this paper, we reflect on our experiences so far, and on practical and conceptual issues concerning transdisciplinary EPAs, such as: who should define, train, assess, and register transdisciplinary EPAs? How can different prior education prepare for similar EPAs? And how do transdisciplinary EPAs affect professional identity?We believe that transdisciplinary EPAs can contribute to creating more flexible curricula and hence to a more coherent, collaborative healthcare workforce, less determined by the boundaries of traditional specialties.

Would I Trust or Will I Trust? The Gap between Entrustment Determinations and Entrustment Decisions for Trainees in Pharmacy and Other Health Professions

Entrustable Professional Activities (EPAs) and entrustment decision making are rapidly becoming mainstream in competency-based education in the health professions. EPAs are the units of professional practice to entrust graduates with once they have developed the required competencies. They were conceived to enable a gradual increase in professional autonomy during training, by allowing trainees to practice activities in which they have demonstrated they have mastered well, with decreasing supervision. However, practicing health care unsupervised generally requires licensure. The question for pharmacy education, as well as for undergraduate medical education, is can students be given any autonomy in practice, even when they have fully mastered an EPA yet remain unlicensed? While entrustment decisions for licensed practitioners have autonomy consequences, some educators in undergraduate programs speak of 'entrustment determinations', to avoid decisions about students that affect patient care, in other words saying, we would trust you, rather than we will trust you. However, graduating learners without the experience of responsibility and reasonable autonomy creates a gap with full practice responsibilities, which may jeopardize patient safety after training. What can programs do to retain the power of using EPAs while at the same time guarding patient safety?