REVIEW

OSCE based assessment of three commonly performed pediatric dentistry procedures.

Abstract
Assessment holds the key to the entire learning process. Assessment is one of the defining features of students approaches to learning. Types of evaluation or assessment tend to determine students approaches to learning. Assessment needs to be valid, reliable and reproducible. The traditional methods of assessment have been challenged. Dissatisfaction has been expressed over their validity and reliability. Several new methods and tools are now available, the use of which requires special training. The need of the hour is to adopt academic practices that are in consonance with those prevailing in the developed countries. This paper suggests an Objective structured clinical evaluation (OSCE) based assessment of three commonly performed pediatric dentistry procedures Key words: Assessment; OSCE; Dental education

1. Dr. Praveenkumar S. Mandroli, MDS Professor, Dept of Pedodontics & Preventive Dentistry Maratha Mandals Nathajirao G Halgekar Institute of Dental Sciences & Research Centre, Belgaum-10. Karnataka state, India

Author for Correspondence: Dr. Praveenkumar S. Mandroli, MDS Professor, Dept of Pedodontics & Preventive Dentistry Maratha Mandals Nathajirao G Halgekar Institute of Dental Sciences & Research Centre, Belgaum-10. Karnataka state, India e-mail: [email protected]

Introduction
Assessment is crucial in the learning process of students (1). As Brown and Knight (2) stated, Assessment is at the heart of the student experience. In general, one can define the process of assessment as taking a sample of student work, making inferences from it and then estimating his/her worth in terms of marks or grades (1 5). The nature of assessment tasks influences the approaches to learning which students adopt (6, 7). Newble and Jaeger (8) described how changing clinical assessment in the final year from a pass/fail system based on ward reports, to a clinical practical examination increased the time spent by medical students on the wards. Thus, change in assessment method may be used to improve the quality of education (4, 5). To enhance assessment and to provide a greater degree of objectivity and consistency in clinical assessment Harden (1975) developed an Objective Structured Clinical Evaluation (OSCE) and implemented this form of clinical assessment into the curriculum (9, 10). The purpose of this paper is to address some aspects of limitations of clinical training and evaluation of clinical skills in the current traditional teaching and assessment system and suggest OSCE based assessment for three commonly performed pediatric dentistry procedures. Assessment methods in dentistry Assessment has an important influence on students learning. Entwistle and Entwistle (11) acknowledged that, the nature of student learning in turn is very closely related to the students approach to learning. Marton and Slj(12) and Ramsden(13) stated that the way in which a student thinks about learning and studying, determines the way in which he tackles assignments and evaluation tasks. Conversely, the learners experience of evaluation and assessment determines the way in which the student approaches (future) learning. Assessment is thus logically, but also empirically, one of the defining features of students approaches to learning.
64 IJCDS been NOVEMBER, 2010 1(1) that 2010 Int. Journal of Clinical Dental Science It has widely accepted both assessment of student performance and clinical competence, along with the measurement of knowledge, should contribute to the

the defining features of students approaches to learning. It has been widely accepted that both assessment of student performance and clinical competence, along with the measurement of knowledge, should contribute to the students' overall evaluation. As rightly pointed out by Plasschaert et al (14) dentistry is a profession that requires a broad understanding of a diverse spectrum of healthcare and basic sciences together with specific education in oral sciences. In preparation for graduation, students must demonstrate a variety of acquired learning outcomes, which in turn demand variety in learning and teaching methods. In order to educate a dentist to become competent, learning and teaching methods should be based on educational need. Undergraduate dental education aims to produce safe, competent and ethical practitioners equipped with the necessary knowledge, skills and behaviours (attitudes) appropriate to the safe, effective and independent practice of dentistry. Plasschaert et al (14) also emphasize that all assessment procedures should be timely, meaningful and appropriate. They should be based upon the learning outcomes of the individual programme / course, so that academic and clinical student activity is directed towards those desirable outcomes. It is a truism that assessment drives learning, so all dental schools should be encouraged to articulate clearly their assessments in a transparent manner, so that students and staff are fully informed of the purposes and processes adopted.

Different assessment methods tend to assess various skills and competences. Table 1 shows assessment tools for various skills. Assessment of clinical competence of students in dentistry Goldstein (15) stated that dentistry is a respected and rewarding profession based on an educational experience that values (a) putting the patients needs first, (b) striving for excellence, (c) not worrying about speed because that comes with experience, and (d) taking care of patients. These factors have been a formula for success, yet we see that graduates today are demonstrating didactic knowledge without clinical acumen. The problem must be addressed if there are to be skilled, knowledgeable clinicians available to treat the needs of patients with respect to oral health. Goldstein (15) also emphasized that dentistry is still a surgically based profession that requires good hand skills, well trained perceptual skills, and psychomotor mastery, Clinical educators know that the circuits need to be trained, even for students who have a natural aptitude for hand skills. For the dental student, the acquisition of clinical competence is of supreme importance. Hence a teaching and assessment method which emphasizes clinical competence is extremely vital. Apparently, traditional written examinations test a different kind of knowledge from that acquired during clinical attachments. Clinical experience may be better judged by the clinical supervisor than by assessment of theoretical knowledge. A good assessment of students should include both clinical skills and factual knowledge, therefore an OSCE should be complemented by other methods of evaluation. Assessment tools suggested SEQ, SAQ, MCQs (testing higher abilities and problem solving) OSCE/OSPE OSCE/ Structured case viva OSCE, Structured viva OSCE Stations, Simulated cases (real/paper), checklist, logbooks

Skills Intellectual Skills

Procedural skills Clinical skills Communication skills Attitude, Behavioral and Ethics

Table-1 Assessment tools for various skills

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should include both clinical skills and factual knowledge, therefore an OSCE should be complemented by other methods of evaluation. The steering effect of examinations is well known. "Steering effect" means that students learn best those subjects on which they expect to be examined (16-19). This effect should be taken into account when evaluating students. The Objective Structured Clinical method of examination (OSCE), for example, whilst no universal remedy for clinical assessment in dentistry, has many attributes that advocate its acceptance and implementation for the teaching and assessment of procedural skills (e.g. clinical skill assessment or infection control). An OSCE is not intended to be the single method for clinical evaluation. More traditional methods such as written (essay-type or multiple choice questions) and oral exams should be used as complementary modes of assessment. Since students are not taught/examined systematically on core clinical procedures in chair-side teaching/assessment objective structured clinical examinations (OSCE) should be the regular for clinical skills assessment. The objective structured clinical examination (OSCE), first introduced by Harden et al, has been in use in many medical schools throughout the world (20-26). In addition to assessing the competency and performance of the learners, the OSCE has many advantages over more traditional methods of evaluation such as the conventional chair-side examination. As an evaluation tool it eliminates the luck of the draw, reduces variation in marking standards from examiner to examiner, and can accurately reflect the real-life tasks of the doctor. Also, in traditional method of clinical assessment the student is "presumed" to have recorded the necessary history and performed clinical examination and the examiner sees only the results of that history and clinical examinations on paper. It is not uncommon that a student cannot perform a properly focused clinical examination of the patient, even if he or she claims to have done a complete clinical examination. For this reason it is necessary to directly measure competencies through performance examinations. Traditional Assessment The current clinical teaching of students in dentistry has some problems, especially with regard to the teaching of clinical skills. There are problems in two areas: (a) lack of observation and opportunity to give feedback to students when they perform the procedures on patients; and (b) assessment. Although a lot of time is devoted to the teaching of clinical skills, most students learn and practice by themselves.

The clinical discussions which is a routine form of clinical training, are primarily an opportunity for the faculty to ask questions to the students to see how they are progressing with regard to their knowledge in that particular subject, but not necessarily their clinical competencies. There is nothing much wrong with this mode of teaching, which is a form of "apprenticeship training," other than the students usually are not observed while taking a history and performing a complete clinical procedure. This means that there is no opportunity for giving feedback to them. Many students perceive traditional assessment tasks as arbitrary and irrelevant. This does not make for effective learning, because they are only aimed to learn for the purposes of the particular assessment, with no intention of maintaining the knowledge in any long-term way. Normal assessment is seen as a necessary evil that allow the students to accrue marks. The accompanying activities are described in terms of routine, dull artificial behaviour. Traditional assessment is believed to be inappropriate as a measure, because it appeared simply to measure memory, or in case of essay-writing tasks, to measure ability to marshal lists of facts and details. Alternative assessment is believed to be fairer, because by contrast, it appears to measure qualities, skills and competences which would be valuable in contexts other than the immediate context of assessment. Need to change? Teaching is a demanding and complex task. According to Srinivas and Adkoli (26), as George Miller observed, It is curious that so many of our most important responsibilities are undertaken without significant preparation. Marriage, parenthood and teaching (in medical schools) are probably most ubiquitous illustrations. It is necessary for the present day teacher to be aware of and become part of far reaching changes that are taking place in medical education. The changes are: shift from conventional role of teacher, changes in learning styles, innovative curriculum models and changes in assessment philosophy, methods and tools. The traditional methods of assessment have been challenged. Dissatisfaction has been expressed over their validity and reliability. Several new methods and tools are now available, the use of which requires special training. Kemahli (27) concluded, it is currently well accepted that the more a situation in which something is learned resembles a situation in which it is applied, the better the performance. Student learning is probably best facilitated by use of a combination of educational methods that emphasize learning skills and competence rather than provision of knowledge alone.

The more important point of introducing the OSCE as an assessment tool in dentistry for clinical teaching/assessment is to make use of its "steering effect" on student learning. Thus, when the student 66 IJCDS NOVEMBER, 2010 2010 Int. Journal of Clinical Dental Science The clinical discussions which is a routine form of 1(1) bears in mind that he/she will be expected to perform clinical training, are primarily an opportunity for the

2 Sl No. 1 2 3 4 5 Steps Correct Arrangement of the instrument tray Correct Positioning of instruments Correct Chair position Correct Operators position General explanation Tell-Show-Do (T-S-D) general explanation 6 7 Isolation Caries excavation Superficial leathery layer excavated with Spoon excavator Infected dentin excavated with carbide burs Unsupported enamel removed with diamond burs 8 Class II Matrix and wedge placed properly 9 10 Conditioning the cavity Mixing GIC Mixing pad and Plastic spatula used Correct Powder Liquid ratio Mix carried into the cavity when surface is shiny Mix Condensed Post-set high points checked Water insulating medium applied
Yes No

3
1

Sl. No 1

Steps General explanation Tell-Show-Do (T-S-D)/general explanation using age appropriate language given

Yes

No

2 3 4 5 6

Correct arrangement of the instrument tray Correct Positioning of instruments Correct Chair position Correct Operators position Oral prophylaxis Disclosing agent applied Correct finger rest and handling of instruments Plaque removed Polishing done 2.

Topical Fluoride Application T-S-D/general explanation using age-appropriate language given Correct tray selection Isolation (cotton rolls & saliva ejector) Loading of the tray (appropriate amount) Application for 4-minutes

11 12

Post restoration instructions Comments

8 9

Instructions Comments

Sl.no 1 2 3 4 5 6 7

Steps Calculation of local anaesthetic dosage Appropriate needle used Correct chair position Correct Arrangement of the instrument tray Correct Positioning of instruments Correct Operators position Pre-injection Tell-Show-Do / general explanation before putting tooth to sleep

Yes

No 10 11 Post Injection T-S-D/age-appropriate language describes sensation Extraction Tell-Show-Do/ general explanation Correct selection of the forceps Correct Extraction movements 12 13 14 Bleeding controlled & Guaze pack placed Post extraction instructions Comments-

T a b l e 4 L o c a l a n a e s t h e s i a

Topical Application T-S-D/general explanation using ageappropriate language given Mucosa dried at the site of needle penetration Topical anaesthetic applied to site of needle penetration Cover topical anaesthetic with gauze Wait 1 min before injecting

Table-2 Glass ionomer Cement restoration Table-3 Oral Prophylaxis & Fluoride Application Table-4 Local anaesthesia & Extraction

Injection T-S-D/age-appropriate language Distracts/constantly Under-the-chin transfer of syringe Anesthetizes the buccal Anesthetizes the lingual

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teaching/assessment is to make use of its "steering effect" on student learning. Thus, when the student bears in mind that he/she will be expected to perform well on an OSCE, then he/she will really have to learn the necessary skills. To facilitate teaching and assessment of clinical skills which is valid, reliable and reproducible OSCE as suggested in Tables 2 (Oral Prophylaxis & Fluoride Application), 3 (Glass ionomer Cement restoration), and 4 (Local anaesthesia & Extraction) can be routinely used. These three procedures are commonly performed by the students during their undergraduate training in most institutes. Conclusion Considering that the present clinical training of undergraduate students in dental institutes, incorporation of OSCE based teaching/assessment along with traditional methods can be strongly considered. This will result in (a) a well designed program involves observation and giving feedback to students for clinical skills when necessary. And (b) ensuring that students acquire appropriate behavior and skills using the steering effect of examinations. Boud (28) concluded that assessment methods and requirements probably have a greater influence on how and what students learn than any other single factor. This influence may well be of greater importance than the impact of teaching materials. Thus, objective structured clinical examinations, which are used extensively in most U.S. and Canadian medical schools, should be one of our evaluation methods. References: 1. 2. 3. 4. 5. 6. 7. 8. Brown G, Bull J, Pendlebury M. Assessing student learning in higher education. London: Routledge;1997. p. 720. Brown S, Knight P. Assessing learners in higher education. London: Kogan;1994. p. 9 42. Boud D, Enhancing learning through self-assessment. London: Kogan; 1995. p. 3647. Rowntree D, Assessing students how shall we know them. London: Kogan; 1987. p. 111. Gibbs G, Improving the quality of student learning. Bristol: Technical and Educational Services;1992. Manogue M, Kelly M, Masaryk SB, Brown G. Catalanotto F, Choo-Soo, T.et al. Evolving methods of assessment. Eur J Dent Educ 2002;6:5366. Entwhistle NJ, Styles of learning and teaching. Chichester: John Wiley & Sons;1981. p. 6586. Newble DI, Jaeger K. The effects of assessment and examinations on the learning of medical students. Med Educ 1983;17:2531.

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27. Sabri Kemahli. Clinical Teaching and OSCE in Pediatrics. Med Educ Online [serial online] 2001;6:10. Available at http://www.med-edonline.org/ 28. Boud D. Moving towards autonomy. In: Boud DJ. & Griffin VR, Developing student autonomy in learning. London: Kogan;1988. p. 17-39.

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