Towards standardized clinical training: Developing an integrated clinical curriculum for dental trainees in a hospital of stomatology

Objective In order to standardize the teaching criterion and improve the quality of clinical training between different dental trainees, an integrated clinical curriculum was developed since September 2014 in the Hospital of Stomatology, Fujian Medical University of China. This article aimed to introduce the development of this curriculum and evaluate the dental trainees’ view on the curriculum. A six-step approach was used to develop the curriculum. Dental trainees (n=142) rated the curriculum with satisfaction scores on a Likert-type scale and answered several open-ended questions. One-way ANOVA and Fisher's exact probabilities were utilized to analyzed satisfaction scores among four types of dental trainees. The (out of There was no significant difference in satisfaction scores among four types of dental trainees and between the two genders (P=0.233). 91.55% of the dental trainees reckoned that the was valuable to their There was no significant differences among the four types of dental trainees in standardize their clinical skills training (P=0.828).

The education of dentistry in China began in 1917, but the development was slow until 1980s [1]. From 1980 to 2004, more than 50 dental schools were set up in China. So far, the most common mode of dental education in China is five-year undergraduate education [2], which usually contains 4 years of didactic and laboratory courses and 1 year of fulltime clinical training (clinical internship). After graduating from dental school and at least 1 year of dental clinical practice, the graduates are eligible to take the National Medical Licensing Examination (NMLE). Once pass through the NMLE, he/she will be qualified to practice as a dentist in China [3].
In some western countries, the applicants to the dental school have a bachelor degree with required pre-dental courses from an accredited college [2]. The enrolled dental students have already got some knowledge of biomedical sciences before entering the dental schools. However, due to the historical and cultural reasons, dental schools in China recruit candidates from senior high schools. Therefore, the current Chinese undergraduate dental program requires dental undergraduates to study biomedical sciences in the first three years of university study. Such as Anatomy, Biochemistry, Cell Biology and so on. The dental undergraduate students start their dental curriculum in the fourth year, and receive the clinical training in the fifth year. As a result, the dental undergraduate students in China have much less time to receive professional dental education than dental students in the US or Europe. Therefore, in order to improve the professional skills, continuing education after graduation is increasingly concerned by Chinese dental educators and the government.
There are four types of dental trainees receiving clinical training in Chinese hospitals, including interns, visiting dentists, postgraduates, and residents. Interns refer to the undergraduate students receiving the clinical training in the fifth year of their university study. Visiting dentists refer to the trainees who pursue continuing education in the higher

Development of the curriculum
The curriculum was developed according to six-step approach [6] and described as follows: (1) Problem identification and general needs assessment: The Teaching Department of HSFMU convened dental trainees and instructors several times to conduct a detailed communication and consultation on the problems existing in the clinical training system at that time. As a result, almost all instructors and dental trainees suggested to initiate a clinical curriculum. And like other scholars opinion [7], they insisted that the new curriculum should include several core dental clinical skills.
(2) Target assessment: The proposed clinical curriculum integrates the most important clinical skills in stomatology, aiming at teaching standards, norms, and unified clinical skills. The clinical skills taught in this curriculum were identified based on the current literature and group discussions among the Teaching Committee members of HSFMU. (4) Educational strategies: The curriculum focused on how to execute step-by-step clinical training procedures. The instructors in this curriculum were attending dentists, and had more than 20 years of dental clinical experience. The curriculum was consist of 115 courses (Table 1 near here) and each course was taught once a week on every Thursday evening (60 min for each course). The curriculum was divided into three phases ( Figure 1 near here). The first phase focused on the basic dental clinical knowledge, such as Periodontology, Endodontics, Oral Maxillofacial Surgery and Oral Mucosal Disease. The second phase was the advanced dental clinical knowledge, including Prosthodontics, Pedodontics, Orthodontics and other related courses. The third phase was a comprehensive application of the previous two phases, including Oral Implantology and Oral Multidisciplinary diagnosis and treatment. All the dental trainees in HSFMU were required to attend this integrated curriculum.
(5) Implementation: To ensure that the contents of the curriculum are the latest and most standardized knowledge, avoiding the irregular teaching caused personal factors of lecturing expert, the contents of the integrated clinical curriculum was internally peer reviewed [8] and finally approved and implemented by the Teaching Committee of HSFMU.
(6) Evaluation and feedback: This integrated clinical curriculum was a new attempt and exploration of dental clinical education in China. After being executed for more than three years, the integrated clinical curriculum was evaluated through an anonymous questionnaire survey with the aim to obtain feedback from dental trainees.

Survey of the curriculum
The study was approved by the Ethics Committee of HSFMU (Grant number: 2017-Res-052). A self-administrated questionnaire ( Table 2 near here) was used to conduct an anonymous survey to the trainees. The trainees were informed that participation was not compulsory and refusal to take part would not disadvantage to them. But the trainees were encouraged to take part in the survey and informed that their comments are crucial to improve the curriculum. The questionnaire included 5 single-choice questions, an openended question, and the satisfaction scores using a Likert-type scale of 1 (very dissatisfied) to 10 (extremely satisfied).
One-way ANOVA was utilized to compare difference between satisfaction scores rated by the four types of dental trainees. Two independent sample t-test was used to analyze whether the trainees of different genders had different satisfaction scores on the curriculum. Fisher's exact probabilities was employed to evaluate the different comment of different types of trainees on whether the curriculum is helpful for them to promote and standardize their clinical skills learning. All analyses were performed using R (version 3.1.1). P<0.05 was considered statistical significance.

Results
The integrated clinical curriculum of Clinical Knowledge in Oral Medicine was developed in September 2014. The contents of the curriculum focused on the diagnosis and treatment steps for specific cases. Lecturers use PowerPoint slides to display pictures of clinical treatment steps and explain the key points and relevant theoretical knowledge of each treatment step to dental trainees. 58 male and 84 female dental trainees completed the survey, and the response rate was 100%. The satisfaction scores of the trainees are shown in Table 3 (Table 3 near here) with a mean satisfaction score of 7.96 (out of 10). The statistics on whether the curriculum is helpful for trainees to promote and standardize their clinical skills learning are shown in Table 4 ( Table 4 near here). 91.55% of the trainees reckoned the curriculum was "Very Helpful" or "Helpful" to promote and standardize their clinical skills learning.
One-way ANOVA showed there was no significant difference in satisfaction scores among the four types of dental trainees (Table 5 near here, F=1.53, P=0.209). In terms of different gender, males have similar satisfaction scores with females (Table 6 near here, t=1.20, P=0.233). Furthermore, no significant differences was found among four types of trainees on whether the curriculum is helpful to promote and standardize their clinical skills learning for them (P=0.828).
As for the question of "How often do you think it is appropriate for the curriculum?", 46 (32.39%) trainees chose "once a week", 90 (63.38%) trainees chose "once every two weeks", and 6 (4.23%) trainees chose "once every four weeks". Regarding the question of

Discussions
In the past decades, Chinese government has taken a lot of measures to improve the quality of medical care, while the personnel training is one of the most important measures [9]. As a task of cultivating the clinical skills of medical talents, Chinese hospitals focused on continuously improvement of the clinical training methods, such as the training skill of clinical instructors, the management of clinical training processes, and the assessment of teaching effectiveness.
Generally speaking, clinical training process emphasizes a personalized one-to-one instruction to guide trainees in a targeted manner based on their personal characteristics [10].In the daily clinical training process, Teaching Committee of HSFMU also pays attention to the personalized teaching of the trainees' personal characteristics, and encourages the clinical instructors to carry out clinical training according to the trainees' knowledge background, understanding ability and personal characteristics. However, due to historical reasons and the large population of China, the ratio of the number of dentists to the population is still significantly lower than that of developed countries [1]. The clinical instructors in the Chinese hospitals not only need to guide clinical training of trainees, but also need to bear the heavy clinical work and scientific research work. Therefore, the standardized clinical training and personalized teaching time for clinical instructors is limited. Moreover, the personalities of clinical instructors are different from each other, and clinical instructor's different characteristics also affects clinical teaching effectiveness [11,12].Therefore, although there are personalized, group-style lectures in clinical training process, it is difficult to achieve complete standardized, unified clinical training effectiveness. It had revealed that the lack of standardization occurs, resulting in discrepancies among training effectiveness [13]. Thus, the unity of clinical training process is important in dental clinical education [14]. In addition, dental trainees need to undergo a range of complex competency training, including theoretical knowledge, clinical experience, critical thinking, and problem solving [15]. What's more, Albino [16]reported that increasing the teaching of relevant clinical knowledge courses in clinical training can promote trainees' memory, enhance relevant knowledge, and help trainees develop critical skills by applying critical thinking and problem-solving skills. Based on these backgrounds, the integrated clinical curriculum, with an aim of standardize and unified the clinical training process and improve the quality of clinical training, was developed.
According to the statistical results, the dental trainees reckoned that the curriculum was valuable for their clinical skills learning. There was no significant difference in the satisfaction scores between the four types of trainees (P=0.209) and between the two genders (P=0.233), and the mean satisfaction score of all the trainees was 7.96 (out of 10). According to previous study, this mean satisfaction score can be considered as "very good" (85 to 75 percent) [17]. As for the whether the curriculum was helpful to promote and standardize clinical skills learning for trainees, 91.55% of the trainees reckoned the curriculum was "Very Helpful" or "Helpful". These results mean that although the four types of trainees had different knowledge background and clinical experience, they showed a positive attitude towards the integrated clinical curriculum.
There might be some explanations for this phenomenon. First of all, as mentioned above, due to the short study time of professional dental courses during their university periods, all four types of trainees mainly receive the education of theoretical knowledge of stomatology, but rarely receive professional and standardized clinical skills education during university period. Secondly, this was a novel teaching method for dental trainees in China, especially the analysis and explanation of the specific medical treatment steps of specific cases, which has practical significance for standardizing and promoting trainees' clinical diagnosis and treatment. Compared with the pure theoretical teaching, this teaching method is more interesting and more attractive to trainees. The satisfaction scores obtained partially support this hypothesis. Thirdly, careful preparation and standardized teaching for experienced lecturers is an important reason for the trainees to welcome the curriculum. Because the lecturer is one of the decisive factors in the quality of curriculum [18]. Fourthly, some relevant and advanced courses were included, such as how to deal with medical disputes, and medical disputes have gradually increased in China in recent years [19,20]. Last but not the least, during the curriculum developing, the Teaching Committee of HSFMU had extensively solicited opinions and suggestions from trainees, and the trainees' requirements have been reflected in the curriculum. The active participation of students can fully mobilize their enthusiasm [21]. The fact that some junior dentists in the HSFMU and dentists from nearby clinics volunteered to attend the curriculum also verified that the curriculum was well designed and welcomed. Moreover, the passing rate of NLME of dental trainees enrolling in HSFMU in recent years has almost reached 100%, while the average passing rate of NLME is less than 40%. And the number of trainees who have won awards in various clinical skills competitions has also increased in recent years. Therefore, although group-based lectures have proven to be an effective way of teaching [22,23],this standardized integrated clinical curriculum was popular among dental clinical trainees in China. However, there was still a small number of trainees commented satisfaction score of 6 (out of 10) on the curriculum and chose "general" as the answer on "whether the curriculum is helpful to promote and According to trainees' suggestions and the results of survey, since January 2018, the frequency of the curriculum has been adjusted to once every two weeks, and the lecturers were informed to exhibit more pictures to describe more specific details of the clinical treatment in the course.
Many dental educators believe that there is a lack of effective articulation between traditional theoretical education and practical teaching, and emphasize the concept of integrated dental education [24]. Integrating theoretical knowledge of dentistry and clinical skill education is highly regarded by several researches [25][26][27]. The integrated clinical curriculum of Clinical Knowledge in Oral Medicine covers all clinical branches of dentistry and integrated the clinical skills. This is in line with the integration of the dental education curriculum promoted by the Institute of Medicine [28]. It is necessary to provide relevant theoretical courses for clinical intern students [29]. Therefore, this integrated clinical curriculum was a beneficial attempt to improve the quality of dental clinical training and suitable for Chinese dental trainees. The curriculum may also be suitable for some other developing countries, such as India.

Strengths and limitations
The integrated clinical curriculum initiate a new standardized and unified clinical training methods for dental trainees. The main limitations of present study is that there was a lack of investigation of the instructors. The instructors can objectively and directly evaluate the degree of improvement of the trainees' clinical skills because they are in direct contact with the trainees. Therefore, the survey to instructors should be carried out in the future.

Conclusions
The present findings suggest that the dental trainees appreciated the integrated clinical      Figure 1 The structure of the Integrated Clinical Curriculum