Fighting middle age spread is always a problem. Through the years, the curriculum has grown through the expansion of our course content and the addition of new courses. This "bloating" of the curriculum was due to an explosion of knowledge (to keep pace with fast changing technological advances and its impact on treatment modalities) and to individuals' pet interests. This expansion has occurred over the years without a comprehensive review of the degree to which the current curriculum meets the faculty's mission and goals. Consequently, despite the bloat in curriculum content, questions have been raised about inadequate coverage of certain topics, topics taught out of sequence and the heavy clinical and laboratory workload in the dental course.

In 1995, the curriculum review committee was given the task of reviewing the current curriculum and making recommendations for a new curriculum to be implemented in 1997. The curriculum review committee consists of academics from the faculty, a general practitioner and a representative from the Ministry of Health.

New Directions

Starting from scratch, planning a zero-based curriculum would be ideal. However, in an established dental school, there are limitations in organisational structure, human resources and central administrative policies. These constraints were considered when formulating our recommendations.

The committee first reviewed the faculty's existing educational goals and objectives to ensure that they are in line with the needs of the profession and society. Disease patterns, health care and social needs were taken into consideration.

When our goals and objectives were translated into an educational programme, it was evident that the new curriculum must be both patient and student-centred, rather than the current discipline-based curriculum. Comprehensive and preventive patient care must be emphasised. Students have to become critical thinkers rather than consumers of information. The knowledge we impart to students has to be more integrated and multidisciplinary in nature, rather than isolated bits of information, which is the product of traditional discipline-based teaching. We felt that a competency-based didactic and clinical curriculum would decrease the problem of "knowledge overload" and facilitate the student's progress in his/her clinical work.

In the course of two years, the committee met with deans from various dental schools from Australia, the United Kingdom and the United States. We also visited four dental schools in the United States and one in Canada to study their curriculum as well as their research activities and use of information technology. These visits confirmed the new directions recommended by the committee.

Competency-based curriculum

Competencies are the basic skills essential to the practice of dentistry. They combine the appropriate supporting knowledge and professional attitudes for clinical procedures to be performed reliably, without assistance.

Our current discipline-based curriculum has bloated the dental curriculum and predisposed students to a mechanistic approach to learning. This curriculum offered no help in drawing the line between what is necessary to know and what is merely "nice" to know. Education is a path, not a destination and not the accumulation of nuggets of knowledge or the repertoire of skills. Competency represents the point along this path where the learner understands the foundations of his/her skills, has internalised appropriate professional values to work independently in normal settings and manages his/her own continued growth.

Our challenge was to develop a competency statement that would define the knowledge, skills and attitudes new dental graduates should possess. This statement became our standard for defining the core curriculum and allowed us to assess outcomes and audit the curriculum content. Course coordinators then drew up their syllabi listing the supporting competencies, foundation knowledge and skills required to reinforce the main competencies.

Requirements for clinical and technical training have always been based on the number of units or pieces of work completed. Students chased their schedule of requirements and patients became a unit of work. This was undesirable but inevitable with traditional training. Another problem with the system is that it did not assess competency. Therefore, the faculty will radically change the traditional schedule of requirements to one of acquiring specific clinical competencies. Students will be required to take competency tests for various procedures, rather than just complete a predetermined number of procedures. The burden of completing a clinical schedule is removed and the amount of work individualised, allowing better students to progress at a faster rate and weaker students to be identified and given remedial help if necessary.

Problem-based learning

One of our faculty's objectives is to provide students with skills to continue learning beyond dental school; that is, to be lifelong learners. The problem-based learning (PBL) concept was designed to encourage students to assume personal responsibility for their learning and to emphasise learning in the context of real situations rather than organised bodies of knowledge. Once the student has mastered the learning process, he or she is equipped to be a lifelong learner. This teaching method shifts from the traditional teacher-centred approach to one that is student-centred. The teacher's role changes to that of a facilitator who stimulates interest in the learning process. With PBL, students are forced to take a proactive role in the educational process.

True PBL courses, however, require far more time and resources, both in terms of manpower and physical resources, than currently practicable. Instead, the faculty decided to modify this teaching concept to one of "case-based learning". Case-based tutorials are meant to integrate knowledge obtained from various disciplines and to reinforce the basic science behind clinical problems. This approach has the added advantage of reinforcing the basic sciences throughout the course.

The concept of integrating various subjects is important. Students tended to compartmentalise their learning because the subjects were taught independently. In addition to integrating subjects through clinical cases, the new curriculum contains more integrated courses like oral biology, radiology, cardiology and behavioural sciences. Multidisciplinary seminars will also be implemented. Other teaching methodologies designed to improve independent learning will be introduced, including self-paced learning packages and interactive multimedia computer-based teaching.

Effecting change

Traditional dental education has had its success and this makes it even more difficult to change old notions. Faculty members may want to justify the past, a source of their pride and self-esteem. Some believe "if it ain't broke, don't disturb it".

This reminds me of the book The Saber-Tooth Curriculum by J. A. Peddiwell. In the early Palaeolithic Age, an ingenious man named New Fist devised a system of education to teach children to find food, clothe themselves and find security. The New Fist curriculum included three subjects: fish grabbing, horse clubbing and tiger scaring. Over the years, the school became very efficient at teaching these relevant subjects. The children were trained and the tribe prospered. After many years, the Ice Age approached and environmental changes occurred. The waters became muddy and people could no longer see the fish to grab them. The forests became too wet; the horses went east and fast antelopes came instead. The air became damp and the saber-tooth tigers died of pneumonia; they were replaced by black bears that were not afraid of fire. There was no fish for food, no hide for clothing and no security from hairy death. A few practical men of the "New Fist breed" soon learnt to adapt. They made nets for fishing, snares for antelopes and pits for bears. But the schools continued to teach fish grabbing, horse clubbing and tiger scaring. "Why aren't the new skills we need taught in our schools?" the radicals asked. The wise educators replied, "If you had any education yourself, you would know that the true essence of education is timeless. It is something that endures like a rock through changing conditions and the saber-tooth curriculum is one of them." As time went on, instructional material became less and less relevant and the tribe was beset with many problems and, eventually, they were overrun by the adjoining tribe whose outlook was more pragmatic.

One of the most important factors in our review process was strong leadership. The leadership directed change and, more importantly, supported it. In our faculty's experience, which will probably be similar in other faculties, there are always those resistant to change. Strong leadership is required to break the tyranny of the old culture, the frame of dysfunctional assumptions. A supportive "working group" ready for change became invaluable in convincing the faculty that the committee's recommendations for change are essential.

Outside counsel can also be invited to present new concepts to the faculty. Those who are not ready for change were still invited to contribute as resource persons for their specialist knowledge. Of course, it is always great to have unanimous agreement, but real life is never ideal. We just have to move on.

Training may be necessary to make change effective (e.g., staff may need training in new teaching methodologies or techniques) and this must be supported by the administration. At our faculty, eight staff were trained in conducting PBL tutorials by an instructor from the United States. Finally, it may be necessary to change the faculty's physical structure (e.g., to make more rooms for small group teaching sessions) and even its organisational structure.

As educators it is our responsibility to not only impart knowledge, but also to respond to change as the profession evolves and to recognise changing trends, envision the future and prepare our students to meet tomorrow's challenges. I have shared our faculty's review process and some changes that we are going to effect. The acid test is in implementing the new curriculum!

References

• H. T. Howell and K. Mattlin, "Damn the TorpedoesInnovations for the Future: The New Curriculum at the Harvard School of Dental Medicine," Journal of Dental Education 1995, 59: 893­898.
• H. L. Dreyfus and S. E. Dreyfus, Mind over Machine, New York: The Free Press, 1986.
• P. Benner, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, New York: Addison-Wesley, 1984.
• R. E. Snow, "Toward Assessment of Cognitive Structures in Learning," Educational Researcher 1989: 18: 8­14.
• D. W. Chambers and M. Ed, "Toward a Competency-Based Curriculum," Journal of Dental Education 1993, 57: 790­793.
• E. M. Libert, "Effecting ChangePrinciples for the Process," Journal of Dental Education 1996, 60: 433­440.
• D. A. Nash, "It's Time to Launch a Counter-Cultural Movement," Journal of Dental Education 1996, 60: 422­432.
• J. A. Peddiwell, The Saber-Tooth Curriculum, McGraw Hill, New York, 1939.