Competency in Clinical Reasoning: Construct Validity of Current Assessment Methods

Objectives: To present views of dental educators from three dental schools on the validity of current assessment methods for competency in clinical reasoning, and their suggestions on incorporating a conceptual framework to improve these assessments.
Methods: Open-ended interviews were conducted with thirty dental educators whereby they reflected on their views of current assessment methods used to evaluate competency in clinical reasoning and how a new model of clinical reasoning could improve these assessments. All interviews were transcribed verbatim and analyzed, deductively and inductively, using the qualitative data analysis software NVivo.
Results: As stated by all educators, competency in clinical reasoning is an ongoing process that extends beyond pre-doctoral dental education. The main objective of current competency assessments in dentistry is to determine students’ readiness to practice as “safe and minimally competent” dentists. Multiple choice questions and daily clinical evaluations are the most commonly used methods, with emphasis on knowledge recall and performance of technical procedures. Often overlooked in assessments are the reasoning strategies for incorporation of mid- and up-stream psychosocial determinants of oral health in diagnosis and treatment planning. The most challenging reasoning strategies to assess include part-whole, narrative, pragmatic, and ethical reasoning. The current “piecemeal” approach to competency assessment fails to evaluate students’ abilities to integrate all strategies of clinical reasoning. To improve the validity of competency assessment in clinical reasoning, triangulation of scenario-based written and oral examinations with objective structured clinical examinations and daily evaluations of students’ interactions with patients are required.
Conclusions: Competency assessment in clinical reasoning requires a comprehensive and continuous approach. Students’ competency in integration of reasoning strategies and application of the biospcyhosocial determinants of oral health can be improved by daily formative assessments in authentic clinical situations, feedback, and reflection in- and on-action.