Competency model for dentists in China: Results of a Delphi study
Competency model for dentists in China: Results of a Delphi study
Yunxia Geng 0 1
Liying Zhao 0
Yu Wang 0
Yiyuan Jiang 0 1
Kai Meng (KM 0 1
Dongxiang Zheng 0
0 Editor: Chun-Pin Lin, National Taiwan University, School of Dentistry , TAIWAN
1 School of Health Administration and Education, Capital Medical University , Beijing , China , 2 School of Stomatology, Capital Medical University , Beijing , China
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: China National Medical Examination
Center has provided all the funds for this study to
Competing interests: The authors have declared
that no competing interests exist.
Two rounds of Delphi results showed that the expert authority, enthusiasm, and
coordination coefficients were high. Constructs of the competency model that included seven
primary indicators and 62 secondary indicators determined the weight of each index. The
seven primary indicators included the following: clinical skills and medical services,
disease prevention and health promotion, interpersonal communication skills, core values
and professionalism, medical knowledge and lifelong learning ability, teamwork ability
and scientific research ability.
In conclusion, the use of the Delphi method to construct an initial model of Chinese
physician competency is scientific and feasible. The initial competency model conforms to the
characteristics and quality requirements of dentists in China and has a strong scientific
basis. The dentist competency model should be used in the National Dental Licensing
Examination in China.
Oral health is an important part of general health that can affect the quality of life. In 2007, the
World Health Organization (WHO) categorized oral disease as a serious public health problem
that requires active prevention and treatment. Dentists provide dental technology services to
patients, and their clinical competency directly affects the overall level of hospital and patient
satisfaction. As the awareness of oral health continues to increase, there is an increasing
requirement for dentists to maintain and improve their clinical competency. The training
process for dentists in medical and dental schools as well as dentist selection, training, and
assessment in dental hospitals has become more stringent. Worldwide and in China, research
regarding maintaining clinical competency has become an increasingly important component
of medical education and training.
In 1973 at Harvard University, Professor David McClelland proposed the competency
concept that includes personal behavioral characteristics that distinguish between levels of
achievement and performance in life or work. The concept of competency also proposes that
traditional assessments should be replaced with a competency measurement [
In 2002, Epstein and Hundert argued that competency for clinicians included the ability to
use communication skills expertly and accurately and to use academic knowledge, technical
methods, clinical thinking, emotional expression, value orientation and personal experience in
daily medical practice in order to benefit individuals and groups [
]. Europe, the US, and
developed countries have established medical personnel training programs based on dentist
competency, and the training program has become the basis of medical education, training,
and assessment [3±6].
The oral practice qualification test is the only way to appoint a dentist. In the five regions of
the US, Europe, Canada, Australia, and New Zealand, the dentist competency model has the
same components: clinical practice skills, oral-related clinical expertise, professional attitudes
and professional ethics, interpersonal communication and teamwork. However, the content of
the competency model still has some differences in the five regions.
At present, in China, a dental student undertakes five years of undergraduate education,
followed by a postgraduate year of standardized training (known as a "5 + 1" stage dentist in
this paper), before applying for the National Licensing Examination. However, China has not
yet established job competency-oriented assessment criteria despite some research in this area
and has not yet built a dentist competency model. Therefore, this study was undertaken to use
the Delphi method to construct a competency model for dentists in China.
Materials and methods
Ethics approval was granted by the Beijing Dental Hospital Research and Ethics Committee.
The study design and information sheets were reviewed by the committee and considered
appropriate for use. All 20 experts signed informed consents and voluntarily participated in
the study. Participant information was confidential, and participants were able to withdraw at
any time during the study.
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Use of the Delphi model
Delphi was originally developed by the Rand Corporation. Some experts observe that when
researchers lack scientific knowledge of the topic being investigated or face-to-face data
collection is impractical, the Delphi method can be applied[
]. In this study, we used the Delphi
expert consultation method, the threshold method and the analytic hierarchy process (AHP)
to establish the initial model for "5 + 1" stage dentist competency [9, 10].
Preliminary competency indicators. First, the framework of the Chinese University
Hospitals' general model for clinicians was used for reference [
]. Second, a literature search and
review were done using databases that included Wan Fang, CNKI, and PubMed to study the
models of dentist competency from Canada, Europe, New Zealand, the USA and Australia.
Third, six focus group interviews were performed. Finally, the initial physician competency
model was constructed. The model included eight first-level indices and 81 second-level
indices, resulting in a "dentist competency Delphi questionnaire."
Design of the Delphi consulting questionnaire. The expert consultation questionnaire
included the background, purpose, and expert basic information questionnaire, AHP matrix
table, index table of all levels, degree of expertise quantification table, degree of expert opinion
coordination and quantification table, and opinion column.
The index evaluation included three aspects: importance, feasibility, and sensitivity. The
scores were between 1±10, where 1 means that the index is least important, least feasible, and
least sensitive and 10 means that the index is most important, most feasible, and most sensitive.
At the same time, experts needed to select the familiarity and judgment scores. Familiarity was
divided into a scale of 1±5 using the Likert scale method, where 1 means that the expert is
most unfamiliar with the index and 5 means that the expert is most familiar with the index.
Judgment was based on four aspects: theoretical analysis, work experience, understanding of
domestic and foreign counterparts, and insight. The judgment scores were used to determine
the degree of influence, with scores of 1±3 points, where 3 = high, 2 = medium, 1 = small.
Selection of the experts. There are 20 experts in 10 national dentistry qualification
examination areas, from 10 universities of stomatology and their affiliated dental hospitals:
the Fourth Military Medical University, Lanzhou University, Sichuan University, Jilin
University, Nanjing Medical University, Shanghai Jiao Tong University, Capital Medical
University, Wuhan University, Sun Yet-sen University and Chongqing Medical University.
The specialties of the experts included management, education, and dentistry. All experts in
their respective fields had high academic attainments; 20 experts had master's degrees or
higher, and 75% had a doctorate or higher education. Information regarding the experts is
shown in Table 1.
Implementing two rounds of Delphi expert advice. Two rounds of Delphi expert advice
were implemented in writing to the 20 experts who were asked to evaluate each indicator and
make comments. After the first round of the survey, SPSS 16.0 statistical software was used to
analyze the questionnaire responses. The degree of coordination of the experts was calculated
to include the experts' positive coefficient and degree of authority according to the boundary
value method to reduce the competency index. The indicators were adjusted and
supplemented according to the comments of the experts. A second round of expert consultation was
made followed by further analysis of the questionnaire and revision of the competency index
and calculation of the index. Finally, the competence model for dentists was constructed.
Positive coefficient of experts. The positive coefficient of experts is the effective recovery
rate of the expert consultation questionnaire and can reflect positive input from the experts.
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Journal of Oral and Maxillofacial Surgery
Department of Oral Medicine
Department of Orthodontics
Department of Dental Pulp
Department of Pathology
Scientific research and teaching
The American sociologist Earl Babble argued that a 50% recovery rate was the minimum
acceptable rate for analysis and reporting, 60% could be considered good, and 70% achieved a
very good standard [
Degree of expert authority. The degree of expert authority was determined by two
factors: the expertise to make a judgment on the program, and the familiarity of the expert with
the problem [
]. In this study, Ca represents the coefficient that affects the expert judgment.
The experts used the terms "practical experience," "theoretical analysis," "understanding of
peers," and "insight" as the basis for judgments. Large, medium, and small judgments were
made to determine the extent of influence. When Ca = 1, the degree of influence of expert
judgment is medium, and when Ca = 0, it has no effect on expert judgment according to the
valuation criteria in Table 2.
Familiarity was expressed in terms of Cs. This study used the Likert scale method to classify
experts into five levels of familiarity: very familiar (5 points), more familiar (4 points),
generally familiar (3 points), less familiar (2 points), and not familiar (1 point) (Table 3). The degree
of familiarity of each expert was calculated statistically.
The degree of expert authority was expressed by Cr: Cr = (Ca + Cs) / 2; values greater than
0.7 were considered to be acceptable [
Degree of expert coordination. The degree of expert coordination is an important index
for judging the consistency of the indicators among the experts, and included the Kendall W
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coordination coefficient and the coefficient of variation of each index; the coefficient of
variation is an important basis for index deletion [
]. The smaller the coefficient of variation, the
greater is the degree of coordination of the experts.
Boundary value calculation methods and results. The method of calculating the cut-off
value of the full frequency and arithmetic mean was as follows: the mean value =
meanÐstandard deviation; a score higher than the cut-off value was chosen. The calculation results of the
boundary values are shown in Table 4.
Guidelines for the selection of indicators. There are three indicators, where the first is
the importance of the three indicators does not meet the requirements; the second is two
boundaries of the importance, feasibility, and sensitivity do not meet the requirements; and
the last one is deleting or modifying the indicator according to the expert opinion.
Index weight calculation method. In order to reflect the importance of the dentistry
competency index, another AHP software was used to calculate the weight of the primary
index in the second round. The weight of the secondary index was calculated by the percentage
weight method. In this study, we used the scale matrix judgment method to allow each of the
experts to compare each indicator in each row and column and to complete the results in the
Positive coefficient of experts
In the first round of Delphi expert consultation, 20 questionnaires were sent out, and 20 were
effectively recovered, resulting in an effective recovery rate of 100%. In the second round, 20
questionnaires were issued, and the effective recovery rate was also 100%. Some experts
modified and improved a number of indicators.
The expert authority coefficients were 0.74 and 0.75 in two rounds of consultation; both of
these were greater than 0.7, indicating that the expert consultation results were accurate and
credible (Table 5).
Expert consultation coordination
The P-value of the coordination coefficient was less than 0.01 (Table 6), indicating that the
expert opinion was consistent.
Screening results of the primary indicator. Statistical analysis of the experts' scores after
the first round of consultation showed that the boundaries of "information and management
capacity" and "scientific research capacity" did not meet the study requirements (Table 7). The
results of the second round of expert consultation showed that the "information and
management capacity" had the lowest weight (0.0668), followed by "scientific research" (0.849). Finally,
combined with the views of the experts, the decision was made to delete "information and
management capabilities" and retain "scientific research capabilities."
Screening results of the secondary indicator. Using the boundary value method
combined with expert advice in the first round, we deleted a total of 10 secondary indicators. In the
second round, we deleted nine secondary indicators (Table 8). Additionally, four secondary
indicators were revised after considering expert advice (Table 9).
Index system and weighting results. Using the analytic hierarchy process and the percent
weight method to determine the weight of the primary and secondary indicators, obtaining
the weight of all indicators resulted in the development of the China dentist competency
model (Table 10).
In recent years, the Delphi method has been widely used in health management and has
become a mature indicator screening method in the field of health care [16±20]. This method
combines qualitative and quantitative research methods to collect and screen expert advice. In
the consultation process, the choice of experts is a key link. Inappropriate selection of expert
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members will not only increase the bias in the evaluation but may also lead to a decrease in the
response rate. In general, there is a functional relationship between the accuracy of the
consultation results and the number of participants in the consultation; between 15 and 50 experts is
considered to be suitable [
]. Based on the principle of a combination of representation and
authority, this study selected 20 experts and scholars involved in the training of dentists in 10
universities nationwide in China. The authority of the experts was greater than 0.7, and the
chi-squared test results of the coordination coefficient showed that the P-values were less than
0.01. In the first round, the coefficient of variation was 0.05±0.50, and in the second round, it
was 0.04±0.35, indicating that the participation of the experts was focused and detailed. Two
rounds of expert consultation questionnaires had an effective recovery rate of 100%, showing
that the experts were motivated and enthusiastic to participate.
In the index screening, we selected three indicators for the screening items: full frequency,
arithmetic mean, and coefficient of variation. Each project determined the threshold. From
the analysis of the screening results, they appeared to be reliable; the weight value of the dentist
competency index reflected the importance of the indicator. Weight is the importance of
indicators and the size of the quantitative performance; a reasonable weight setting is significant
for establishing an index system. In order to quantify the importance of competency, we used
the analytic hierarchy process to calculate the weight of the first-level index, used the experts'
importance score, and combined the weight of the primary index to calculate the weight of the
secondary index, so that the calculation of the weight of the evaluation index was more
In this study, among the first-level indicators, the top three weights were clinical skills and
medical services (0.2309), disease prevention and health promotion (0.1564), and
interpersonal communication skills (0.1343); these weights were related to the occupational
characteristics and competence of the dentists. Dental practitioners are knowledge-based skilled
personnel with solid professional theoretical knowledge and skill. In addition to a high level of
practical skills, each dentist must be able to ensure harmonious dentist-patient relationships;
these relationships require effective communication between dentists and patients, as well as
good interpersonal and communication skills. Also, because prevention is becoming an
increasing part of clinical practice, the dentist has a role in patient and community health
In this study, the weights of "scientific research ability" and "core values and
professionalism" were analyzed through two rounds of expert consultation. We merged the second index
of "information and management ability" into the "scientific research ability" index. The
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Importance Feasibility Sensitivity
X CV F X CV F X CV F
7.95 0.21 0.25 8.15 0.26 0.40 7.75 0.32 0.35
8.85 0.16 0.50 7.45 0.27 0.15 7.20 0.32 0.10
subjects of the study were dentists who had graduated from medical and dental colleges and
universities and received a one-year standardized training in residency. The main goal for
dentists at this stage is clinical skills training. From the dental student's point of view, the vast
majority of students also believe that practical clinical teaching is helpful when supported by
clinical research. Experts also believe that dental training should be based on clinical skills;
some controversy regarding including research in the training process remains.
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Clinical skills and medical services(0.2410) 1.1 Complete and accurate collection of important medical history.
1.2 Standard medical record writing ability.
1.3 Relatively standard for oral-related physical examination.
1.4 Proper use of commonly used equipment and supplies and able to standardize the basic oral treatment
1.5 Independent reception capacity.
1.6 Ability to combine theoretical knowledge with clinical practice.
1.7 Translate the terminology into language that is easy for the patient to understand. Develop and discuss
treatment plans, cost estimates, time requirements, and patient responsibilities.
1.8 Correctly select the auxiliary inspection items.
1.9 Mastering oral surgery for local anesthesia and treatment-related complications.
1.10 Report orally to a superior doctor the standard clinical problems encountered and analysis of the
1.11 Explicit indications and contraindications of medications used in oral procedures and correct prescription
of medications for oral treatment.
1.12 Master the skills of mainstream technology.
1.13 In the course of oral therapy, consider the patient's needs, explain the etiology, diagnosis, treatment results,
risks, benefits and the expected effect of different treatment programs, grasp the overall goal of oral care.
1.14 Can identify and actively participate in the general, acute, heavy, dangerous patients in the field treatment.
1.15 Multi-disciplinary comprehensive analysis capabilities.
1.16 Process of patient referral, including referral, referral or transfer records, can be recorded consistently,
accurately and clearly.
1.17 Use evidence-based medicine to make health care decisions, and use a reasonable diagnosis and treatment
1.18 For difficult cases, have a certain degree of independent analysis
1.19 Reasonable and effective management of patients.
2.1 Find statutory infectious diseases and report them in a timely manner.
2.2 For the prevention and treatment of oral diseases.
2.3 Prevent the spread of infectious diseases by following current infection control guidelines.
2.4 Recognize oral health for the individual and the important role of the health of the population and actively
participate in oral health education and health promotion.
2.5 Assess the patient's oral disease or risk factors for injury.
2.6 In the diagnosis and treatment of rational use of medical supplies, avoid unnecessary waste.
3.1 To protect patients' right to know, access to informed consent of patients.
3.2 Protection of patient privacy.
3.3 Attentively listen, collect information related to synthesis and patient issues.
3.4 Understand, trust and respect patients and their families.
3.5 Actively prevent and resolve doctor-patient conflicts.
3.6 Effective oral expression and transmission of information capabilities.
3.7 Appease the patient's anger and misunderstanding mood.
3.8 With the patients and their families, make clinical decisions.
3.9 Communicate effectively with patients, parents or guardians, employees, colleagues, other health
professionals and the public.
3.10 Properly deal with the ethical issues arising in the health care process.
Disease prevention and health promotion
Interpersonal communication skills
In the treatment of patients, the dentist usually works independently. Because of the limited
number of nurses, China's "four-hand" operation is not universal. Therefore, in this study, the
"team cooperation ability" index weight value was low. In the interview, some experts noted
that the practice of the dentist was uniquely independent and that the dentist's competency
and the clinical physician's competency have some differences.
According to the competency ªonion model,º among the seven first-level indicators we
obtained in this study, "clinical skills and medical services" and "disease prevention and health
promotion" reflect knowledge and skills; "medical knowledge and learning ability,"
"interpersonal communication skills," "teamwork ability," and "scientific research ability" reflect
selfawareness and training ability; and "core values and professionalism" reflect characteristics
There are 62 second-level indicators in the dentist competency model; this number is less
than the 82 second-level indicators in the competency training for physicians and surgeons in
]. Because the dentists in this study had standardized training for one year after
graduating from university, and the physicians and surgeons had standardized graduate training
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for three years after graduating from college, there are differences in the competency
indicators. Furthermore, this study reflects the professional characteristics of dentistry and includes
the evaluation of practical skills, such as tooth repair, surgical extraction, and traditional
preparation of dentures, as well as management abilities including the rational use of drugs, avoiding
unnecessary waste, and local anesthesia technology skills. Dentists also need to inform patients
about oral health and actively participate in oral health education and promotion.
Compared with the competency model of the other five countries, we found the
following commonalities and differences. We all have the following four competencies:
ªProfessionalismº, ªCommunication and Interpersonal Skillsº, ªHealth Promotionº, and ªPractice
Management and Informaticsº. However, ªCore Values and Professional Qualities of
Doctorsº is also important in this study and helps define the first competencies. In China, we
place great emphasis on the cultivation of doctors' values and their enthusiasm for work. In
addition, each of the competencies has a corresponding weight that helps us to apply our
model to practical work, including the development, admission, training and assessment of
This study had several limitations. The use of a single model, the Delphi model, to construct
the competency model for dentists in China was not verified with the use of alternative models.
The constructed model has not yet been tested in clinical practice or postgraduate dental
training and evaluation. Although the experts in the study had discipline, enthusiasm, and national
geographical representation, their input was subjective and not objective [
future follow-up studies on the use of the model will evaluate and validate the model with a
behavioral event interview method in addition to being assessed nationwide in China to
develop a dentist competency model that is suitable for our country.
This study describes the process of constructing the initial model of dentist competency using
the Delphi method to develop an assessment method that contains seven primary indicators
and 62 secondary indicators. The dentist competency model is scientifically based and
clinically relevant and should be suggested for use in the National Dental Licensing Examination in
S1 File. Expert consultation questionnaire (first round).
S2 File. Expert consultation questionnaire (second round).
S3 File. Expert consultation questionnaire (first round) in Chinese.
S4 File. Expert consultation questionnaire (second round) in Chinese.
The authors gratefully acknowledge the contribution of the experts who took part in the
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Conceptualization: Kai Meng.
Data curation: Yunxia Geng.
Formal analysis: Yunxia Geng, Yiyuan Jiang.
Funding acquisition: Dongxiang Zheng.
Investigation: Liying Zhao, Yu Wang.
Methodology: Kai Meng.
Project administration: Dongxiang Zheng.
Resources: Dongxiang Zheng.
Software: Yunxia Geng, Yiyuan Jiang.
Supervision: Kai Meng.
Validation: Kai Meng.
Visualization: Yunxia Geng.
Writing ± original draft: Yunxia Geng.
Writing ± review & editing: Kai Meng.
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