A qualitative study of dental internships in Saudi Arabia: moving beyond perceptions to the reality of the practices of dental interns – BMC Medical Education

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The current work marks the first qualitative research to apply a performative knowledge approach to the exploration of dental internships with a focus on the practices of dental interns. Five key themes emerged from the data: exploration, addressing knowledge gaps, responsibilities, decision-making and social connections. Regarding the theme of exploration, the findings suggest that dental interns perform both clinical and personal exploration. Clinical exploration refers to the fact that dental interns practice outside their universities in diverse clinical settings where they learn from more experienced colleagues and are exposed to different skills and knowledge. In contrast, personal exploration refers to the fact that dental interns pursue and form new hobbies and interests during their internships. Dental interns also use their internships to bridge any gaps in their undergraduate education. They achieve this by observing others and engaging in activities that give them the practical experiences their undergraduate degrees did not. Moreover, the practices of dental interns reflect the new responsibilities they are given during their internships regarding clinic management and patient care. While supervisors are available if required, interns do not need to seek their guidance for day-to-day clinic management. Regarding patient care, the data reveals that interns prioritize patient care over their own needs. Furthermore, the research results reveal that dental internships represent a stage in dental interns’ education where they can make important decisions regarding their careers and the specialist areas they wish to work in.

Finally, dental internships are found to be a period during which interns forge professional connections with doctors and colleagues and seek out a romantic life partner.

Only a relatively small amount of the existing literature [12,13,14, 23, 24] has explored dental internships and dental interns’ experiences. Nonetheless, despite the limited number of studies, their aims and research approaches vary significantly. Shenoy KS et al.’s [13] qualitative study and Ramalingam et al.’s [14] quantativatve study, for example, aimed to understand dental interns’ experiences regarding specific clinical elements of their internships. The focus of Shenoy KS et al.’s [13] research was interns’ experiences and perceptions of emergency rotations while Ramalingam et al. [14] were interested in exploring the knowledge and opinions of interns regarding a specific procedure, namely, placing dental implants in patients who were medically compromised. A further qualitative study by Ali et al. [12] was more general in scope and sought to understand the benefits and challenges of internships for dental interns. The present work overlaps to some degree with Ali et al. [12] as it also applies a qualitative approach and is not exclusively concerned with the clinical elements of dental internships.

Importantly, the findings of the research in this area [12,13,14, 23, 24] address various elements relating to dental interns and their internships, ranging from clinical and professional to social and personal. To illustrate, Ramalingam et al. [14] are primarily concerned with clinical elements and how interns perform regarding a specific clinical procedure, while other research [12, 24] explores the personal and social elements as well as the clinical aspects of dental internships. For example, study [24] found that dental interns (74% of participants) consider the clinical experience they gain during their internships to be the most valuable part of this experience with social interactions (42% of participants) considered the second-most important and personal experiences considered one of the least valuable (13% of participants). However, as this was a quantitive study, it was not able to report any details regarding the personal, social and clinical experiences of the participants. In contrast, study [12] covers the personal, social and clinical aspects of dental internships. On the clinical side, for instance, it explored dental interns’ viewpoints regarding increased patient loads. On the social side, it [12] dicussed the establishment of professional relationships, and regarding the personal, it highlighted the importance of personal traits in the creation of personal relationships.

The findings of this research support the results of other studies [12, 24] that show that dental internships are not solely clinical experiences but also include strong and vital social and personal components. However, this study goes further to present the novel discovery of previously unacknowledged aspects of the personal and social components of internships. Specifically, the sub-theme of personal exploration reveals that dental internships are a period when interns explore new interests and hobbies outside the clinical space and pursue their personal interests. At the social level, this research also reveals that dental interns seek romantic life partners during their dental internships. This research was able to identify these findings because of the wide scope of qualitative methodologies and, in particular, the flexibility of the topic guide the researchers used to gather data, which allowed the participants the freedom to address a broad variety of their activities as interns.

According to the findings of this research, dental interns complete their internship programmes in various settings and centres where they can learn directly from seasoned healthcare professionals. Through these experiences, they acquire a variety of oral health skills and knowledge. This result is in line with the existing literature on dental internships [25, 26], which similarly reports that dental interns benefit from a valuable diversity of training contexts during their internships, as well as insights and guidance from experienced healthcare professionals.

The evidence reported in this research plainly shows that dental interns actively use their practical clinical knowledge in their internships. In this way, they can fill gaps in their knowledge that were not addressed in their undergraduate course. The existing literature [24, 27, 28] also finds that undergraduate dental students can have gaps in their knowledge of certain areas of oral health and dental practice. Importantly, the existing research [24, 27] finds that prosthodontics and minor oral surgery are insufficient in dental courses. Among vocational dental professionals, research [28,29,30] has also found that education and training in surgical extractions, endodontics, prosthodontics and orthodontics can be lacking. The present study confirms the need to improve the education and training of undergraduate dental students in key areas. The problem of persistently low knowledge and self-confidence among dental students in key areas has not been adequately dealt with in recent years [29, 30]. To address this, dental education institutions should consider the use of internships as the optimal way to allow their students to develop the necessary knowledge and skills. This will achieve the primary objective of internship or vocational training, namely, to enhance interns’ confidence in clinical practice [8, 9]. Interestingly, the vocational training students surveyed by Patel et al. [31] reported that their education had, in their opinion, sufficiently addressed the knowledge and skills that they needed. These opposing findings about the adequacy of the education and training dental interns receive before their internships may be due to variations in the undergraduate courses completed by the research subjects.

The importance of the role played by supervisors during dental internships and their availability to interns is recognised in this as well as the existing research [25]. However, the current study and existing work on this topic have explored different elements of internship supervision. For example, existing research [25] has found that dental interns’ learning experiences can be improved if the supervisors fully understand the learning outcomes of the internships. However, the dental interns surveyed in this research benefited from readily available supervisors but showed a reduced dependence on supervision. In particular, it was found that the interns assumed primary responsibility for clinical tasks related to the management of their dental clinics without actively seeking guidance from supervisors. This suggests that the subjects of this research may, to a large extent, have achieved their professional aims during their internship.

An important consideration when comparing this work to the existing literature is what was deemed to constitute ‘knowledge’ in the other studies, which impacted what type of data they collected. To a large extent, all the studies discussed [12,13,14, 23, 24] adopted the perception-based approach. The perception-based approach is very valuable and completely valid if it is used in the right way. However, it can be problematic if it is used inaccurately. Nonetheless, proper use of this approach can be found in the existing literature in study [12], in particular, in that participants’ perspectives on recruitment for internships were captured to reveal that heavy competition made recruitment challenging. This is an example of the valid use of the perception-based approach as one of the best ways to capture information on the challenges confronting participants is by asking them for their perspectives on the challenges they face.

Another example of how this approach is implemented in this area of study can be found in a study [13] on emergency dental rotations that found that, after completing the rotation, dental interns ‘felt’ sufficiently confident to manage emergency cases. Another example is seen in the discussion section of study [14] where it is stated that 78.1% of the dental interns surveyed ‘perceived’ that they had a good amount of knowledge regarding the placement of dental implants in medically compromised patients. It is worth noting that the findings of these two examples [13, 14] are interesting and informative. However, from a knowledge perspective, this approach is not ideal. The finding of study [13] that interns feel able to manage emergency cases following completion of an emergency internship rotation has some limitations. The obtained knowledge here could be correct but it could also be incorrect as it may not reflect the reality. In simple terms, yes, the interns ‘feel’ confident but a consultant may evaluate them in practice and find that there are, in reality, not competent to manage such cases. This limitation is the same for study [14], which argues that dental interns feel confident that they can place implants in medically compromised patients.

In contrast to the above, the approach applied here is based on performative knowledge. This approach avoids perceptions and feelings to a large extent if not completely. It directly captures the reality of what dental interns do in practice during their internships by asking them to recount real stories and conclusions are then made based on what the interns do in practice.

To better illustrate this approach in comparison with the perception-based approach, one can look at Ali et al.’s [12] study, which identifies establishing professional relationships as a theme. This study captures data on the participants’ perceptions to underline the importance of good communication and teamwork skills in establishing professional relationships. This result reveals the participants’ viewpoints and is thus valuable. However, it is suggested that the social connections theme identified in the present research using the performative knowledge approach has greater value. This is because this theme emphasises the actions taken by dental interns regarding their relationships and not their opinions of whether communication skills are vital for relationship-building. In particular, the social connections theme directly explores what interns do and finds that interns form connections with a variety of colleagues. In sum, the performative knowledge approach raises the quality of the knowledge obtained in this study as it is not concerned with the participations’ opinions on the value of communication skills to relationship-building (these may be right or wrong as they reflect a point of view) but instead goes directly to the point by capturing the action of dental interns establishing relationships with colleagues. The knowledge that interns establish professional connections is thus unquestionably correct. It is real; it is something that has happened and still happens.

All the findings of the current work reflect the performative knowledge approach. The theme of responsibilities is a particularly clear example. The data captured under this theme does not show whether the participants ‘feel’ that they have greater responsibilities as interns than they did as students, it shows the actions they take that reflect their new responsibilities. The research reveals that dental interns have a different role to play than they did as students regarding clinic management and patient care. Specifically, they do not need to seek guidance from their supervisors before taking action in their clinics and their supervisors do not monitor their work. Moreover, dental interns prioritize the care of their patients, sacrificing their own needs to make sure their patients are comfortable by, for example, working additional hours to do the work needed to help the patient or take a full medical history, as shown in the ‘ Results’ section. As regards the theme of decision-making, this theme again demonstrates how decision-making takes place as a practical process through the actions of dental interns. For example, one intern wrote a list of specialties to help them choose what career path suited them best, observing their colleagues and removing the specialties that did not appeal to them until they had only a couple left to choose from.

Other valuable and interesting studies [32, 33] in this area do exist but they are unlikely to add much to our understanding of dental interns and internships as they do not explore either the practices or perspectives of dental interns but assess internships from the perspective of ‘outsiders’. To illustrate, one study [32] examined the opinions of students on mandatory internship programmes. While such research can build on the existing literature in various ways, it offers limited insight into internships. Preferably, the need for compulsory internships should be evaluated by interns who have or are completing an internship. They experience internships first-hand and are thus the best people to ask about their value. Educational specialists may also be able to offer valuable insights into the advantages and challenges of internships but students who have no experience of mandatory internships are not in a position to provide useful data on this topic.

The present study and the existing literature on dental internships [12,13,14, 23, 24] cover many of the same research areas as the literature on medical internships [34, 35] and pharmacy internships [36, 37]. The clinical elements of internships is one area where these studies overlap. One study [35], for instance, examined the perceptions of medical interns regarding the clinical training they were receiving as interns and whether it was sufficient. The same topic has been explored concerning dental interns [14] who were asked their opinions on the adequacy of their clinical knowledge after their internship was complete. The difference between these two studies is the clinical procedures involved as one was concerned with medical specialties [35] and the other [14] with dental procedures. Relating to the same topic, research on pharmacy interns [37] concluded that internships helped interns to improve their professional and clinical skills. The confidence concept in internships has also been explored in relation to pharmacy interns [36] and dental interns [12]. As internships in the areas of pharmacy, medicine and dentistry have common objectives as well as similar training environments and approaches to supervision, studies on pharmaceutical, medical and dental internships will undoubtedly address similar topics. Consequently, knowledge-sharing and cross-disciplinary collaboration between researchers in these areas have the potential to enhance internship programmes and create better-trained professionals in various healthcare fields.

Study implications

The findings of this research have several implications. This research finds that internships play an important role in bridging the gaps in dental interns’ knowledge and provide them with the education and training that was lacking from their undergraduate courses. Thus, the curricula of dental education courses should be reviewed to make sure that students are being taught real-world, practical knowledge. Moreover, this study’s results regarding the personal and social elements of dental internships stress the value of taking a holistic approach to dental education to ensure that social and personal as well as clinical development is addressed.

A further implication of the findings of this research concerns the value of developing a flexible topic guide to help capture data in qualitative research. This approach can help reveal unanticipated results as was the case in this research regarding the personal and social elements of dental internships. In addition to the above, this research validates the usefulness of the performative knowledge approach as a means of discovering integral findings about dental interns’ real-world experiences, for example, as seen in the findings on the themes of responsibilities and decision-making.

Finally, the participants of this research were dental interns in Saudi Arabia’s Riyadh Province currently completing a mandatory internship but the study findings have implications for a wider population. What happens in one sphere can inform what happens in another. This concept was discussed by Mol [20, 21] and Silverman [38] and their discussions on the notion of generalizability. To expand, where there is an internship programme, whether it be in medicine, dentistry or pharmacology, there is decision-making, responsibilities, training and so on. Minor variations between these contexts (dentistry, medicine, pharmacology) do not prevent the experiences and lessons learned from one context from being transferred to another, for example, from a dental intern deciding during their internship to specialize in orthodontics or periodontics to a medical intern choosing between family medicine and public health. Nor do these small variations prevent the transferability of the experiences of a dental intern in one country to a dental intern in another country. What matters here is the existence of, for example, the decision-making concept across all contexts. Conclusions can be drawn here and applied there, but the question is to what extent?

The results of this study and their current alignment with medical internship literature support this assertion. To illustrate, the theme of “Clinical Exploration” identified in this study discusses the opportunities that dental internships provide for interns to practice in various clinical settings beyond their universities, allowing them to learn new and varied knowledge and skills. The studies on medical internships [39, 40] reveal similar findings, namely that internships give interns practical experience and expose them to various duties (or rotations) in a range of contexts. Additionally, our results show that dental interns assume new responsibility for duties regarding clinic management and patient care. The medical internship literature [39, 41] reflects this finding, highlighting the broader span of responsibilities that medical interns adopt.

Study limitations

It must be noted that there are two key limitations to this research. To begin, it does not capture data on the participants’ subjective experiences, information that could help to better understand the participants’ viewpoints regarding, for example, their needs and concerns. Also, the research only collected data using diaries and interviews. These collection methods are widely used and valid but observation could also have been used to enhance the study results’ validity. The study participants’ statements about their practices as interns (captured via diaries and interviews) could have been combined with the observation of their practices to strengthen the data that was collected.

Suggestions for future research

The researchers of this study have one key recommendation regarding future research in this field. Increasing numbers of studies are being conducted on internships but the specific dimensions of internship programmes have still not been properly defined. Future research should thus aim first to clarify the dimensions of internship programmes, such as personal, social and clinical elements, and benefits and challenges, creating a valid theoretical framework that covers all aspects and dimensions of internships. Consequently, these dimensions could then be systematically explored through empirical research to enrich the literature in this area.

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