We are all rightly proud of the dental profession and the important service it provides to the general public. However there is some concern, within the profession, that clinical ‘de-skilling’ is a growing problem. Perhaps it is time for an honest debate on the core skills a dentist needs to be an effective UK dental practitioner. This debate should include the views of local education training boards (LETBs), undergraduate dental schools, foundation training practitioners, and other state and private educators.
It is also worth reflecting on the 2009 Adult Dental Health Survey which included the views of patients, on their relationship with their dentist at their last visit. Of those surveyed 20 per cent gave at least one negative response. The main areas of concern included: inadequate involvement with discussions, problems with respect and dignity, not receiving answers to questions and a lack of confidence and trust in the treating dentist. This is something that the dental profession ignores at its peril.
Recruitment and undergraduate education
To address these concerns it is essential that the right people are recruited to enter the dental profession. These young men and women require strong core skills in several important areas. They must be able to connect quickly with people from all backgrounds, and create professional confidence and trust with their patients. They must display empathy and a vocation to care for others. If individuals are weak or deficient in these core areas then they are likely to struggle to serve the dental needs of the UK population; irrespective of their academic achievements.
Anyone entering the dental profession must understand, from the outset, that their primary duty of care is to their patient, and that their profession is a practical science.
Dental undergraduate training has the responsibility to introduce the skills and thought-processes needed for future dentists, and set the scene for life-long learning, with a commitment to improve. This training must also include a sufficient volume of different types of treatment procedures to allow a satisfactory level of competence. As well as modern prevention, and minimally-invasive procedures, training must include repetitive practical-skillstraining (both on patients and within controlled simulation environments), so that the techniques learnt hold-up under the pressure of a busy general practice. Although adhesive dentistry has its place, and has revolutionised many areas of operative dentistry, young dentists must also understand its limitations, and know when the use of conventional techniques and materials is more appropriate. For example the clinical problems of many middle-aged ‘heavy-metal-brigade’ patients cannot be resolved with minimally invasive procedures.
Postgraduate development
There is currently significant debate on how dentists can best consolidate and improve on their clinical competence after qualification. Is continuing professional development (CPD), as we currently use it, the answer? Or should we, like airline pilots, submit ourselves to more robust exercises to demonstrate our professional competence to others? Some will take the view that we are already too heavily regulated, while others might feel that more robust tools are necessary such as GDC re-validation, to continue to drive up clinical standards, and hopefully address the ever increasing number of complaints currently received by the GDC and the defence organisations.
Postgraduate dental education programmes must also respond to the findings of the 2009 Adult Dental Health Survey. They should aim to help those dentists who have problems developing professional relationships with their patients. For example human contact courses, where practitioners are directly observed during patient interaction, can be very valuable in helping to improve ‘professionalism’. For many reasons, some qualified dentists are finding themselves ‘de-skilled’ in core clinical areas (exodontia, removable prosthodontics, dismantling restorations, endodontics, and paediatric dentistry).
My concern is that core traditional prosthodontic skills are gradually being lost from the UK dental workforce. We must not forget that there are still 3.5m edentulous patients in the UK, and many more who need to wear substantial partial dentures supported by only a few natural teeth. Unfortunately the cost of implants is prohibitive for many patients. I do realise that the demands on the undergraduate curriculum are very tight, and that the present GDS NHS contract does not financially incentivise some of these treatments, but even so, it is essential that these skills remain core to dental education and training.
We all need to be aware of the procedures we find more challenging. For example exodontia, the extirpation of acute ‘hot’ pulps, and the dismantling of fixed failing restorations. None of these skills will be improved by avoidance. Continuing professional development for dental practitioners must adapt and respond to the issues discussed above. It will need to be flexible and include multiple formats including: human contact, dental simulation laboratory work, log book assessments, case presentations, web-based learning (including webinars), together with formal lectures and structured courses. It is my view that some of this education should take place where the practitioner works, and the dentistry is delivered. In the UK 93 per cent of dentistry is carried out in the primary care environment.
Deep knowledge-based learning must also start early in professional development to help avoid long-term over-reliance on the views of others for decision making and material choice (sales reps, manufacturers, labs and so on). The importance of reading peer-reviewed papers and journals, and taking a personal responsibility for professional knowledge must be seen as the norm for all dentists.
Regular scanning of the Cochrane dental library can help all of us keep up to date with important developments in clinical dentistry. Such resources in a digital world are easy to access, and easy to use. Some specialist societies also provide webinars which are relevant to all dental practitioners. There is also a large resource of dental procedures and lectures on YouTube, for example.
Accepting personal responsibility
In dentistry one still hears familiar excuses for a poor outcome, the lab, NHS contract, equipment and so on. In the 21st century we all need to try and create a ‘blame-free’ environment that is ‘bought-into’ by all members of the dental team. The goal must be to aim for quality and to adhere to team agreed standards, constantly reflecting and measuring the performance of the team against them. Reflective learning is the best way to drive up standards by referring to what we can all do to improve our performance throughout our careers.