Kevin Lewis questions whether our academic system is geared to producing dentists with the ideal blend of intellectual and technical skills.
Fit for purpose
On a recent visit to the southern hemisphere, I was privy to a fascinating conversation between a group of dentists that included the dean of a dental school, a member of the local dental council and a seasoned GDP who owned a reasonable sized practice.
The practitioner was bemoaning the fact that the dentists who came to work in his practice had little or no experience in carrying out what he regarded as some pretty routine dental procedures. He blamed the dental schools for failing to equip graduates for the real world.
The dean was quick to defend his position and explained that the aim was to attract, recruit and train students who could last the undergraduate course and graduate. That was his remit and anything else was a bonus. Not surprisingly, therefore, universities and dental schools were more attracted by those with proven academic skills. More surprisingly, perhaps, he believed that technical and practical skills could always be added, while the inherent intellectual and academic skills were a pre-requisite because the students would never have a chance to demonstrate their technical skills unless they were also capable of passing the various academic exams along the way.
The dental council member observed that nobody arrives at the disciplinary ‘sharp end’ of a council because they are not bright enough. They may well do so because of a perceived deficiency in their technical/clinical skills – even though these might have been ‘signed off’ by examiners at some previous moment in time – but more often the issue in question is one of professionalism. The worst possible combination, he believed, was someone who was highly intelligent but unethical and/or unprofessional.
There followed an interesting debate about where professional judgement and insight comes from. Is it already present (or absent) – in embryonic form at least – when someone enters dental school, or is that what five years at dental school sculpts from the raw clay of the academic and intellectual skills, personal and human values that one takes into dental school?
What are the necessary ingredients, and what is the recipe for a dental health professional who can not only qualify, but who also has a realistic chance of lasting 35-40 years of providing dental care of an acceptable quality, in an ethical and professional fashion? Given the significant cost of training a dental student, there is a sizeable public interest dimension to this question.
The educational imperative is now to teach students how to learn, equipping them with the tools to assess situations and make sound decisions. In the old days students were taught how to carry out procedures, and they were often given ‘targets’ of how often they needed to carry out these procedures before being deemed competent in them. We hear a lot about the problem-based learning (PBL) approach which some dental schools have enthusiastically embraced – of course, we always had problem-based learning; the difference is that we used to encounter the problems long after we left dental school, not while we were still in it.
Is it possible that we are recruiting people with stand-out academic and intellectual skills, spending five years diligently re-confirming those skills while instilling and developing some technical/manual skills, but overlooking the skills and qualities needed to convert all that into a meaningful career?
The dental school dean reminded the rest of the group that this was not his remit. The seasoned practitioner observed that most of what he considered to be the best dentists that had passed through his hands had not actually been the brightest. Nor were they necessarily those with outstanding technical, manual skills. He believed that the key to success was one of attitude, coupled with the possession of human ‘people’ skills and the ability to communicate effectively.
Moreover, he was convinced that a dental school would know pretty early in the course whether a student had these skills or not. He made the point that the staff of an average dental practice can pick a winner (or a loser) pretty quickly. And they are usually right. Do patients really want (or need) dentists with top-end academic skills? Does dentistry make best use of the academic and intellectual resource that the dental schools deliver into the workplace each year? Or is the situation actually self-correcting in that the most academically minded of our graduates will seek out positions in research, teaching or elsewhere that challenge them intellectually, rather than in other ways. Meanwhile, those with outstanding technical skills will probably put themselves into positions where they can put these skills to full use.
People who need people – as Barbra Streisand would say (or indeed, sing) – will probably gravitate towards jobs where they can spend their time with people. But all this does not necessarily ensure that the dental workforce is fit for purpose. Nothing in the criteria for our recruitment into the profession, nor in our undergraduate training, nor in anything that follows, ensures that we are equipped for the wear and tear of a career in dentistry – whichever branch of dentistry we choose. Each type of dental career brings its own pressures, albeit of a different kind.
Life dishes out some spectacular challenges and knock-backs and neither academic and intellectual excellence, nor technical competence, provides you with ‘coping’ skills, nor a broader mix of ‘life’ skills. Other professions and not least, medicine and the law, have latched on to this mismatch and are trying to address it – however belatedly.
What dental school teachers, experienced practitioners, and those who regulate and govern the profession, might just agree on is that it is not enough to rely upon intellectual capacity alone, nor the ability to create intra-oral masterpieces. Even specialist training might simply perpetuate the historic fault line if it concentrates on enhancing and measuring academic and clinical skills, while failing to address the need for a wider mix of skills.
Instead of delivering a bundle of skills that we as a profession, or an authoritative body within it, or our professional masters, or the government, feel to be desirable, maybe we should all pause to ask what patients would like and expect from us. In short, shouldn’t we be selling what the customer is buying? To take any alternative view might smack just a little of the very paternalism that the profession is trying so hard to distance itself from.
Meanwhile, the GDC finds itself in a position where it has little alternative but to register many people who, if the truth be known, may not fit the bill at all. In many cases, someone somewhere will already know that a particular registrant is an accident waiting to happen at some time during the years ahead.
There have already been cases where a student has passed finals, only to discover when attempting to register with the GDC that the dean of the dental school has expressed the opinion that the graduate, despite having passed five years of internal assessments and external university examinations, is not fit to be a member of the profession. If the dean is right, then the question is not simply one of whether the individual concerned is fit for purpose, but whether our whole system is fit for purpose. Some would criticise the dean for speaking out in such a situation – others would be more critical if he/she failed to speak out, if this is what he/she believed. Many GDC erasures, when viewed objectively, are an indictment of the system every bit as much as an indictment of the individual.