Are universities adequately preparing new dentists?

Neel Kothari questions whether new graduates have the competency, training and confidence required for safe clinical practice.

You may have heard of the 10,000-hour rule popularised by Malcolm Gladwell’s book Outliers, where Gladwell asserts that the key to achieving true expertise in any skill is simply a matter of practising in the correct way, for at least 10,000 hours.

The concept can be traced back to Professor Anders Ericsson et al (1993) paper called The Role of Deliberate Practice in the Acquisition of Expert Performance. This highlights the work of psychologists in Berlin, who demonstrated vastly differing levels of practice hours between elite musicians and the less able ones.

Professor Ericsson further goes on to say that it’s not just the quantity of the practice, but also the quality and how ‘deliberate practice’ goes on to influence the development of expertise.

Why is this important? Well for quite some time there has been an increasing perception within the profession that newly qualified dentists are carrying out far fewer procedures during their undergraduate years than historical norms, leaving them precariously placed to provide general dental services to the public.

While there is no expectation for universities to produce dental ‘experts’, one would expect, at the very least, that dentists have a basic standard of competency.

This is also necessitated by General Dental Council (GDC) standards 7.2.1 and 7.2.2 which compel dentists to only carry out treatments if they are appropriately trained, competent and confident to do so.

How do you measure competency?

A 2017 survey of 312 foundation trainers by Oxley et al in the BDJ concluded: ‘…a large proportion of foundation trainers consider the current standard of new graduates to be unsatisfactory for entering foundation training.’

Real or perceived, this has undoubtedly been made worse by the COVID-19 pandemic restricting patient access for undergraduates, but this alone isn’t entirely to blame.

It’s noteworthy that Aberdeen, Dundee and Glasgow dental schools all decided to repeat the 2020-21 academic year, citing a ‘lack of experience’ and ‘patient safety’ in stark contrast to universities in England and Wales.

This begs the question: how exactly do we decide if someone is competent? Well, almost every dental procedure involves a complex set of steps that, if we are to believe the experts (and possibly our own intuition?), requires repetition to at least get a basic understanding of.

Potentially one could give a single ID block to a patient and then be deemed ‘safe’ to do so, but would anyone seriously argue that they are then competent at giving ID blocks?

Lack of experience

Retired dentist and former educational supervisor Donna Jackson told Dentistry: ‘Undergraduates are doing far fewer procedures than when I graduated, reaching the lowest point just after COVID-19.’

When discussing foundation training, Donna says: ‘VT (vocational training) used to be about teaching NHS regulations, practice management, business etc, but more and more it is about teaching basics that, in theory, should have been done in an undergraduate course.

‘Instead, you have new dentists who need more and more support. You now must watch them do a restoration, crown prep etc on a phantom head because they have so little experience, before they can be let loose on a patient safely and yet they are qualified.’

Undoubtedly, there will be significant variation between teaching establishments and individual dentists over the output during their undergraduate years.

This article isn’t intended to criticise the excellent work carried out by some of the best educators in our profession, but rather highlight the teaching limitations within foundation training and the risks placed on both the public and the dentist in the day and age of ‘no win, no fee’ rascals, as well as GDC regulations that are more complex than Apple iPhone’s software terms and conditions.

‘Worrying reality’

Further, the nature of foundation training means that dentists may not be accessing the ‘deliberate practice’ as described by Professor Ericsson. While foundation training may share overlapping aspects with undergraduate studies, their roles vastly differ and aren’t intended to be interchangeable.

Despite what is posited above, there is a glaringly obvious counter argument, which is that almost everyone feels that things were better in the past, so it’s hard to know for sure what is rosy retrospection and to what extent things have changed.

Much of what is reported is opinion (albeit from dentists closely involved), not raw data on actual output, so another plausible explanation is that the output of undergraduates hasn’t changed that much, but the world around it has and newly qualified dentists no longer have a space where they can fail safely.

This is a worrying reality for dentists who enter the rat race with often an £80,000+ debt.

What we need is data, and thankfully this is being addressed by the British Dental Association, who I am reliably informed are conducting research on this that feeds into work being done by associations in the Council of European Dentists, as this is not only a UK perception.

I hope to report back on this in due course as more information becomes available.