Staying ahead in dentistry: Pleading for language competency and communication skills
Language competency can mean different things to different people. A dentist and dental nurse for example, will use a completely different vocabulary to discuss the care of a patient to the one they will use when explaining the treatment and prognosis to the patient and his or her family. A different approach also needs to be adopted when giving emotional and palliative support to the patient and his or her relatives.
Socio-economic change over the past 65 years has allowed international migration and led to multicultural societies that would have been unthinkable two generations ago. Improvements in transport links, combined with changes in political and social attitudes towards professional and skilled migrant workers, have presented significant opportunities to those wanting to work abroad. There are a number of professional qualifications that are accepted globally, allowing dental practitioners to work without having to retrain before applying for new overseas posts.
But what about language skills? It is widely acknowledged that it is only a matter of time before all members of our profession, not just those from outside the EU, will have to demonstrate that they are proficient in English if they wish to practise in the UK. A dentist needs to be able to communicate on social, palliative and clinical levels using appropriate language for all three. For example, good social English is not specific enough when having to ask a patient appropriate questions during a consultation, and a dentist and dental nurse need to use specific clinical vocabulary to communicate effectively during a procedure.
Dentistry differs from other health professions in that much of what a dentist does is procedural. It does not just entail consultation: it also entails explaining to every patient what is being done, why it is being done and what the experience is likely to be. Treatment plans and alternatives need to be clearly explained and understood. Records have to be maintained accurately and be fully comprehensible to another dentist if it is a group practice. Letters of referral must be comprehensive and unambiguous.
Another factor that is relevant to the UK, Australia and New Zealand is that all three countries have a large number of immigrants, so it is not at all uncommon to have the situation in which neither dentist nor patient has English as his or her first language. In this situation, competency has to be at a high level. Workarounds such as telephone-based interpreter services have been trialled but often dismissed as unsuitable, as they rely on the interpreter having profession-specific vocabulary in multiple languages.
In order to work in many English-speaking countries, dental professionals whose first language is not English and have not trained on a course taught in English often need to demonstrate a level of competency by way of an International English Language Testing System (IELTS)* examination or similar. However, the required IELTS score varies from governing body to governing body and from country to country. Overseas-qualified dentists from outside the European Economic Area whose qualifications are not eligible for full registration with the General Dental Council (GDC) in the UK are required to pass the Overseas Registration Examination (ORE). Successful completion of the ORE allows these dentists to register with the GDC and practise unsupervised in the UK.
Prior to taking the two-part examination to demonstrate their clinical skills and knowledge, applicants must submit details of their clinical experience and a single academic IELTS test report form less than two years old with a minimum overall band score of 7.0 and no score lower than 6.5 in any section.
However, overseas-qualified dentists from within the European Economic Area are currently exempt from submitting an IELTS test report form as part of the ORE, although this might change within the next several years. The UK government is currently consulting on changes to the Medical Act 1983 that would introduce legislation to “seek to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests”. The proposed amendment is more comprehensive and includes both EU nationals and non-EU nationals. While the proposed amendment does not currently affect dentistry, it is highly likely that the GDC would follow suit and tighten its English language competency requirements further still.
The GDC should be applauded for setting the bar on language assessment with UK dentistry and going beyond what is currently required by the Medical Act 1983. The very fact that candidates must demonstrate their language proficiency before sitting an examination demonstrates the importance of good communication. Any change in legislation or desire to improve language practice would be an opportunity to make language proficiency requirements at entry more industry-specific.
With this in mind, it is instructive to review how tighter English language controls have already been implemented in Australia. The Australian Dental Council (ADC) requires overseas-trained dental practitioners to complete a three-part exam, one part being proficiency in English. As well as IELTS, the ADC recognises Cambridge English Language Assessment’s Occupational English Test (OET)**, which differs from IELTS in providing a profession-specific, fit for purpose assessment that uses typical clinical scenarios to test knowledge and use of language. OET includes four subtests (on listening, reading, writing and speaking) and, uniquely, all of these tests are rooted in the context of working as a dentist and using specific language that is relevant to being effective as a dentist.
A typical example in the dentistry speaking examination presents the candidate (who plays the role of a dentist) with the scenario of a parent of a six-year-old boy who grinds his teeth at night, asking for advice about this problem. The parent is on a limited income and is very concerned about the extent of possible treatment. In this example, the candidate is required to explain the boy’s problem, tell the parent ways of dealing with the problem, and reassure the parent about his or her concerns.
In the context of the clinical scenario, the candidate must demonstrate that he or she not only understands the vocabulary, but also can recognise the context and subtle variations of the conversation and respond accordingly. This particular scenario includes language functions concerning asking for advice, expressing concern, and looking for reassurance that would be common in a clinical communication event. The candidate’s use of language must demonstrate that he or she understands that he or she is not a friend putting an arm around the parent’s shoulder but a professional giving advice tailored to the parent’s circumstances in a competent and authoritative manner.
Several years ago, the ADC identified that a lack of confidence in English was by far the most common cause of failure among candidates. As a result, the ADC raised the entry requirement from OET Grade C to Grade B in each of the OET subtests. Subsequently, the requirement has been raised further to grades of A or B. Personal experience also highlights cases in which, despite demonstrating the required language skills prior to entry, clinically excellent fifth-year dental students had English language skills that were inadequate and not fit for purpose. Rather than indicating any failure in teaching, this simply reinforces the need to provide specific training in clinical communication skills.
By introducing enhanced language testing requirements, it is vitally important to ensure that examinations are not only fit for purpose, but easily administered, fair and secure. Cambridge English Language Assessment’s experience in running global, high-stakes, secure examinations, such as IELTS and OET is the best and meets very high standards in terms of authentication, security, reliability and validity. The organisation’s expertise and reputation can help provide regulators with a high level of confidence.
One issue that we are very aware of in the UK is increasing pressure on limited resources leading to restructuring within the National Health Service. With global issues of an ageing population, people living longer and a greater need for health care, there is going to be more scrutiny on regulators to recruit internationally to meet the resourcing needs. Testing language competency and communication skills is fundamental to this changing landscape in health care, and examinations such as OET are becoming increasingly important in this, in terms of not just regulation, but also ensuring patient safety and patient outcomes.
*IELTS is jointly managed by the British Council, IDP: IELTS Australia and Cambridge English Language Assessment.
**OET is owned by Cambridge Boxhill Language Assessment Pty Ltd. It is a joint venture between Cambridge English Language Assessment and Box Hill Institute.