Graduation: A minefield for the younger generation of dentists

In the last year of dental school, those wishing to enter vocational training are pitted against each other, then ranked nationally and allocated a training position according to their performance in that selection process. Whatever happened to being interviewed by a future employer and performing at that more personal, mutual assessment level? It appears that the system is becoming increasingly mechanistic, a conveyor belt if you will, where a college student enters, is educated in a cost-effective manner, assessed and allocated around the country.

The issues involved in undergraduate training, as opposed to education, have been topical recently.[1, 2] Dentistry has both educational and training aspects. Undergraduates need to undergo appropriate volume-based improvement of their diagnostic, planning and hand skills, linked to appropriate knowledge. Pure education will never be enough for a practical profession where one is more likely to be judged against a technical outcome yardstick than on purely theoretical knowledge. Are dental schools providing this requisite training or are these absorbent minds being failed by the environment that they now have to learn the practical, technical aspects, as well as some helpful clinical tricks of the trade? The fault seems now to lie more in the lack of appropriate nurturing of these talented and capable individuals, as opposed to unfairly criticising their nature, abilities or motivations. I think less of the “when I were a lad” and more of the realisation of the difficulties they face is required.

NHS dentistry: A brave new world?
Once they have attained a position in the system in which they then work, this should surely be conducive to providing the right treatment to the right patient at the right time, right? Wrong. Even if skills were attained at the undergraduate level, the current NHS system based on units of dental activity (UDA) does not reward those most technically demanding, most rewarding procedures that can improve quality of life, such as saving a molar tooth with endodontics. These time-consuming delicate skills with expensive single-use instruments are rewarded financially at the same level as an extraction.

Therein lies the paradox, and consequently the problem. Dentistry does not appear to be valued to the same level as other professions. We tend to undersell and understate ourselves compared with other professions. Doctors tend to be looked upon favourably—there when patients need help most. Lawyers are viewed in a different, more formal way, especially when disputes arise. In contrast to its perception in many other places in the world, dentistry is portrayed as pain inducing and expensive in the UK.

Somewhat ironically, NHS medical services are free at the point of delivery and NHS dental treatment is not. Cue every patient comparing us to our medical colleagues where there is no bill for a hysterectomy or a hip replacement, but they have to pay £200 for a spoon denture. As such, the perception by the public and the media may always be more negative than positive, and the government may play on this to squeeze the pips of goodwill out of dentists until nothing is left.

PurSUEing a career
The NHS system is not the only daunting aspect of this brave new world that young dentists are entering. Dental litigation in the UK is rife and ever increasing and, as expected, indemnity premiums are increasing. Young dentists may well be nervous and risk averse, if not outright defensive, when treating patients for fear of litigation or a complaint to our regulatory body, however trivial that may be. Can we expect them to develop and hone skills in such an environment? This is highly unlikely where self-preservation becomes the understandable consideration. As such, “defensive dentistry” can override instinctive motivation to treat deserving and unfortunate patients and thereby discharge our wider duty to society.

This increase in indemnity premiums is unlikely to have been instigated by a swathe of amalgam carvings without secondary fissures by dental foundation trainees. An increase in procedures such as implants, short-term orthodontics and elective cosmetic dentistry is more likely to have had an effect on premiums for all.

As a growing number of settlements become increasingly sizeable, those possibly avoidable mishaps by the more senior, supposedly experienced, among us make the environment more difficult for our junior colleagues.

There is so much overt dental disease and a great need for this to be treated using predictable methods, and it baffles me that despite this many young dentists see opportunities to supplement their income and skill set with high-end, high-risk procedures more likely to lead to litigation well before the basics of proper, proven dentistry have been learnt, attained and honed. Unfortunately, the skills they may feel or be led to feel they want to achieve are not routinely what they probably need most or possibly what potential employers really want and likely what the public requires. Recently, a colleague in practice called me about the CV of a young graduate with only four years of experience. He had gained “qualifications” in facial aesthetics and cosmetic dentistry, had completed a course in super-quick orthodontics and was studying for an MSc in metal screws. My friend commented, “If I take him on, who’s going to do the dentistry, the therapist?”.

Again, the NHS UDA system may be blamed for not rewarding the management of plaque-associated disease to the level it merits, and because of that perception such individuals may hunt for more supposedly rewarding opportunities.

Further specialist training is seemingly London centric and expensive. It looks increasingly unlikely that a UK graduate with five years of debt in tuition fees will be able to afford to train and develop comprehensively if he or she desires this without falling deeper into debt. As such, these postgraduate specialist courses are popular among overseas students, whose large fees are welcomed by academic units. Unfortunately, the overall experience and skill set within these shores is likely to decrease as a result of much of this postgraduate effort with a net increase for countries abroad where they will then bring that expertise.

Positive aspects of globalised dental education include the improvement of oral health in those countries less developed than our own. Despite this, a balance should be struck. Rewarding those hardworking, committed and talented of home candidates with scholarships for further training is common overseas.

Spare a thought…
A young graduate recently told me about his experiences of applying for jobs. Three people, two of whom were friends, had applied for a position in the North East. The interviewing principal came into the waiting room and said that he was not interviewing, as they all had very similar qualifications and credentials. All he wanted to know was who of the three would take the lowest sterling amount for a UDA.

He promptly gave them three envelopes and asked them to write down the magic number. One applicant wisely got up and left. Two of the friends remained and seemingly agreed to write down the same amount. Unfortunately, the friendship came to a catastrophic end when one applicant broke the pact and wrote a lower amount. He got the job and the principal pocketed the difference. The conscientious and capable, yet unsuccessful, candidate eventually relocated to Australia, the reservoir to which some of our UK talent drains.

When I heard this, my jaw dropped and my heart sank. This story smacks of a profession being squeezed from all sides, resulting in such acts of desperation. Imagine if you will dentistry in the UK as a sand-castle and we dentists each a grain of sand. When building a sand-castle, gently cupping the sand in a supportive way, as opposed to squeezing it tightly, is a more efficient way of dealing with it. Squeezing it too tightly results in grains escaping between the fingers, and by the time one reaches the castle site, there is nothing left in one’s hands, but a few grains. It appears that the hands that are designed to facilitate and accommodate our efforts to treat patients are gripping too forcefully, resulting in frustration and anger. Our young colleagues desperately want to build a career in this difficult and hazardous environment. Spare a thought for them and help if you can.

Editorial note: A list of references is available from the publisher.