SIR IAN GAINSFORD
Keywords: dentistry, education, training
J.R.Coll.Surg.Edinb.,44, June 1999, 141-5
Historical Background
In historical terms, dentistry has developed alongside institutions or centres of learning. A papal edict in 1072 required monks and priests to be clean shaven, and this introduced the professional barbers into the monasteries. A subsequent papal edict in 1163, which prohibited members of the church from taking part in operations involving blood letting, led to the development whereby those professional barbers became barber surgeons, who performed in the monasteries the lancing of boils, the setting of broken bones and the pulling of teeth.
Thus, medicine and dentistry started in tandem, with little organised teaching other than by apprenticeship. The pupilage system of education was in vogue at that time, as it still is for barristers today. In conjunction with a good basic education, the apprenticeship system had and has much to offer; after all, isn’t that what the Vocational Training Scheme is also about!?
Historically, however, although there were many students undertaking indentured apprenticeships with the surgeons, there were relatively few so called medical students, apprenticed to the physicians for clinical instruction. Even William Guy recounts that in his day, 3rd and 4th year medical students took jobs as unqualified ship's surgeons.
It wasn’t till the Apothecaries Act of 1815 that the Society of Apothecaries was provided with the power to decide on the requirements and regulations for their qualifying diploma. This, in the main, demanded at least six months walking the wards in a recognised hospital with courses of lectures in anatomy and physiology and two courses in the practice and theory of medicine. The Royal College of Surgeons of England, not to be out-done in terms of standards, also demanded similar requirements before their examination and so began a more formal programme for medical education. The Royal College of Surgeons of Edinburgh, I am informed, was ahead of them by a hundred years - although it wasn't until the Medical Act of 1858 that medical education was statutorily established.
Dentistry also had a background based on the apprenticeship system, with stories of practitioners reneging on their indentureships and starting up their own practice after only six months as apprentices. Thus, both the unqualified dentist and the so called qualified surgeon shared the practice of dentistry, although in the latter case it was mainly for dental extractions. However, it was William Guy’s tenacity, together with his colleagues, that led the drive to stop dental practice by unqualified dentists. As he says in his book, “I resolved to devote such energy as I possessed to arouse my colleagues from their lethargy and to persuade them, that legislation prohibiting unqualified practice was absolutely essential for the protection of the public.” He achieved success with the 1921 Dentists Act.
The founding fathers of the dental profession, amongst whom were Samuel Cartwright and John Tomes, wanted to establish a dental qualification in England, and proposed it through the Royal College of Surgeons of England. They clearly hoped that by doing so, it would be a separate, defined professional activity within medicine. They had the concept of the ‘licensed surgeon-dentist’. Others, however, wanted every qualified dentist to have the MRCS diploma by examination.
The issue and controversy at the time, I suspect, had more to do with the politics in relation to the refusal of the Royal College in England to accept specialisation of any sort, be it dentist, oculist, orthopaedist, or midwife. In any event, they stuck to the requirement of the basic MRCS diploma.
However, in institutional terms there is nothing like the risk of a break-away College to concentrate the mind. The establishment in 1856 of the College of Dentists in England certainly created strains. A group, opposed to this break-away College of Dentists, founded the Odontological Society of London, with Samuel Cartwright as President. Clearly, Cartwright and Tomes, of the Odontological Society, were more acceptable to the English Royal College that the breakaway College of Dentists. Although the Royal College of Surgeons of England still preferred to press for the MRCS diploma as the prerequisite for membership, it did at least help in formulating the clause in the Medical Act of 1858 which said; “It shall be lawful, for Her Majesty by charter, to grant to the Royal College of Surgeons of England, power to institute and hold examinations for the purpose of testing the fitness of persons to practice as dentists, and to grant certificates of such fitness.”
The English Royal College set up the LDS RCS diploma a year later and organised the first examination in 1860, the year that saw the birth of the Edinburgh Dental Hospital as the Edinburgh Dental Dispensary led by John Smith. The first dental diploma examination at this Royal College wasn’t until January 1879.
However, the architects of this dental diploma had to concede that the diploma did not qualify the holder to be entered on the General Medical register set up by the new General Medical Council under the Medical Act of 1858. From then on, the paths of medicine and dentistry went along separate but often parallel lines and ever since we have seen ourselves as the little sister to big brother.
There have, of course, been great leaps forward in the thinking and planning of medical and dental education since then. Perhaps the most significant, certainly since the Second World War, has been the Report of the Royal Commission on Medical Education, under the Chairmanship of Lord Todd, which reported in 1968; known as the Todd Report. It is to medicine what the Nuffield Foundation Inquiry into Dental Education in 1980, is to dentistry. So many of today's changes within medicine can trace their slow evolution from this Royal Commission. Clearly, the Nuffield Inquiry must be seen as the catalyst for significant changes in dentistry.
Whenever I hear or read the word ‘changes’ I am reminded of the famous quote from Gaius Petronius who wrote in 66AD regarding change “we trained hard, it seemed that every time we were beginning to form into teams, we would be reorganised”. He goes on, “I was to learn later in life that we tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.” How completely modern those words sound today.
However, the 1965-1968 Royal Commission on Medical Education, the Todd Report, did make a significant impact on medicine, but what was the response from dentistry to that Report? An ad hoc Sub-committee of the Education Committee of the GDC met over the period of 1968-1972 to consider the implication for dentistry of the Todd Report and also to consider ‘Related Questions’. They produced their report in November 1972, only just over 25 years ago.
The group’s remit was not only to examine matters relating directly to the recommendations of the Royal Commission, but also, to look to the ‘principles’ applied by the Royal Commission and consider how they might affect the future patterns of dental education and dental practice.
Amongst a whole host of definitions, was the one on Continuing Education. This the Report defined as the process whereby a dentist continues his education throughout his working life; and it says, “Where dentists in general practice are concerned this will normally be by way of refresher courses”. Clearly, there was an expectation that on qualifying there was nothing really more to learn but just to reinforce what one had been taught. This is confirmed to a certain extent by a further paragraph that reads “It is our view that the basic objective of dental education is, in general, being achieved at present so far as the ability to practice on graduation is concerned. We are not, however, so sure that all newly qualified dentists will necessarily either wish to seek continuing education or be able to absorb it as it develops”.
In a further paragraph, it goes on to say; “We accept the view implicit in all the evidence submitted to us, that to achieve the basic objective, dental students should be educated, so that, on graduation they have been provided with the academic background, skills and attitudes necessary to begin the practice of dentistry without further training ... At present we cannot see any trend in the development of the pattern of dental practice which will demand in the future any radical change in the nature of dental education. We share the view evident in the vast majority of submissions before us that no new objectives for dental education will need to be sought in the foreseeable future.” This, I remind you, was only just over 25 years ago.
The theme was that all dentists must be capable on graduation of providing treatment in all branches of dentistry. The only caveat to this was, that dentists should know their own limitations and should realise that it was no reflection on competence, that one recognised ones limitations.
Undergraduate and Postgraduate Training
What of the current GDC views some twenty five years on? It was perhaps the proposals of the Education Committee of the General Medical Council that has most concentrated our minds, in recent years, in that they issued a discussion document in 1991 on Undergraduate Medical Education - the Need for Change, which recommended a radical new approach to undergraduate medical education. After a period of consultation and with some modification, the GMC circulated its recommendations on Undergraduate Medical Education as a publication entitled “Tomorrow’s Doctors” and this now forms the basis of UK Medical School’s curricula.
Just to remind you, until the introduction of provisional registration in 1953, newly qualified doctors were legally entitled to undertake any form of medial practice without supervision and without any requirement of further training. They were free to engage in single-handed general practice including obstetrics, and frequently did so. Up to that time it was regarded as essential, in the public interest, that the doctor graduating from a Medical School should have a comprehensive knowledge of medicine to meet all contingencies. In legal terms the requirement was that “the standard of proficiency required from medical candidates at a qualifying examination shall be such, as sufficiently to guarantee the possession of the knowledge and skill requisite for the efficient practice of medicine, surgery and midwifery.”
It was the Goodenough Committee in 1944 that advocated that introduction of what was to become known as the pre-registration year. Arguing that it was no longer appropriate to let newly qualified doctors loose on the public, it recommended a period of service, providing general experience under supervision prior to the acquisition of full registration. It saw this period as an extension of the undergraduate course, still under the authority of the Universities, with a significant educational component and with gradually increasing responsibility for the care of patients.
The notion of a pre-registration year as part of the continuum of basic medical education, easing some of the pressure on the undergraduate curriculum, was endorsed by the Todd Report in 1968. This Report affirmed that “The undergraduate medical course does not provide sufficient training for the immediate practice of medicine”.
In 1975 the Merrison Committee of Inquiry into the Regulation of the Medical Profession regarded the pre-registration year as a failure, having found that; “all too often the graduate is treated as a much needed extra pair of hands rather than a probationer doctor still requiring supervision and training at a significant point in his career. Some doctors find themselves burdened with responsibilities they are not yet in a position to assume; others are given duties not necessarily relevant to their training needs.”
Dame Barbara Clayton, the Chairman of SCOPMDE (the Standing Committee on Post-graduate Medical and Dental Education), has highlighted that this also applied to Senior House Officers. However, with the Calman proposals in relation to specialist training in Medicine, we have seen a major shift, certainly in principle, to ensuring the relevance of these posts to training.
Although the Merrison Report did not improve the lot of the Pre-registration House Doctors, it made a number of recommendations which were embodied in the consolidating Medical Act of 1983, amongst which was a relaxation of the statutory requirements of the medical undergraduate course as assessed by examinations. No longer, for example, was the efficient practice of medicine, surgery and midwifery guaranteed.
In spite of the introduction of the pre-registration year and the relaxation of the statutory requirements imposed upon the curriculum, the perception of what newly qualified doctors should know and be capable of doing did not appear to have altered significantly in the eyes either of their teachers and examiners, or of those for whom they would work as house surgeons. There was a persistent drive towards an unrealistic degree of completeness in the curriculum, reinforced by a reluctance on the part of some Medical School departments to surrender what they saw as their entitlement and domain.
The new GMC recommendations remind us that, now, all doctors must undertake postgraduate training after pre-registration, in order to be able to practice independently in the public service, be it hospital or primary care. So, it is suggested that it may be appropriated to transfer some specialist work to the postgraduate years thereby freeing the undergraduate curriculum of some of the undoubted overload of factual material.
Such freeing up of the undergraduate curriculum would allow more time to be spent on encouraging medical students to develop appropriate attitudes and professional skills, including the ability to train themselves for a lifetime of self education.In my own Medical School a survey of recent medical graduates, in whatever practice they were now in, has revealed that as many as one in five wished that he or she had not studied medicine. Judging by what many of my general dental practitioner colleagues tell me, this is true for dentistry as well. Given that all our students are highly selected and brimming over with enthusiasm when they first come to us, this is without doubt a tragedy. The survey also showed that many of our graduates felt that the course they had gave too much emphasis to the accumulation of factual knowledge, but left them ill-equipped for their house jobs. I hear the dental graduate saying amen to that as well.
Specific proposals made by the GMC have also emphasised the importance of developing professional skills in the under-graduate. These should include communication skills, research and self directed learning. There should be both horizontal and vertical integration of teaching, with the boundary between pre-clinical and clinical being less distinct, and new methods of education should be available, including computer assisted and problem based learning - all maintained at the highest of academic standards.
Thus, the time has become ripe for dentistry, too, to re-evaluate its approach to the continuum of education, and recognise that the object must be to have a seamless education from the undergraduate period, through vocational training, through speciality training (of which general practice must be seen to be part), to self directed learning throughout the professional career. This has been recognised with the publication last year of the GDC’s Curriculum Review Group’s Report “The First Five Years”.
The Education Committee of the GDC sees the current debate as having several important components in this seamless educational programme of a lifetime of practice, often for more than 40 years, for the Dental Practitioner. The first component is the undergraduate course. Both medical and dental under-graduate courses are of five years duration, and both see some specialist knowledge in the current undergraduate curricula being transferred to the speciality or vocational training periods. Is it not time to see if there would be benefit in closer co-operation between the two professions in relation to their educational bases?
We recognise that the dental graduate shares many characteristics with the medical graduate but, of course, there are important differences. In contrast with the medical course, which has been stated to provide medical education for the generalist, the dental course is designed to educate a specialist within medicine as a whole.
One of Scotland’s distinguished sons, Sir David Mason, has written; “there is now a growing realisation that the dentist of the future should be a broadly educated health professional, who after a period of vocational or specialist training, becomes an ‘oral health care professional’ capable of combining the diagnostic and treatment planning abilities of the physician with the traditional manual skills of the dentist”. So perhaps, in my view, with a greater justification for the courtesy title of Doctor being recognised.
It has also been argued cogently that all medical and dental students should spend the first three years at University in a School of Life or Biological Sciences working for, say, a B.Med.Sci. degree with other health science students. After, maybe, a year and a half, students selected for medicine or dentistry would undertake appropriate clinical modules. Students not wishing to take up medicine or dentistry would proceed to complete their three year degree course. Equally, there would be science students on the course who would wish to switch to medicine or dentistry and, by following this B.Med.Sci programme, could do so without additional preclinical years of study.
Among the advantages of this approach would be: 1) it would produce better scientifically trained doctors and dentists; 2) it would allow for less wastage either by those dropping out after the current pre- clinical course, leaving without any degree; or by providing good science graduates who previously did not have a clinical place, opportunities from vacancies in the clinical course.
Dental schools do have reservations about common teaching to medical and dental students, for a number of good academic reasons, such as: the interests of medical students would take precedence; there might be a lack of dental relevance in the basic science courses; there would be problems associated with teaching large groups of students; and there would be disadvantages associated with one group of students attending only parts of a course designed for another group. We have, of course, to ensure that decisions are made with sound educational principles in mind for the benefit for the health care team of tomorrow, of which dentistry is a part. I am sure this debate will continue on a broader front and, if I can be excused a modicum of cynicism, will also be influenced by financial constraints imposed by the Education Funding Councils.
In any event, a combined course for Medicine and Dentistry could only be acceptable for dentistry if it were seen as part of the continuum of dental education. There should be an emphasis on encouraging dental students, like the medical students, to develop the ability to train themselves for a lifetime of continuing education.
So, a commonality of the early part of the Medical and Dental courses is perhaps the middle road between the founding dental fathers who wanted to be seen as members of the medical profession and those that see dentistry as totally separate.
Vocational and Specialist Training
This brings me to the second component of this seamless educational continuum, namely Vocational Training. The now well recognised benefits of this training have resulted in its mandatory status, although only, at the moment, for the General Dental Services within the NHS. It will need a change in legislation to make it mandatory for all UK graduates, and this is eagerly awaited.
The GDC accepts that, with the steady increase in dental knowledge and with the variety and complexity of dental techniques, it will not be possible for a student to become capable of sound independent judgement in regard to all aspects of clinical care, by the time of primary qualification. It is the policy of the Council that, regardless of the present statutory requirements, every dentists should undergo appropriate vocational training before entering independent practice; and should be aware of the limitations of their experience on qualifying and of the need for continuing education throughout their practising lives.
In our view, a two year period of vocational training, with the first year more closely supervised, is sensible. Necessarily, the first part of an expanded vocational training will be a time for some further instruction whilst the latter part might remain similar to the present highly successful Vocational Training programme in General Dental Practice. It would also allow more flexibility for the trainee to choose some additional experience in other dental specialities.
I referred earlier to the CMO’s review and subsequent Report on the Training of Hospital Doctors. This was mirrored by the CDO’s Report on UK Specialist Dental Training in 1995, which has allowed the GDC to progress its introduction of Distinctive (Specialist) Titles and Distinctive (Specialist) Lists. I have been privileged to be a party to many of the discussions that have led to the Accord between the Universities, the Dental Faculties of the Royal Colleges, the Postgraduate Deans and Directors and the Specialist Societies, which has ensured the implementation of the processes for Specialist Lists under the general direction of the GDC as the sole competent authority.
By establishing recognised training programmes leading to a Certificate of Completion of Specialist Training, under the aegis of the JCSTD, the GDC will issue the certificate and monitor the enrolment on the relevant specialist list. Of course, there will be a problem in relation to the transitional period. There will not be an equivalent to the so called 1921 Dentist, the last of whom gave up registering his name in 1994.
But, as many of you will know, there will be a transitional period of two years when there will be an opportunity for mediated entry to a specialist list. This will be based on an assessment of previous training, appropriate qualifications, clinical experience, relevant research and publications, teaching experience, continuing professional education and professional standing. In order to make this work, it is essential to apply a level of flexibility in its interpretation, recognising that the application of properly audited continuing professional and postgraduate education should be an essential component for retaining ones name on a specialist list.
A too rigorous interpretation of the regulations for mediated entry could result in others outside the profession being the arbiters in this matter. I consider the preferable option is the safety net of retention of one’s name on a specialist list being determined by the evaluation and audit of continuing postgraduate education.
Continuing Education
Which brings me to the last component of this continuum, and this relates to ‘continuing education’, which must be based on educational audit. I do not agree with the views of the 1972 GDC ad hoc group, who felt that not all newly qualified dentists would necessarily either wish to seek continuing education, or be able to absorb it as it develops. The General Dental Council would today, expect every graduate to undertake continuing self learning based on self assessment and peer review procedures. As Sir David Mason has said, “Educational Audit would encourage ongoing education and personal development, and re-certification and even re-registration might become the norm in the more distant future. But for the present we should see how much can be achieved by voluntary participation in these activities”. The proposals for Re-accreditation and Re-certification, which the present President of the GDC launched last year is currently being discussed in the profession and I have no doubt will become as important a feature for retention for dental practitioners generally as it will be for those on Specialist Lists.
I don’t need to tell this audience that dentistry has changed over the last ten years and dentists who qualified more than a decade ago, let alone three or four decades ago, now need properly audited and relevant further education. We recognise that much has been done, but we believe that the time has come to arrange standardised and comprehensive curricula for further education for all dentists, general practitioners and specialists alike, and in fact, all members of the dental team. This was highlighted in the Nuffield Foundation Report on the Education and Training of Personnel Auxiliary to Dentistry and has been incorporated in the GDC’s thinking for undergraduate education. We would encourage Postgraduate Deans, appropriate Colleges and other bodies to develop such curricula for continuing education in consultation with the dentists themselves as well as with dental auxiliaries, bearing in mind the special needs of individuals as well as professional groups. Ultimately, we hope that this process will enable the Council to satisfy that part of its statutory duty, by coming forward with future recommendations relating to continuing education.
There has been much discussion on how to monitor the specialists’ and practitioners’ commitment to continuing education. It is clear that we have a long way to go to ensure that this is honoured by all, not only the well motivated and dedicated. Audit and peer review, coupled with sanctions where appropriate (for example, by the protection societies, the private health insurance schemes, the new Faculty of General Dental Practice, the Specialist Advisory Committees of the Royal Colleges and by future statutory powers of the GDC), have all been suggested. But when one sees the success of the voluntary approach in the initial development of the mandatory Vocational Training Scheme, I can’t help but feel that an evolutionary approach might be the way forward.
Voluntary self regulation based on sound educational principles, including the use of self assessment and review techniques established in the undergraduate years, should ensure that the professional of the future can be a continuing student, without the need for sanctions (unless in exceptional circumstances), as envisaged by the Performance Review Scheme currently being debated. It is imperative we keep the debate alive and that everyone is involved in the interests of our profession and what is more important, in the interests of the public we serve.
Copyright date: 26th February 1999
Correspondence: c/o The Secretary of the Dental Faculty, The Royal College of Surgeons of Edinburgh, Nicolson Street, Edinburgh EH8 9DW, UK (Email dental@rcsed.ac.uk)
©1999 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.,44; 3: 141-5