Professional opinions

30 August, 2010 / business

Despite covering topics as diverse as dental education, the commercialisation of dentistry and the problems surrounding decontamination, those attending the latest round table evening kept coming back to one element that seemed to neatly underpin the whole debate: professionalism.

There was unanimous agreement that in order to survive the various slings and arrows that come your way through a typical dental career, the one thing that will stand you in good stead is a commitment to professionalism in all its forms.

With two dental school deans in attendance, Kevin Lewis, Dental Director of Dental Protection Ltd (DPL), opened the evening by talking about education, both undergraduate and postgraduate. He remarked that DPL often see people who have “slipped out of the profession” by not attending courses and meetings, and having regular contact with their colleagues and peers. They then head off on a short course on something as complex as implants and start working beyond their competence without realising it.

Professor Bill Saunders, Dean of Dundee Dental School, responded by saying: “What we are really talking about in many ways is professionalism in its widest remit. We try very hard, and it is difficult, to teach professionalism, to try to understand what is meant by professionalism and how indemnity and so on fits into this. Overall I think we have still got a lot of work to do but sometimes when you go into these cases, it’s not as a result of their experiences as an undergraduate, it’s their experiences when they leave.”

He said he felt the new generation of dental graduates may not have the same level of commitment as previous generations: “I know that when rotary endodontics first came up, I spent hours in the lab playing around with blocks and extracted teeth, and learned how to do it. There doesn’t seem to be that attitude these days. Come five o’clock they all want to disappear and do other non-dental related things.”

Kevin Lewis agreed by saying that the young people coming into the profession seem to be of a different world and these generational issues do create different problems dento-legally. But, he also argued that: “You are taking in a much richer crop of academic people, I mean I probably wouldn’t get into a dental school today.”

Professor Jeremy Bagg, Head of Glasgow Dental School, remarked that he was offered a place at Edinburgh to read dentistry if he achieved two D grades at A-Level. “And now if you haven’t got straight As you haven’t got much chance of getting into Dundee or Glasgow,” he said. “In a sense if dental students are not successful in their education at university, it is actually us who have failed, because we get the absolute cream of the crop.”

Returning to Professor Saunders’ point, Charles Ormond, Falkirk-based GDP and Vice Dean of the FGDP, said that younger dentists want different things. He said: “They want instant gratification, they also want a better work-life balance, which is why they don’t sit all night with their blocks. They are a different breed probably from what, looking around the table, we were.”

Professor Saunders agreed with Charles Ormond’s assertion but also pointed to the fact that the dental students are “the best students in the university”. He continued: “Sometimes they ask us: ‘Why am I still here working in a clinic when the whole of the law faculty has graduated?’ And maybe sometimes we are a bit hard on them. But one of my worst jobs, I think, is standing up in front of the first years when they first arrive and saying: ‘Welcome to Dundee, this is a great place but don’t let me catch you doing this, this and this, because professionalism starts now’. And it’s tough for an 18-year-old.”

The discussion then turned towards the pressures placed on dentists and the temptations to see dentistry as a way to make money ahead of patient care. Kevin Lewis pointed out that today’s UK dental graduates are statistically much more likely to be sued during their career than a graduating medic, lawyer, accountant or architect. “But they are all coming from the same generation, so other factors must be at work here,” he said.

“I think it has got a lot more difficult for the new graduate,” Charles Ormond replied. “In my day we were brought up on this concept that you had to make somebody dentally fit. That gave you a goal to go for and it was an easier remit to work to, whereas it has got more difficult for them in some of the things that they are being asked to do.”

Professor Bagg then highlighted the way dental outreach training gives undergraduates valuable clinical experience. He explained that he believed it was a great way for them to develop confidence and their clinical skills, in a real world environment. Professor Saunders agreed and noted the success not just of the local outreach but the distance outreach his students were undertaking in Inverness and Aberdeen. Yann Maidment, private GDP from Edinburgh, then said: “This goes right back to when we were talking about professionalism. Outreach is where they are going to learn the soft skills of how to apply things as well as professionalism. Yes, you can learn the clinical skills in a dental school, but are they going to be able to apply it in a proper fashion? That’s where the outreach fits in I think.”

The question of competence was then touched upon with Professor Saunders saying that there is a need to challenge the idea that you are a competent dentist on qualification: “We need to say to students ‘You might never be competent to do this’ and therefore you must know that you are not competent to do it and refer it to someone who is competent. I think this is already being seen in practice in Scotland because of the number of referrals we now have to secondary care. It is shooting up.”

Andrew Lamb, National Director for the BDA in Scotland, then posed the question as to what we are training dentists to be in the future? With dentistry becoming more and more complex he asked: “Is the general practitioner going to be a gatekeeper and farm people off in different directions for example to hygienists, therapists or specialists and do very little hands-on dentistry? Or are they going to be more oral physicians, making judgements about the risk of oral disease developing?”

Professor Bagg replied by saying: “I don’t think the profession knows at all where it is going in terms of what the roles of all these people are going to be. I think a lot of it comes down to how dentists are remunerated.”

Hugh Harvie then asked the group what their thoughts were in relation to the growing commercialisation of dentistry, in particular dentists responding to commercial pressures by embarking on courses of treatment or techniques that they have little knowledge or experience of.

Andrew Lamb replied: “We started off talking about professionalism and if the dentists behave professionally they will not go beyond their competence. I think that’s the important thing.”

Kevin Lewis said that as dentistry is continually evolving, every generation of dentists has no doubt ended up doing things that they weren’t taught at dental school. “Some dentists will become competent to carry out these procedures but others will not,” he said. “Education can teach people how to learn and apply new skills and knowledge responsibly, but competence and ethical responsibility go hand in hand. If treatment isn’t necessary in the first place, the fact that you can do it outstandingly well is irrelevant.”

Yann Maidment responded by saying that it can be difficult for dentists to know where their competencies lie and when to refer and seek advice. He argued that if you have given your best dental advice and the patient still
wants the other option, do you let them walk away to another dentist or do you try and find a way to meet their desires? He said: “This is how as a profession we can get people to come and see us because of what they want and hopefully guide them towards what they need as well.”

Hugh Harvie then spoke about how he has seen, over a number of years, a rise in complaints associated with over-ambitious treatment plans and not matching the patients’ expectations.

“The expectations of patients are now so high and in some cases they are completely unrealistic,” said Professor Saunders. He went on to argue that his medical colleagues don’t have anything like the amount of problems facing dentists in this regard. He said: “If you have a total hip replacement and it still gives you a bit of pain afterwards, that’s life. If you do a root canal treatment and the patients still gets pain, you get sued.”

Charles Ormond argued that dentists might set themselves up for a fall in some respects as medical doctors will cite the odds and statistics for success and failure, while dentists rarely give out the failure rates for their treatments. When they do it is often only after a failure, which can then come across as the dentist making excuses.

Helen Kaney, dento-legal adviser for Dental Protection based in Edinburgh, said: “And that’s what patients think sometimes, that when you explain that to them afterwards, they think it’s an excuse. This is a known factor with patients proceeding with complaints and claims.”

Inevitably if you bring a group of dentists together the conversation will at some stage come round to the thorny issue of decontamination, and this evening was no different. However, with Professor Bagg at the table there was an opportunity for the other guests to quiz the microbiologist who has been a member of the group that has been producing guidance documents on the subject for the Scottish Dental Clinical Effectiveness Programme (SDCEP).

Professor Saunders raised the issue of the ongoing costs of single-use instruments and central sterilisation at the main hospital in Dundee. He explained that he can use up to £70 worth of sterilised instruments for one case. “It’s crazy,” he said. “How can you expect an NHS dentist to do a decent job of molar root canal treatment when he’s having to fork out that sort of money before he even starts?”

Andrew Lamb agreed by saying: “It’s the revenue costs of running the LDUs that will be far more taxing for dentists than the money that is required for the capital. It is the revenue costs that are really going to hit the practices in the long term.”

Professor Bagg responded by saying: “In terms of endodontic instruments, I accept that the costs are big. Andrew Smith and I have published three papers where we have looked at visual contamination, we’ve looked at blood contamination and we’ve done work with a physical chemist in London looking at protein contamination. You cannot clean these instruments.

“If you can’t clean it properly, you cannot sterilise it. So I have absolutely no problem with the science or the evidence behind saying that these instruments should be single use.”

He went on to explain that he believes it is about finding a balance and assessing risk. He spoke about the advantages of getting decontamination procedures out of the surgery but he questioned the suggestion that you need four rooms in order to undertake decontamination successfully. He then highlighted the Scottish survey on decontamination that he was involved with and said: “There were a lot of practices that were trying very hard, but there were a large number of dental nurses that were working their socks off to do the wrong thing, because they hadn’t been told how to do it properly.”

Yann Maidment, who has been running an LDU in his practice for the past eight months, said: “It has to have someone on it all the time or it will slip back. It has to be managed, there has to be a management system that returns to it, and the people doing the job know it is going to be returning at regular intervals. Or you will start to find bits of cement on your probes.”

The conversation then returned to the revenue costs with the agreement being that while the capital money available to dentists was welcomed, it is the revenue costs that are the real worry. Professor Bagg then highlighted the fact that there are fundamental differences of opinion between the experts. He asserts that instruments need to be ‘sterilised’ but not ‘sterile at point of use’, while he has colleagues who believe they need to be sterilised and also sterile at point of use. In order to satisfy the latter you need to be wrapping all instruments before sterilisation and working with a vacuum autoclave as well as contending with all the running costs that involves.

He said: “I would be perfectly happy having dentistry performed on me with instruments that have been sterilised in a non-vacuum autoclave and appropriately stored under aseptic conditions. You have a fairly rapid turnaround of dental instruments in general practice and I would much rather that the instruments were sterilised properly, unwrapped in a non-vacuum autoclave, than to go down the vacuum route and having people not doing the testing and having packaged instruments coming out of autoclaves that might not be working properly.

“If you take the vacuum autoclaves out of the equation, it would make a huge difference to the revenue costs.”

Professor Bagg also explained that it is very difficult to prove that an infection is, or has been in the past, transmitted to patients in a dental setting. He said: “It’s easy to see MRSA on a surgical ward because it presents in the form of post-operative

infections. You do microbiological cultures, undertake typing of the organism, show commonality and you know you’ve got an outbreak. But with something like hepatitis C it could be 25 years before the patient develops symptoms and trying to pin the source of infection down to a single dental appointment is virtually impossible.”

Andrew Lamb then asked if the focus on vCJD that followed the Glennie technical requirements has made things more difficult for decontamination to gain full acceptance amongst the profession.

Professor Bagg said: “The Government hadn’t taken any serious interest in instrument decontamination since the Nuffield review in 1959. Concerns were raised with the emergence of prion diseases and suddenly a transition to gold standard procedures was expected in a short period of time.”

He explained that he had hoped that revised decontamination procedures would have been introduced more gradually over a longer period of time: “By dealing with some of the straightforward issues, it didn’t need to cost a lot of money to get us to a quality standard where we could say to the public that we are confident they can go to the dentist safely.

“Yes it is always great to be gold standard, but if risk-benefit analysis is considered, I think the acceptable standard is actually slightly below what some of the authorities are suggesting we aspire to.”

With thanks to Dental Protection Ltd and the Apex Waterloo Place Hotel, in Edinburgh.

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