Main

Vocational training (VT) was devised as a method of providing a structured introduction to general dental practice for newly qualified dentists. The idea was first mooted in the late 1960s following the publication of the Todd Report.1 Subsequently in 1976 the BDA Working Party Report on Dental Education2 was published and stated, 'In the same way and for the same reason that an undergraduate course cannot equip a student to be a 'finished' doctor, neither can it turn out a ready-made fully competent practising dentist. And it seems to us that the traditional objectives of dental undergraduate education, of producing dentists ready immediately for independent practice, must now be discarded.'

The first vocational training scheme was introduced in 1977 on a voluntary basis. Training Schemes were gradually developed around the country as funding mechanisms were put in place, and in 1986 a Committee on Vocational Training for General Dental Practice — England and Wales was set up by the Chief Dental Officer to allow for the introduction of a national voluntary scheme of post-registration vocational training, commencing in January 1988. By the early 1990s about 75% of new graduates were enrolling voluntarily on vocational training courses and the decision was taken that VT should be established as a requirement for entry to NHS dental practice. From October 1, 1993 it became mandatory for all dentists who wished to become principals in general dental practice within the NHS to undertake a 1-year vocational training course.

It therefore seemed that there was an opportunity for conducting a retrospective analysis of the opinions and experiences of young dentists who graduated during the years when vocational training was available but optional, and to compare and contrast the views of those who participated in the scheme with those who did not. Other studies which have explored these topics have indicated that a high proportion of recent dental graduates have been pleased that they chose dentistry as a career and have been happy in their chosen sphere of dental practice.3 Opinions on their experience of vocational training and the degree to which it prepared them for independent practice have also been positive, though there has been some criticism of the quality of training in some practices.4,5 The aim of this paper is to compare the experiences of dentists who spent their first year in practice as vocational dental practitioners (VDPs) with those who spent their first year in practice as associates (non-VDPs). The data used were extracted from two postal questionnaires circulated in 1997 as part of a larger study looking at the long-term effects of vocational training.

Method and materials

The sample

The sample was drawn from dentists who graduated from the University of Leeds Dental School in the years 1988–1990, dentists who graduated elsewhere, but participated in a vocational training scheme in Yorkshire in 1989–1991, and dentists who graduated from other dental schools in 1988–1990 and who were practising in Yorkshire in 1997. The addresses of Leeds graduates, obtained from the administration office of the Leeds Dental School, were checked against current and past Dentists Registers. The addresses of dentists who graduated from other dental schools, but participated in a vocational training scheme in Yorkshire, were obtained from the VT registers kept in the Dental Postgraduate Office at Leeds. These were also checked against addresses in the Dentists Registers. The names and addresses of the sample of graduates from other dental schools, but working in Yorkshire in 1997 were obtained from the general dental practitioner database kept in the Dental Postgraduate Office at Leeds. The names were then checked against the VT registers obtained from the Committee on Vocational Training.

A self-administered questionnaire with a covering letter, giving details of the study and asking for their co-operation, was sent with a stamped-addressed envelope during October and November 1997 to the 210 dentists selected. Around 43% of questionnaires were returned within the time specified and a further 14% within 6 weeks. A first reminder letter was sent out at the end of November and a further reminder letter in January. Telephone calls were used to follow up the remainder of the sample who had not responded. Forty-seven questionnaires had been sent to invalid addresses. Thirty-three of these could not be traced but 14 were successfully redirected. Two questionnaires were not returned because the recipients were currently medical students and felt the questionnaires were not applicable. One questionnaire had been sent in error to a dentist who had qualified in 1985, one of the returned questionnaires was not completed and 19 questionnaires were simply not returned. At the final count 154 (73%) of the questionnaires had been returned and found suitable for inclusion in the study. In total, 50% of the study sample had participated in vocational training.

The questionnaires

A questionnaire was designed for graduates who had participated in a vocational training scheme and a second questionnaire for graduates who did not do vocational training. The questionnaires covered three main areas. The first section asked for personal details, eg age, gender and qualifications. The second section sought the opinions and experiences of the newly qualified dentists during their first year in practice as vocational trainees or associates. Questions were also asked about their choice of entry into dental practice, the effect of their first year on their continuing education, aspects of general practice not covered during vocational training, and the advantages and disadvantages of vocational training. The final section asked, in detail, about their continuing professional development. This paper is concerned only with Sections 1 and 2. The resultant data were analysed using the statistical package SPSS for Windows. The baseline numbers vary as not all the respondents answered all the questions.

Results

Of the 154 respondents used in the study 82 (53%) were male and 72 (47%) were female. This approximates closely to the proportion of male and female graduates from the Leeds Dental School between 1988 and 1990: 51% male and 49% female. However, a slightly higher proportion of females undertook vocational training and they accounted for 54% of the vocational dental practitioner group. More than half of the sample, 57%, had graduated from the Leeds Dental School and the remainder from the various dental schools throughout Britain (Table 1). The majority of the dentists, 84%, fell into the 30–34 years' age group.

Table 1 Table 1
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Vocational trainees (VDPs)

All of the VDP respondents except one, who had worked for a year as a house officer in the hospital service, commenced VT immediately following graduation. Sixty-nine (90%) completed a year in vocational training while the remainder spent between 6 and 11 months in the scheme. Of those who did not complete the vocational training year, one left to work in Australia in the Flying Doctor Service, and the remainder secured positions as associates. One was offered an associate position in the training practice and continued to work there for 5 years. The others moved to work in other practices and in three cases stated that their decisions were prompted by feelings that they were not receiving support from their trainers.

Several reasons were given for choosing vocational training (Table 2). It was seen as a good career move by 53% as they felt it would provide a gentle introduction to general practice and an initial structure to their careers. Forty-six per cent thought the educational component would be beneficial and found the study days attractive. A similar proportion thought the salary would provide security and would not put them under pressure to work fast to increase their earnings. Twenty-eight per cent hoped the support they would receive would give them confidence and provide guidance.

Table 2 Table 2
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Seventy-seven per cent of respondents said they had been offered a sufficiently wide variety of practices from which to choose to do their training. When asked to identify any aspects of general dental practice which they felt had been omitted or poorly covered in their training year, 40% identified business/practice management, quality of training and experience in minor oral surgery. Overall the training received was rated as satisfactory by 87% of respondents and as very good or excellent by 39% of respondents. Only 13% rated it as fairly poor or poor. If they had to make the choice now, 95% said they would still choose to do VT although 43% felt they would have liked their VT year to be different. A very wide range of reasons was given as to what differences they would like to have seen in their VT year. These included more informative study days, more supportive or better trainers, a closer monitoring of trainers, a different adviser, a better practice and more experience with difficult patients. Despite these drawbacks, 86% of VDPs were satisfied that their vocational training year had met their professional needs, and 92% indicated that it had fulfilled their personal needs (Fig. 1). Fifty-five per cent of the sample continued to work in the same practice at the end of their vocational training year: 17 dentists stayed up to 1 year, 7 up to 2 years and 10 were still there after 8 years.

Figure 1
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Vocational training met personal and professional needs (% n = 77)

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Opinions were sought on the three most useful and three least useful experiences gained during vocational training (Table 3). Seventy-four per cent of respondents put clinical experience at the top of their list of most useful experiences. This included gaining 'clinical confidence in decision-making', 'trying out new techniques without time pressure', 'dual sessions with the trainer in more complex treatments' and producing realistic plans of treatment. Contact with colleagues, which included weekly contact with other trainees and meeting other dentists was considered the second most useful experience by 42%. The third most useful experience, indicated by 35% of the cohort, was the educational component acquired through the study days, which helped to consolidate undergraduate teaching and encouraged an interest in postgraduate education. In contrast, when asked to identify the least useful experiences, 60% of those who responded were critical of their study day experience. Some lectures had not been of a high calibre and contained information which had already been covered in their undergraduate course. Twenty-two per cent were critical of their trainers, and a similar proportion felt their clinical experience had been unsatisfactory. Various reasons were offered, including 'not enough patients', 'too many patients', 'not enough supervision' and being given awkward or difficult patients. Five trainees had found the attitude of the ancillary staff difficult to cope with.

Table 3 Table 3
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In response to questions about the advantages and disadvantages of vocational training (Table 4), just over half of those who responded, 51%, considered the gradual introduction to a career in dental practice was the main advantage. This provided the VDP with 'the opportunity to advance and improve and learn about all aspects of practice in a low pressure environment'. Thirty-seven per cent thought the social interaction with their peers, enabling them to compare experiences and to receive support was a major advantage while 31% thought the support of the trainer and other colleagues in the dental practice important. Several other advantages were put forward including the security of having a salary, the continuing education component, the fact that practices were vetted for standards, and training in business management.

Table 4 Table 4
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Eighty-two per cent of the sample responded to the question on the disadvantages of vocational training. Twenty-five per cent of this group voiced the opinion that there were no disadvantages in vocational training. On the other hand, 27% suggested poor trainers were a significant disadvantage. Vocational training 'relies heavily on trainers to provide necessary support – there will always be trainers who will not provide adequate clinical assistance or trained nursing staff'. Twenty-two per cent saw imperfections in the scheme, such as 'lack of parity between trainers and practices', and the difficulty in 'changing practices if the wrong choice is made' as serious deficiencies. Eleven per cent thought the poor use of study days was disadvantageous to vocational training. A similar number suggested the trainee was 'cushioned too much', and vocational training did not allow the trainee 'to appreciate the amount of work needed to actually earn a living balanced with an acceptable standard of work'.

When asked if they were satisfied that dentistry had met their personal and professional needs over 80% of the sample said they were satisfied or very satisfied with their chosen career (Fig. 2). In addition 74% indicated that vocational training had encouraged them to maintain an involvement with further education and professional development.

Figure 2
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Career in dentistry met personal and professional needs (VDPs %, n = 77; non-VDPs %, n = 77)

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Non-vocational trainees (non-VDPs)

Respondents who did not do vocational training were asked why they had not taken up this opportunity. An assortment of reasons was given. The majority, 58%, gave the scheme itself as the main reason for not participating. At that time places were limited, the choice restricted and it was difficult to get on a scheme. It was also seen as an easy option, which catered for those who lacked confidence. Further, some considered that as a relatively new system, VT was not organised enough and there was not enough financial incentive. More personal reasons were given by 51% of respondents. These included a preference 'to go it alone', or a feeling that 'training was adequate'. A sizeable minority of dental graduates, 27%, wanted to work in hospital either because they thought they might want to follow a hospital career or felt they would improve their confidence and skills by spending their first year as House Officers. Individual dentists indicated that they had received negative feedback on the quality of trainers, training practices and educational study days.

The questionnaire asked the dentists what they felt were the three most useful experiences they had acquired during their first year as dental practitioners (Table 5). Clinical experience, learning how to run the business of dentistry, and patient management skills were most useful. A number of dentists found learning to work as part of a team, dealing with staff and the importance of working with a good nurse, practice manager and receptionist very useful. For 17% of respondents the first year in practice taught them to stand on their own feet, what to look for in a principal, and what sort of dental practice to look for, while others found the support and accessibility of experienced practitioners very useful.

Table 5 Table 5
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Respondents were also asked what they felt were the three least useful experiences they had undergone during their first year in practice (Table 5). Twenty-two per cent said they did not have any experiences that were not useful. However, 37% found their team experience, ie working with poor staff and lack of help and support from the principals, to be least useful. Thirty-three per cent felt their clinical experiences in some instances had been unsatisfactory and found it difficult to 'maintain high standards of work compared to training'. The personal experiences of 27% of respondents identified problems which included feelings of isolation and financial pressure. Business management problems were encountered by 24% of respondents, and included, 'time management' and 'struggling to fill out NHS forms'.

When opinions were sought on their perceptions of the advantages and disadvantages of vocational training, several strengths and weaknesses were presented despite the fact that the respondents had not participated in a training scheme (Table 6). Fifty-one per cent said they thought a VT year provided security and an insight into the running of a practice. It further offered a good foundation on which to build a career regardless of whether one followed a career in the hospital service or general dental practice. Thirty-two per cent felt it encouraged postgraduate training and provided a structured learning pathway. Other advantages put forward were the support received by the VDP, and the inculcation of the idea of good clinical practice. On a more personal level they considered that VT allowed for social interaction with one's peers. Seventeen per cent of those who had not participated in a training scheme indicated that there were no disadvantages in vocational training. On the other hand, 28% of respondents felt vocational training could have a detrimental effect on the career of the VDP because it did not prepare for the rigours of NHS dentistry, and the incentive to work hard was not there. Also it delayed entry into hospital for those who wished to follow that pathway. Twenty-six per cent considered the salary was disproportionate to actual earnings and 15% thought some trainers were 'not ideal'. A small number of dentists felt there were too few places and inconsistencies in practices, the educational content not stimulating and that the VDP 'tended to get everything nobody else wanted to do'.

Table 6 Table 6
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The majority of this group was satisfied or very satisfied that their career in dentistry had met their personal needs (80%) and professional needs (88%) (Fig. 2). Twelve of the non-VDPs were still working in the practice in which they started and 17 spent 4 or more years in their first practice. Five dentists stayed in their first practice for 6 months, 5 for up to 1 year and 18 for up to 2 years. Only 48% indicated that their first year in practice had encouraged them to continue with the development of their education and professional training.

Discussion

Most of the dentists who took part in the study were under 35 years of age and just under half of the group were females. The majority of respondents saw vocational training as the way forward. If they had to make the choice now 95% of those who had participated in a vocational training scheme would still make the same choice, and 45% of dentists who had not entered the scheme indicated that they would do so if they were making the choice today. The vast majority of VDPs indicated that they were satisfied or very satisfied that their training year had met their personal and professional needs and both groups were satisfied that their career in dentistry had met their personal and professional needs. Very few expressed dissatisfaction.

Perceptions of vocational training clearly influenced the choice of whether or not to enter the scheme. The prospect of a structured introduction to practice and the support of trainers, advisers and the peer group appealed to many. Others were attracted by the greater freedom and independence of associate status and were also influenced by critical feedback from colleagues on aspects of the vocational training programme.

A number of respondents from each group felt all their experiences, both positive and negative, during their first year in practice were useful learning curves. For those who felt some experiences were more helpful than others, the priorities of each group, with the exception of clinical experience, were quite different. The VT group put social interaction with their peers and the educational component at the top of their list whereas non-VDPs found learning how to deal with patients and the business of practice of most use. Perhaps because business management and patient management skills were integral parts of the study day curriculum, VDPs did not consider them in isolation as most useful experiences.

Most VDPs were very positive about vocational training. Where criticism was made, it tended to be directed towards the content of the study days, poor relationships between trainers and trainees and unsatisfactory clinical experience. The views and opinions of the respondents suggested that the experiences of vocational dental practitioners varied greatly and that there was a wide variation in the standards of training, training practices and trainers. Interestingly dentists who spent their first year in practice as associates produced a similar picture to VDPs with regard to their experiences of working in a practice. Most were happy with their situation and felt their principals had provided excellent support and training during their first year in practice. However, a substantial minority felt there was room for improvement. Over 30% had difficulties working with other members of the team and in particular with their principals; they felt they had no encouragement, support, or help from them. Three associates said the principal did not work in the same practice, therefore 'there was no mentor to ask for advice'. More non-VDPs experienced problems in the areas of business management and personal development. Losing contact with colleagues led to some dentists feeling very isolated. Others missed a structured dental education programme and realised that it was up to them to seek out postgraduate education for themselves.

Prior to the introduction of vocational training schemes many principals provided high standards of training and support for the newly qualified dentist. This is borne out by the views and opinions expressed by the respondents who had not participated in a vocational training scheme. However, there was no mandate for principals to support new associates and standards varied greatly. It was intended that the vocational training scheme would provide a framework in which all newly qualified dentists should have the benefit of the best support and advice available. Yet, a proportion of those who participated in vocational training suggested that standards within and across training practices remained inconsistent. It is important to bear in mind, of course, that these were early days when relatively few dental practitioners were willing to become trainers and therefore choice was limited. Although vocational training is now well established, with protocols in place to deal with problems, the dynamics involved remain fluid and thus the monitoring of standards should still remain a priority.

Conclusion

Vocational training was highly regarded both by VDPs and non-VDPs. The training relationship in the practice is central to the success of vocational training. Advisers need to have strategies in place to foster that relationship and to provide help when problems arise. The content of study day programmes needs to be reviewed regularly to ensure that it is relevant to the needs of VDPs and that it sustains their interest and fosters the commitment to lifelong learning and continuing professional development.

The sample used for this study was a selected group and therefore the results cannot be generalised beyond the confines of those who participated. Nevertheless, the information gleaned from the study is relevant to the on-going debate on the structure and content of vocational training to ensure the scheme, at a national level, meets the needs of the newly qualified dentist.

The authors are most grateful to the dentists who participated in this study.