Introduction

UK university medical and dental schools have well established career pathways for full-time academic and clinical staff,1 leading ultimately to appointment at either consultant or professorial level.

However, the potential for career progression for the part-time general practitioner who contributes one or two days per week to clinical teaching is limited. In the institution where the authors teach, grades are currently confined to clinical teacher and senior clinical teacher. If the teacher is on a specialist list then the grade senior specialist clinical teacher applies.

In addition, the requirements for promotion from clinical teacher to senior clinical teacher are onerous, including a minimum of three days per week clinical teaching, demonstrable leadership within the undergraduate syllabus and possession of a relevant postgraduate qualification and a teaching qualification.

Dental education in the UK has experienced a period of unprecedented growth over recent years. There have been huge increases seen in the numbers of both undergraduate and postgraduate students2 together with an accompanying growth in diversities,3 new pedagogic advances,4 higher all round expectations and of late, a funding squeeze.5

Current dental educators face a bewildering array of complex challenges and issues. The constant drive for personal professional and public accountability is ever set against the growing needs and demands of a sophisticated student body.6

Integrated primary patient care drives a plethora of research and development activity, which in turn feeds into the general milieu of dental education. The standard of education is regulated in accordance with the 1984 Dentists Act and the relevant regulations through the guidance published by the General Dental Council (GDC), the current one being Preparing for practice: dental team learning outcomes for registration.7

Within this guidance, the GDC, inter alia, places much emphasis on communication skills for the dental team, teamwork and professionalism, and the management of the clinical and working environment for individual patient care.

Primary dental care is perhaps the most significant area of clinical activity in the UK and where the majority of practising dentists are to be found. Committed part-time teachers drawn from this sector form a hugely important resource for any dental school, supporting as they now do the majority of the undergraduate clinical curriculum8 and a growing share of responsibilities in the post graduate sector.

Aims

This subject area is poorly reported with very little targeted research published. There are many widely held and differing opinions as to why general dental practitioners teach. Some are incorrect, incomplete or based on assumptions and perceptions that have no evidence base. This study attempts to address some of these shortfalls by exploring, through qualitative methodology, issues that affect the practitioner teacher. It is hoped that this work will stimulate a forum for debate and discussion for clinical educators from the rest of the UK and beyond. The authors believe it is timely to look into this important but long neglected area in order to better inform practice and to address some of the needs of part-time practitioner teachers.

Methods and materials

The cohort (n = 40) identified from the department's e-mail list were sent an anonymous online questionnaire (via www.surveymonkey.com) that had been developed, piloted and modified. They were invited to express their views as current clinical teachers. A follow-up reminder was provided two weeks later.

The survey was anonymous and designed to elicit both mixed qualitative and quantitative data. The questions are displayed in Table 1.

Table 1 The questionnaire used in the survey
Full size table

Results

The data derived from the questionnaire are presented in Tables 2,3,4,5.

Table 2 Response rate for the survey
Full size table
Table 3 The cohort structure and identification of key teaching attributes
Full size table
Table 4 Main quantitative findings of the cohort
Full size table
Table 5 Representative responses in respect of identified themes
Full size table

The total number of completed electronic questionnaires received was 31, giving a response rate of 78%.

Information in relation to the post-qualification experience, the length of service and the relative amount of teaching undertaken by the part-time clinical teachers in the department are collated in Table 3.

The two main thematic responses arising from the qualitative questions are collated in Table 5.

The respective quantitative findings for teachers expressing satisfaction or dissatisfaction are collated in Table 6.

Table 6 Respective quantitative findings for teachers expressing satisfaction or dissatisfaction
Full size table

The typical qualitative themes identified from teachers expressing overall satisfaction (73% of the cohort) or dissatisfaction (27% of the cohort) is collated in Tables 7 and 8.

Table 7 Respective findings for higher aspirational teachers seen as dissatisfied overall n = 8 (27% of cohort)
Full size table
Table 8 Respective findings for higher aspirational teachers seen as satisfied overall n = 22 (73% of cohort)
Full size table

Discussion

The use of an electronic questionnaire to gather data for this study offers many advantages. It has enabled an entire cohort of part-time teachers working on different days to be anonymously surveyed with relative ease and convenience. This approach is both cost effective and efficient compared with other more resource intensive methods.

The overall response rate of 78% is broadly in line with other similar non-incentivised surveys.9 However, there may have been a degree of selection bias within the respondent group. It is reasonable to assume that those who were more enthusiastic about their work would be more likely to respond than those who were not.

The design of the questionnaire allowed respondents to answer the questions honestly and in privacy, thereby potentially increasing the validity and reliability of the study.

Although comparatively small in terms of overall numbers, the survey covered an entire cohort of part-time teachers and provides a useful insight into the reasons behind their continuing involvement in clinical teaching as well as their professional aspirations.

Tables 5, 7 and 8 summarise the recurring themes identified throughout this study. They were arrived at by immersing the data and scrutinising the text responses in order to develop collective generalities, thereby confirming the theme.10

From this study two principal cohorts of teacher were identified. In the first the majority of the head count belonged to staff with five years or less teaching experience (61%) with almost a quarter of these (23%) in their first year of teaching. This is similar to the findings reported by others.11 The mean post-graduation experience was 16.5 years in the first group rising to almost 21 years in the second. Both cohorts contained practitioner teachers with advanced training and experience in primary dental care. The amount of time spent in the department was almost identical in each case, being on average a little over one day per week.

Nearly two thirds of the overall group appeared satisfied with their current position with a similar number seeing clinical teaching (part-time) as a long-term career option. However, one significant and striking observation was the virtually unanimous recognition across both groups of the need to acquire formal teaching and training skills12 in order to fulfil the role of a present day clinical teacher.13

This finding alone has potentially far reaching consequences for those who organise and employ part-time clinical teachers.14 It is becoming an inescapable fact that teaching (delivered at a dental school) should conform to a core of knowledge and be within a framework that demonstrates that required professional standards have been met.15

This institute currently offers its teaching staff free access to an extended teaching programme, which has enabled increasing numbers of part-time staff to further develop their contextualised skills and understanding of clinical teaching and education, mapped to the UK Professional Standard Framework in accordance with the guidelines from the Higher Education Academy.16

Of the 27% of teachers identified as not satisfied with their position, the numbers were principally (but not exclusively) drawn from those who had spent significant amounts of time in the department (Table 6). On average this cohort had spent 69% more time in the department as compared with those who stated they were satisfied with their position.

The key issues raised by many of these experienced teachers appear principally to be associated with perceived lack of status, title and career progression. The survey also reflects the fact that the current part-time teaching workforce stays with the department on average for 5.8 years, with 25% of them within the first year of their appointments. This level of dissatisfaction tends to reinforce the case for a coherent career pathway in order to improve quality, retention and job satisfaction for part-time clinical teachers, in line with observations reported by others.17 There are also echoes in this study that link to the known economic pressures on healthcare, dental schools and recruitment.18 The reliance on part-time clinical staff19 and the conflicting demands of research, service, teaching and practice commitments for part-time teachers,20 together with perceptions of the student clinical experience21 all add further support for the case for more work in this area.

With more graduate entry students found in dentistry, including those from parallel disciplines such as medicine and pharmacology22 it is suggested that their differing outlooks and demands, in part reflecting new fee structures will need to be addressed by an increasingly effective teaching workforce.

An encouraging trend seen in this study was the positive ranking of vocation, career development and professional contact, ahead of such attributes as lack of career direction, remuneration or status. Furthermore, professional contact with colleagues was considered important for a sizeable proportion (26%) of the survey; perhaps reflecting in part the often isolated nature of general dental practice. Indeed 91% of dentists on the GDC register according to the Faculty of General Dental Practice are described as general dental practitioners.23 An interesting observation reported from the respondents confirmed that on average part-time teachers spend 1.3 days per week in the department and deliver approximately 85% of the overall clinical teaching received by the students.

Part-time clinical teachers bring with them a wealth of experience, knowledge and expertise from precisely the area in which most dental graduates will practice. Their continuing contribution remains vital for the department to function as a viable teaching entity. A recent advance towards investment in educational development by individual teachers themselves now means there are already practitioner teachers at masters level with others to follow.

Allied to this there is significant growth in outreach teaching and its attendant need for additional high quality primary care practitioner support.24 This picture of increased part-time teaching activity contrasts sharply with the shrinking number of career academics now to be found within dentistry.25 To date there are no signs of any current changes to this trend.26

Conclusion

Part-time teachers have a very strong influence on the success or otherwise of the modern clinical curriculum. In our view they remain a vital but largely overlooked resource. To quote directly from one respondent:

'The Dental School would simply not survive without their contributions... a proper title and a viable career pathway would cost the institution very little'.

It is clear from our research the majority of part-time teachers do not seek remuneration as their main reward. It is our belief that job satisfaction, career enhancement and, in appropriate cases, a title befitting of status along with a viable career pathway are the likely main drivers. It is not known if other UK dental schools have similar experiences to report and what career structures are in place to encourage and reward teaching excellence and leadership.

These findings challenge the traditional ad hoc approach to clinical teachers that for so long has underpinned the system both in the UK and elsewhere. It is difficult to see how high teaching standards will be maintained when more and more reliance is placed upon part-time teachers, many of whom may have difficulty accessing appropriate teacher training and whose efforts are often insufficiently accredited or recognised.