Taking time to train

When you have the privilege of teaching in small groups, it is a wonderful moment when a student looks you in the eye and tells you 'Oh, now I see, yeah thanks, I get it - that was much simpler that I thought'. It is worth all those hours of background reading as a tutor, thinking how I can explain this in different ways so that all my students 'get it'. As a postgraduate student I can also identify with that 'Eureka' feeling, when an expert sat down with me to carefully explain growth rotations and their impact upon treatment planning within the context of a particular case (it's an ortho thing, you had to be there!).

The key factor in both stories is the importance of time – time taken to consider the individual students within the group and how they might build on their current knowledge, the engagement over time by the student when trying to master a problem, the time of the expert so freely given to support a colleague. There is also a shared element to these stories – in both cases the student and tutor had been working together over a period of several months. Several episodes of formal and informal teaching had allowed a level of trust and understanding of each other and their peers within the class.

The race to the exam, the ranking, and eventually the job now seems to overwhelm our undergraduate dentists, doctors, vets and nurses. There is a sense, possibly from GCSE onwards, of 'what do we need to know and when and how do you want me to show I know it?' The newly qualified dentist does, however, have an advantage over other professional colleagues.

Direct funding for training by GDPs

General dental practitioners directly funded the development of a 12-month programme of vocational training in the UK in the early 1990s in a move to support the newly qualified dentist. It was modelled upon the best experiences of those dental graduates who had found themselves an 'apprenticeship' within supportive practices with mentoring from senior colleagues and generous monitoring of their appointment books to ensure they had time to develop their clinical skills. These benefits were retained in vocational training schemes and combined with regular educational meetings with small groups of fellow new graduates.

Deanery involvement led to formalisation of teaching programmes, albeit with some flexibility each term for the group to shape the curriculum to suit their particular needs. The deaneries created standardised contracts of employment for both the newly qualified dentist and their mentor that preserved an educational environment within the training practice and ensured a year-long binding commitment from both parties to play their part in building the dental practice within which they both worked. Usually the practice owner was the 'trainer' (now 'educational supervisor', ES) who had a vested interest in developing a professional who enhanced the reputation (and the income!) of their business. If the young dentist enjoyed the experience and was then offered a position in that practice, it could lead to a smooth transition into self-employment with a team who already know them and who would support them when asked.

Risks of the current programme

No system is perfect. The development of the training portfolio was fraught with difficulties but gradually dentists followed the nursing and teaching professions in creating a professional portfolio that combined certain elements such as self-reflective journaling, logged activity, assessment and feedback. There were cases of difficult mentoring situations with unsupportive trainers who undermined or overworked the fledgling dentist or provided inadequate chairside assistance. Equally there have been sad tales of demanding or challenging young dentists with unrealistic expectations of their first workplace experience. Not every training experience was positive.

Benefits of the current programme

The weekly educational meeting with peers and a respected member of the Deanery educational team – firstly called advisors, more recently training programme directors (TPDs) – helped to slowly build networks of peer support that still exist 20 years later. Even if the training practice was less than ideal, a whole day each week to practise a new skill, refresh some relevant knowledge and also learn to help each other through difficult weeks were invaluable in developing membership of a professional body. The open yet protected environment of the small group or 'Community of Practice'1 who trusted each other was particularly important with 'best' and 'worst' parts of the previous week in practice shared and facilitated in the first hour of the day by expert TPDs. The TPDs and the lecturers invited to speak at these meetings were often general dental practitioners and trainers who acted either consciously or unconsciously as role models. Trainers were also required to attend regular meetings to develop their knowledge of educational theory and practise their teaching skills, which in turn created a further network of like-minded professionals that supported and learnt with each other.

Additionally the young dentists had at least one protected hour with their own trainer, once a week throughout the year in which to discuss – well, anything! This could include cases that had been particularly challenging, treatment planning, management scenarios, particular clinical skills such as suturing or crown preparation, or career advice. This is more than just role modelling, an important process in itself which often takes place when the role model is doing other things such as leading practice meetings or treating patients. The longitudinal nature of the vocational training relationship is more akin to one to one mentorship, considered to be beneficial for several areas of professional development including career success and career preparation.2 Successful mentorship should balance three key elements: support, challenge and a vision of the individual's future career.3 Mentorship is particularly effective when it is a two way process and both parties contribute their own area of expertise – for example a new graduate may have learnt the theory and evidence for a particular approach but had limited opportunity to undertake a technique practically, while the Trainer may have completed the procedure successfully hundreds of times without knowing that there was scientific support for that technique. These tutorials provided opportunities for both dentists to build on their strengths and discuss their weaknesses in a place of trust – perhaps over a mug of tea in an unhurried atmosphere.

Valuing the importance of time

A decade after the 'new' dental contract, some elements have been broken. The changes in contractual arrangements create little opportunity for young dentists to consolidate their skills by remaining within their training practice, fuelling the 'what do I have to do next?' rush to the next position. Increased numbers of summative assessments between 'trainer' and 'trainee' with satisfactory 'completion' has considerable potential to detract from the previous model, where newly qualified dentist and expert work together as qualified professionals, sharing knowledge and experience. Some training schemes have suggested larger weekly groups as a cost-saving exercise, diminishing the supportive nature of the community of practice. All of these factors were previously considered to contribute to the success of this training programme. However, one other element often remains ignored.

The particular beauty of the scheme relies on a 12-month-long relationship between practice teams, trainers, patients and a small group of peers. It allows everyone to move through Tuckman's stages of high-functioning groups – 'forming' with the polite introductions and doing as we are told, 'storming' where the strengths and weaknesses of the team's members are often identified, 'norming' where everyone learns to work together and to build trust, hopefully resulting in 'performing'.4

We ignore this crucial element of time when we talk about teaching and assessing professionalism. We talk instead of improving communication, observing self-reflective behaviour, competencies and clinical skills with the necessary armamentarium of work-based assessments and directly observed procedures in a largely summative portfolio to ensure accountability. We recommend Multi-Source Feedback for our graduates and also that they seek feedback from patients to ensure that their perception of their professionalism matches with the observations of those who surround them during their working day. All of this has become part and parcel of Foundation training, as we know it today. Yet our medical colleagues conduct workplace-based assessments for new graduates as part of short three-month placements, with different teams and changing peer groups. There is rarely a mentor who takes a personal interest, week by week for an hour at a time to help develop the professional identity of our medical, nursing or veterinary colleagues. When we talk about the development of insight within the monthly 'A DEPT' (A Dental Evaluation of Performance Test) assessment of our dental graduates, the trainer can score this from their longitudinal knowledge of the young dentist's approach, their assessment of a situation in a particular setting and their management. It fits rather well with the general dental professional's approach to patient care, striving for improved oral health with regular check-ups, preventative advice and long-term maintenance, rather than infrequent restorative or surgical interventions.

Conclusion

There is an undercurrent in educational theory that is acknowledging the bigger picture and respects the judgement of the fellow professional.5 Twelve months spent with the same members of a team, including long-term care of the same group of patients, provides the newly qualified dentist with ample opportunity for feedback, within a caring trustworthy setting. Public praise and private criticism allows the developing professional time to reflect, time to share their achievements and concerns with a successful and interested fellow professional, time to share their professional lives with peers and other role models.

There are times when speed is essential – no patient wishes to spend longer in the dental chair than necessary and equally students resent long hours spent in a lecture theatre when there are patients to treat and practical skills to hone. It is our opinion, however, that 12 months spent in the company of a team who care about your development, with caring mentorship from a fellow professional and a day spent each week learning from role models with your peers to support you, is an excellent way to develop professional identity.