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A number of years ago a Dutch Professor of Orthodontics was visiting Leeds to lecture to postgraduate students in orthodontics and paediatric dentistry. During an evening dinner, he suddenly asked:

'Why are you British so obsessed with Alphabet Soup? You have strings of letters after your names, sometimes more than in your name, yet you do not seem to be any better qualified than the rest of us.'

Since then I have often thought about those remarks as I read papers and documents related to postgraduate education by authors with strings of letters after their names. I hasten to add that I am guilty as the rest of us on this issue. As I have also had opportunities to visit with colleagues in dental specialities around the world I would have to agree with that Dutch professor that our specialists have no greater knowledge or capability despite all these qualifications.

Reading the postgraduate qualifications list we see FDS in various forms, DRD, MRD, MSc, MDentSc, MClinDent, M/D. Orth and Memberships in various specialities. Multiple FDSs are also common whereby postgraduate students have taken several as insurance to passing. And then there is the strange qualification of RCS that appears along with FDS as FDS, RCS. Many parents have over the years told me that their dentist has a number of qualifications including RCS.

How did all this come about?

The system of postgraduate studies leading to specialisation is old in the United Kingdom dating back to the gradual separation of oral surgery and orthodontics from mainstream general dentistry over a hundred years ago. This meant that it was rooted in an approach that I would describe as a Victorian apprenticeship training system. The emphasis here is on the word training that continues to affect our attitudes to postgraduate studies.

A training apprenticeship requires repeated repetition of tasks to achieve a necessary standard of skills. By and large the educational aspects of such an approach are neglected or reduced to a minimum. Therefore, the student achieves a high standard of skill but does not necessarily have an in-depth knowledge of the aetiology and science of the skill in question. The result of this approach is that there are many courses insisting on eight or nine clinical sessions per week with hardly any didactic study at an advanced level. Research studies and practice in these programmes is minimal.

The net result is a system of apprenticeship examinations each tier a higher one than that before and each with a qualification generating yet more alphabet soup....

This attitude of training persists and is seen even in the terminology that we use. Thus, we talk about postgraduate training, national training numbers (NTNs) and training programmes. The terminology in the twenty-first century should be 'education' and we should only talk about postgraduate 'education' programmes. The use of the word 'training' inevitably leads to the concept of restricting postgraduate studies to limited numbers, as has been the attitude for centuries in restricting entry to ancient guilds so controlling the number of apprenticeships and hence Masters available. This mind set is particularly prevalent in the Department of Health who, year after year, obstruct enlargement of speciality numbers by a system of NTNs etc. The net result is a system of apprenticeship examinations each tier a higher one than that before and each with a qualification generating yet more alphabet soup.

Proliferation of qualifications

Because of the way that the specialisation process has been allowed to develop, bit by bit, so there has been a proliferation of qualifications generating more alphabet soup. Before entering any postgraduate studies in the UK a special 'entry' qualification is needed. This requires the prospective student to study, yet again, those subjects completed in dental school and, to be sure of a better chance of passing, attending cramming courses.

Once embarked on a 'training' course further qualifications are required in order to complete the programme. The GDC issues only a certificate of completion of specialist training (sic) or CCST, yet all three year courses require a Membership and in many cases a Masters degree. Once over this hurdle the aspiring hospital specialist (consultant) has a further period of 'training' before embarking on an exit fellowship/intercollegiate examination.

Not only do all these examinations require many hours of additional cramming, and not study, but also expense. The total of examination fees, courses, living costs, as well as perhaps a young family to support, add up to a considerable financial burden.

Other Approaches

In North America we find dental specialists in practice with a DDS and a letter of specialisation or DDS, MS. This simplified approach seems to serve just as well....

In many so-called Western Countries, specialisation is now recognised or there are courses of study leading to dentists who specialise in one particular branch of dentistry. By and large there are no entry qualifications, as the undergraduate dental school records and interviews are felt to suffice. The educational programmes are between three and four years' duration and students complete the course with a certificate, or even just a letter, that is used to apply for specialist registration (where this is legally possible). Some programmes offer a Masters degree but often this is not compulsory, and usually only taken by those wishing to pursue a full or part-time academic career. This simple system seems to be able to produce well-educated specialists without any alphabet soup. In Scandinavia we see Lic. Odont, and a letter or Dr Odont., for full time academics. In the Netherlands a graduation certificate enabling registration as a dentist is followed by a similar specialist certificate. In North America we find dental specialists in practice with a DDS and a letter of specialisation or DDS, MS. This simplified approach seems to serve just as well.

The Way Forward

The system needs to be simplified and moved away from the training apprenticeship concept to one based on postgraduate education. Entry to specialist education should be on an applicant's undergraduate academic record, particularly in the subject(s) that the prospective student wishes to study, and a structured interview. As all students will also have completed a period of Vocational Training there will be records of their performance to assess.

Entry requirements

There should be no need to restrict entry. Each programme can decide how many students it can take and accommodate. What a postgraduate student does with their specialist education qualification is up to them in a free market. In most specialities there are a number of avenues that can be taken, hospital, university, community dental services and private practice. Therefore, it should be entirely up to each dentist to decide if they wish to undertake a specialist educational programme.

Higher levels of specialisation

But there are also those whose intent is an academic career that the present system discourages....

Because of the uniqueness of the British National Health Service there is a need for consultants to gain further education and experience to an even higher level. This period of more intensive clinical education and experience should then lead to an appropriate qualification. Here there is a place for a Fellowship. But there are also those whose intent is an academic career that the present system discourages. Therefore, it should be possible for dentists to embark on combined five-year educational programmes as specialist/consultant or specialist/academic. The former course should lead to a Fellowship and the latter to a Doctorate. The educational programmes for each need to have a different emphasis.

Accreditation

The question of accreditation is also pertinent here. Under the present system each and every postgraduate student is accredited. But it would be far simpler if the GDC visited and accredited postgraduate specialist education programmes on a periodic basis in the same way as it does for undergraduate programmes. This, again, would simplify the system.

Simplified system

The end result would be very well educated specialists who have a deep knowledge of their subject and the latest developments including basic and material sciences, specialist clinical care, scholarship and research underpinning their clinical skills. The emphasis for each student would be tailored according to their ultimate career aims. Under a simplified system the qualifications would be BDS, (CCST) for those wishing to be in private practice, BDS, FDSRCS for those in hospital and consultant service, BDS, MDSc for those in combined practice and teaching and BDS, PhD for those in academia. The alphabet soup is thus reduced to a minimum.

Now that we are in an era of increasing specialisation we should ensure that the appropriate programmes are based on education, scholarship, clinical expertise and research. The system needs simplification so that it encourages dentists to embark on the courses of their choice without inhibitory hurdles and unnecessary alphabet soup.