Background

The General Dental Council's (GDC's) Lifelong Learning initiative1 was a legacy of Nairn Wilson's tenure as its President between 1999-2003. The writer was fortunate enough to have been a member of the original working group for that initiative, which was prescient in the sense that the GDC of that era seized the opportunity for the profession to demonstrate its appetite for, and commitment to, continuing professional development (CPD) and to devise a workable scheme on its own terms, rather than waiting for one to be imposed from outside agencies. It is relevant to note that UK healthcare was, at the time, reeling from a series of high-profile medical scandals, including the conviction of Dr Harold Shipman in 2000, the shocking Bristol cardiology events (and the resulting Kennedy Inquiry published in 2001), and the measles, mumps and rubella vaccine furore. It is no exaggeration to say that the clock was ticking on the healthcare professions and government patience with their ability to self-regulate competently and responsibly in the public interest.

Initially introduced as a voluntary scheme, Lifelong Learning was rolled out in three cohorts, commencing 1 January 2002, with the most recent dental graduates. This apparently counter-intuitive prioritisation was deliberately designed to give the scheme the best possible start and to deliver a 'quick win' that would build confidence and reduce the risk of outside interference. After the 2005 Amendments to the 1984 Dentists Act (which paved the way for the registration of all categories of dental care professionals [DCPs]), mandatory CPD followed in August 20082 for dentists and DCPs alike.

The original mandatory framework defined a series of required 'core topics' for all registrants. The measure of 'activity' was simply the number of hours undertaken, distinguishing between 'verifiable CPD' for which there were some formal (but relatively loose) requirements to satisfy and self-directed/self-declared 'general professional development' activity. Most of the required minimum hours were in the latter, less rigorously policed, category.

After a review of the practical operation of this early system, the Privy Council approved a change in the GDC's rules for mandatory CPD, and the current 'Enhanced CPD' (eCPD) framework was rolled out for dentists with effect from January 2018 and for DCPs, August 2018.3,4 These changes were a significant improvement in some fundamental respects but sadly proved to be a missed opportunity in other respects, that I will discuss shortly.

CPD means different things to different people and until the 'Lifelong Learning' scheme was launched, most postgraduate courses had been clinically focused, mostly didactic and fact-based. Educational thinking has moved on since then and instead of a heavy reliance upon 'didactic' teaching (the stereotypical school classroom/lecture theatre approach centred around what the teacher/lecturer says rather than what the learner does), a mix of educational approaches now allows for different preferred learning styles and different learning and development experiences (more on this shortly). But a much greater emphasis has also been placed on reflective learning and (predictably, in today's world) on maintaining evidence of this reflection for third parties to review. The emphasis is more on the audit than on the development benefit for the individual. Another key factor - one too often ignored - is the generational shift. Today's young dentists have grown up in a very different world, where changes in IT, consumer attitudes and career/life perspectives have created a cohort of young professionals that is very different from anything we have seen before. As well as being the cream of the crop academically, they are wired to have a very different relationship with 'the establishment' in all its forms and not least with education;5 their aspirations, demands and expectations are certainly very different. The fact that the menu of available CPD is longer and more varied does mean that they have more choice and more buying power but it does not necessarily ensure that they will be better-informed and more discerning when exercising that choice and increased power. Instead, they may be making different choices, for different reasons.

The expansion and wider registration of the dental team from 2006 created a massive short-term challenge in terms of the availability of suitable learning opportunities and a level playing field for all registrants, but it wasn't long before the market responded to fill the gap, just as it did a decade or so later when faced with the COVID-19 pandemic.

The market has responded in other ways too, and amidst all of today's deafening postgraduate 'noise', it is more polarised. Because communication, behavioural and other 'soft' skills training was bizarrely never included among the 'core topics' identified by the GDC before e-CPD, it remains quite a challenge to track down such courses, even today. Those that do exist tend to be poorly subscribed because less relevance and end-value is attached to them; there are none so blind as those who will not see?6 Meanwhile, the market has become crowded and highly competitive in other, 'hotter' areas, like implant dentistry, aligner/short-term orthodontics, dento-facial aesthetics and cosmetic restorative dentistry, and alongside all this, marketing, merchandising and selling techniques. The crisis that has befallen NHS dentistry has created a windfall for those who offer to show ways to escape it, creating markets for learning to do and sell private dentistry. This in turn has fuelled an increasing divergence between courses supporting the delivery of NHS dentistry and those primarily supporting the delivery of private dentistry. It is no coincidence that the former market is shrinking while the latter is thriving.

In the years before Lifelong Learning, the postgraduate education 'market' was more modest in scale but nevertheless alive and well, offering reasonable variety from both 'official' and private sources. Both had taken a beating from the gradual withdrawal of 'Section 63' funding7 as from the early 1980s, before which NHS dentists could at one stage even claim direct reimbursement of travel, hotel and subsistence expenses when attending 'approved' courses - another demonstration of how much the CPD landscape has changed. What hasn't changed is the fact that when attending good-quality postgraduate courses, you are often surrounding yourself with fellow enthusiasts and rekindling your own interest in dentistry and the acquisition of new knowledge and new skills.

Differentiating an educational offering in the current dental professional environment relies much more heavily upon delivering tangible outcomes, like a certificate, diploma or registerable postgraduate qualification, or some other form of actual or artificial 'recognition', and preferably doing so in a way that is cheaper, quicker and easier/less demanding for the participant than alternative offerings. Quality assurance in terms of the actual teaching (or the teacher) remains a lower priority and that tells you all you need to know about the direction of travel - course directors are not being bombarded with questions about this aspect if the other boxes are ticked. It's more about the competitive advantage that the course promises to deliver. It is into this space that the plethora of manufacturer- and supplier-led short courses have arrived, with a self-evident vested interest in maximising the uptake of the product and driving sales and market penetration. Some courses currently offer the option of an automatic recognition or award, irrespective of whether or not you take (or pass) any concluding assessment or examination. Others allow participants to opt out of parts of the course that some find the most testing/challenging, inconvenient or time-consuming (such as preparing case presentations) without it affecting the participant's entitlement to the final award. Everyone's a winner as long as they pay the course fee.

Self-styled private 'institutes' and 'academies' and other such 'ersatz' marketing vehicles are vying with recognised colleges, faculties and universities to capture a greater market share. And even the most cursory trip around social media and the dental press will swiftly introduce you to many impressive-sounding 'Ratner professorships',8 associate professorships, visiting professorships and other such accolades and virtual titles that you (and many of your colleagues) never even knew existed (Box 1).

Quality assurance

One of the missed opportunities that existed before Lifelong Learning and persists even since the launch of eCPD is the lack of meaningful quality assurance. Hours of participation is a very convenient, administratively simple, but clumsy (and lamentably poor) measure of the value of the CPD undertaken in terms of value, experience and outcomes. Awarding a certificate of attendance to 'validate' or 'verify' CPD activity would be limp enough if it required the participant to complete the arduous journey from the registration desk to the auditorium and/or to stay awake or off their phone for the whole session; awarding it simply for showing up is a real cop-out. Similarly, insisting on feedback forms which simply confirm in some cases that the speaker and content turned out to be every bit as uninspiring as they had threatened to be in the published aims and objectives for the session is meaningless tokenism. But the GDC is not the only professional regulator in the UK (or the world) to have decided that assessing and policing the delivery of CPD is in the 'too hard' basket. The recent proliferation of online CPD delivery has added a further dimension to this challenge, making it more difficult in some respects (while easier in others). One is forced to the conclusion that, in the eyes of most regulators, it's not really about the outcome at all, but about the principle and the process and how it looks to the key external audience(s).

Some dental regulators around the world have adopted a compromise solution whereby they accredit the providers of continuing dental education irrespective of the specific programmes they are delivering. It's arguably better than nothing, but only by the narrowest margin, I would suggest. Other regulators go further and are more prescriptive in the qualifying parameters they require;9,10,11 although, most acknowledge the impracticability of quality-assuring every single CPD activity or even carrying out random sampling on a 'secret shopper' basis. The polar opposite is seen when attendees are offered significant and often valuable incentives in return for posting favourable reviews online - an example of a self-promoting free market operating in its own interests under the nose of a regulator that feels powerless to control fast-moving events in an increasingly digital environment. Had he practised in the modern era, even Harold Shipman would have been knee-deep in 'likes' and been able to boast about having thousands of followers - his adoring patients were his greatest fans right up to the moment when he killed them. I have always been a strong believer that postgraduate training and CPD should be enjoyable, but is that really the only kind of currency we should be using when making decisions about our postgraduate education and the skills and values we need for the next stage of our career?

A responsible regulator acting in the public interest would surely take a greater interest in helping registrants to make wiser and better informed choices in terms of the people and places from which they seek their CPD. Incentivising appropriate choices by attaching different 'weight' to different kinds of activity from different sources need not be excessively complicated or onerous but it would be a useful start and help to debunk the 'equivalence' myth (see 'choices and challenges' below). The Dental Board of Australia is an example of a regulator that distinguishes between formal courses that award a qualification and where the content is clinical/scientific in nature (as distinct from increasing treatment uptake, practice promotion, finance or practice management for example) and those that do not meet these conditions.12 Simplistic perhaps, but at least it signals the Board's priorities. Reflecting the National Law in Australia, it bears recording that same Dental Board's priorities are further demonstrated by the absolute prohibition of any advertising which directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services. In short, you can't advertise or otherwise promote your services in a way which encourages patients to seek the provision of dental treatment which isn't strictly necessary, or which will not benefit them, or which might even harm them in some way. So, there is little point in attending courses on promoting or carrying out such treatment anyway.

Collegiality and choosing the right learning approach

The GDC's relatively recent move to eCPD places more responsibility on an individual registrant to identify how to choose and prioritise their own CPD activity and also to make their own reasonable enquiries to satisfy themselves about the quality of the training and the people who would be delivering it. Decide for yourself whether you view this as sensible delegation, or pragmatic abdication; either way, it seems somewhat perverse to be making such a virtue of empowering registrants to make their own CPD choices, while reserving the option of then having those choices criticised by a Professional Conduct or Professional Performance Committee and concluding that the registrant clearly lacks insight.

It is human nature to gravitate towards courses that seem most relevant and interesting, so it is a familiar pattern that dentists return again and again to lectures on similar or related topics, as well as to the recommended CPD subjects. This makes more obvious sense for specialists, but even then, it runs the risk that they will become progressively de-skilled on all aspects of dentistry beyond their narrow field of special interest and expertise. Time spent keeping your wider knowledge as broad and current as possible is seldom wasted.

We might want and need a 'hands-on' course at one moment and a problem-based approach at another but prefer a didactic course for some purposes and access to online resources at other times to suit us and the subject matter. Many of us derive added value from some degree of 'blended learning' in which different styles and formats of learning are combined in a synergistic way, which allows each learner to choose their own preferred 'mix' to enhance their personal learning experience and maximise the depth of their learning. Educational theory has become something of a moveable feast, with very different theories moving in and out of fashion at dizzying speed;13 the jury is out more often than any broad consensus of views is ever achieved.

It is less in dispute, however, that some individuals benefit much more than others from learning in a group setting, or one which involves a much more direct relationship with the person whose knowledge and skill you want to tap into. The optimal (or desired) level and type of engagement and interaction will vary according to the subject matter and the people who are delivering and receiving the learning experience. The COVID-19 pandemic has changed the way many of us have obtained our CPD and has highlighted the advantages and limitations of different ways of teaching and learning and our appreciation of the fact that some online platforms are a lot better (and easier) to use than others. However, many believe that when launching eCPD, the GDC missed a golden opportunity to do something about professional isolation, which is well-known to lead to a range of problems. It is entirely possible to satisfy the eCPD requirements without ever moving from the front of your computer screen or tablet and there is no requirement to spend any time at all mixing with (and learning from the experiences of) your professional colleagues. The pandemic presented exceptional challenges in that regard, but for most of us, it has massively increased our experience of online CPD and we will all draw from that experience in the post-lockdown future and hopefully make smarter CPD choices as a result.

Digging the same hole deeper?

Returning to a point made earlier, it is hardly surprising that most of us will tend to gravitate towards our favourite topics or speakers that we know/have a good reputation. There is also an understandable natural tendency to choose postgraduate training and development that is directly relevant to the field(s) in which you spend (or would like to spend) the majority of your working time. But your knowledge and awareness of other areas of dentistry can quickly wither on the vine unless you make the effort to keep yourself updated. It is, as always, a question of finding the right balance.

One of the laudable aspects of eCPD is that it gives each registrant control over their own CPD rather than insisting that every registrant needs the same training on the same topics, irrespective of their starting point and the kind of work they do. 'One size fits all' has been banished from the CPD agenda and in its place, your personal development plan (PDP) sits at the heart of eCPD. Put simply:

  • You reflect, assess and identify your personal needs and priorities

  • You decide what you want to achieve

  • You plan how you would like to get there and over what timescale

  • You think about what you are learning, what it means for your professional practice, what changes you might make, what else you need to know etc

  • You choose what activities to take part in and when. You take personal responsibility for the quality of that teaching/training and the people providing it, and are able to demonstrate how you did that

  • You keep a record of all of this, including your personal reflections on what you have learned

  • You update your PDP...and so on.

Choices and challenges

But this logical and welcome autonomy can also act as a double-edged sword. The pattern of our CPD choices can assume centre stage if and when third parties are assessing our self-awareness and insight, and our commitment to standards, self-improvement and professional development. If our PDP amounts to little more than a generic drop-down menu, pre-populated with text that others have written, to save our beleaguered brain cells from having to apply themselves to anything more demanding than box-ticking and bereft of any genuine reflection, we will be on the back foot from that moment on. If every course we then attend is straight off the 'quick, easy and cheap' shelf, and/or about making money, third parties like the GDC or a Professional Conduct Committee, or an external agency like Health Education England, might well view this unfavourably. But if we can show through our reflective log and PDP that we have responded to a clinical setback by taking sensible steps to recognise and address any actual or perceived deficiencies in our knowledge and experience, this will demonstrate insight and certainly count in our favour. We don't need to wait until somebody sues us or complains about us to realise and act upon our relative strengths and weaknesses. It should be an ongoing, continuous process for anyone who claims to be a professional person.

Obviously, the reverse is equally true. A prosecuting barrister and legal team will have a field day if you can be shown to have consistently chosen the 'lite' training approach, opted out of the difficult bits and shunned more academically robust/demanding courses or any kind of examination or independent evaluation to demonstrate your competence (or otherwise).

For as long as market forces are left to establish the pecking order in the postgraduate education and training market, we will continue to witness a dumbing-down, de-professionalisation and progressive commercialisation of the content. Success and sustainability will be dictated by how well the product is marketed and how well the power of social media is harnessed, not by the inherent educational quality and genuine credibility of the product.

An often-used selling point is 'equivalence', claiming that the same or a similar endpoint can be reached with less effort and/or at a lower cost. A famous New York opera singer, Beverly Sills, observed half a century ago that 'there are no shortcuts to any place worth going'. How right she was. I am similarly attracted to a further one-liner on the subject: 'a shortcut is the longest distance between two points'. This little gem is widely attributed to another American, Charles Assawi, an Egypt-born academic of similar vintage to Beverly Sills, who also ended up in New York (in his case, via a scenic route which included Oxford University), so his aversion to shortcuts is a matter of record. Demonstrating a commitment of time, effort and (often) money in pursuing an extended, structured training programme of substance from an authoritative and respected provider - especially one which includes robust standards and independent assessment of knowledge and competence - can make a huge difference to how others view you. This is especially true if and when they are looking for evidence that any past problems or deficiencies have been addressed and are not necessarily a fair indicator of your likely future performance. Providers of professional indemnity/insurance are included among those who might well take an active interest in these matters.

Demonstrating insight and self-awareness often requires evidence of honest and thoughtful reflection on our own strengths and weaknesses. But the high-profile, tragic and controversial case of Dr Hadiza Bawa-Garba, a paediatric medical registrar at the time, raised many questions about the status of your PDP and learning/reflective records.14 In short, who owned them and how could they be used? Were they really 'personal' at all? Can you afford to reflect honestly about your own personal deficiencies, if this document can later be used against you, to demonstrate just how deficient you really were? Unlike most of the population, healthcare professionals consistently face double or even triple jeopardy anyway and the requirement to maintain reflective logs can amplify that risk. During the Bawa-Garba investigation, the British Medical Association advised disengagement from reflective learning processes until legal safeguards were put in place to prevent reflections being used against medical practitioners.

In this connection, the GDC's guidance on eCPD4 remains somewhat misleading. It states: 'the GDC may ask to see your PDP to check you are keeping records which meet the minimum requirements as set out above. Beyond this, the details about which CPD you plan within the PDP are not evaluated by the GDC'.

While this may be technically true as far as meeting your minimum CPD requirement is concerned, it certainly does not preclude a Professional Conduct Committee or Professional Performance Committee taking your CPD records into account as part of the evidence in a GDC fitness to practise investigation. One can hardly fail to be simultaneously amused and dismayed by situations (which have actually happened) where registrants produce CPD attendance records which, on closer inspection, confirm that they were supposedly undertaking several different CPD activities at the same moment in time and claiming the relevant hours for all of them: clearly a registrant who needs no further training in time management (?!). But it is no laughing matter when dishonesty is added to the list of charges.

Summary

O wad some Pow'r the giftie gie us

Tae see oursels as ithers see us!

It wad frae mony a blunder free us,

An' foolish notion.

Or for those who prefer a less eloquent, literal English translation: if only some power would give us the gift of being able to see ourselves as others see us, it would spare us from many mistakes and daft ideas.

The legendary Robert (Rabbie) Burns, late eighteenth-century Scottish poet and creator of 'Auld Lang Syne', penned these words as part of a poem with a comedic context but deadly serious and insightful underlying message.15 Even 150 years later, it still resonates as strongly as ever, and particularly so in the context of many a professional career in dentistry.

Regulators like the GDC throw a lot of time and effort (and registrants' money) at setting specifications and standards and assessing and inspecting undergraduate training facilities and what kind of graduates they produce in the four or five years they have in which to fulfil their role. But after that, they mostly wash their hands of all responsibility for what happens in the ongoing training and development of those registrants over the next 30-40 (or more) years, and that's just not good enough. From the moment of our graduation, the fate of our individual professional development depends upon the personal choices we make. The course of our career is similarly determined by our insight, judgement and the decisions we take, as well as by luck. Others can see that, even if we can't. Perhaps the final word, then, should rest with Ken Levine, the prolific American blogger, whose gift for comedy screenwriting has brought us classic moments in TV series' like M*A*S*H, The Simpsons, Frasier, Cheers and many others. Levine has observed that: 'we all make choices, but in the end, our choices make us'. And where our professional development is concerned, we would all do well to keep that in mind and invest wisely.