Dr Stuart Ellis FCGDent, Director of the Postgraduate Certificate in Dental Education at the University of Cambridge and Guest Editor of the new issue of the Primary Dental Journal (PDJ) dedicated to dental education, reflects on the meaning of competence in dentistry.
Competence. It is worth pausing for a moment and reflecting on what we mean by this word, which at first glance may seem obvious. Competence is the central concept that dental education has been revolving around since dentistry first became a profession. Competence has become, as Lingard pointed out, a “god term”.1 It has evolved into a word that sits superior to all other expressions of ability. As a “god term” it is often used as the final word in debates on how dental professionals should function. It is a term with such high moral power that it is inherently accepted, without question, as a self-defining trump card. The new edition of Primary Dental Journal (PDJ) explores deeper thinking about competence by addressing questions such as, what is it, how do we know we have it, how do we hold on to it and what can we do if we lose it?
At undergraduate and postgraduate levels, we pass examinations to show that we are competent. We aim to demonstrate that we can be trusted to treat patients safely. Since Biggs’ model of constructive alignment highlighted the need to ensure that assessments measure what they should measure, healthcare educationalists have been striving for better ways to assess the competence of professionals.2 It became clear that a dentist who could write a competent essay in an examination was not necessarily demonstrating the ability to be a competent dentist. The paper in the new issue of PDJ by Thomas O’Connor explores the increasing use of Entrustable Professional Activities (EPAs) as an assessment tool in dentistry. The utilisation of EPAs as a form of workplace assessment was first proposed by ten Cate as a means to bridge the gap between theory and “real world” clinical practice; a tool to enable a person to demonstrate what they can do, rather than just what they know.3
The conventional understanding of competence, as a predetermined stage of ability to be reached by an individual, has its limitations. After gaining a dental degree, a postgraduate certificate or a postgraduate diploma the expectation is that the dental professional has reached a general level of competency in a specified field of learning. This simplistic conceptualisation of competence fails to account for the complexities of human performance. An individual may be competent one day, and incompetent the next. Human behaviour is multifaceted and sinuous. Numerous emotional factors can exert a significant influence on the actions of professionals. Particularly prevalent in surgical fields, such as dentistry, ideas of competency are situated within a narrow and highly technical orientation. We tend to look at communication skills, diagnostic skills and operative skills without consideration of the wider context that dental professionals work in. The airline industry realised long ago the effect that human factors could have on the situational awareness, communication and decision-making abilities of air crew, leading to the introduction of training programmes in non-technical skills for pilots.4 The paper by Christopher Fowell describes the introduction of non-technical skills training for surgeons and explores how improved training in this field could help to improve patient safety in dentistry.
“Patient safety” has become another “god term” with such enormous rhetorical power that it deserves a closer look. Again, it is the airline industry who led the way when realising that passenger safety was best served through an open culture of transparency, where professionals are encouraged to report near misses and honest mistakes, so that the entire industry could learn from them. This was facilitated through the development of a “Just Culture”, where the focus of the system is on understanding why honest mistakes happen rather than punishing those who make them. Pilots are encouraged to admit errors without fear of unfair punishment, within an open system of learning that is overseen by a Just Culture Champion appointed by the Civil Aviation Authority.5 Shamir Mehta’s paper on Early Remediation explores ways in which the General Dental Council are working towards a more open culture of learning in dentistry through changes to the Fitness to Practice (FtP) procedures. Accepting that otherwise competent dental professionals can, for a variety of reasons, lose their competency, Early Remediation aims to support dental professionals in difficulty during the early stages of the FtP process. My own paper on mentoring in dentistry explores how this underutilised resource, which is awarded a high degree of importance by many other professions, can help all of us whether we are a practitioner in difficulty or just a professional seeking supported career development.
The other two papers that I have contributed to the issue delve into what we mean by competency and how we can show patients and colleagues that we have achieved a certain level of knowledge and skill. The research study that I conducted with my University of Cambridge colleague, Rachel Williams, explored the opinions of learners who took a practical skills assessment in implant dentistry, with no time limits for the assessed tasks. The responses showed that, in our fast-moving modern world, competency is often equated with speed. Faster operators are viewed as better operators, faster thinkers as smarter people. It is interesting to see how this concept has changed over time. Many of the greatest thinkers in human history, from Socrates to Descartes, were valued for the depth of their thinking rather than the speed of their thinking. These great minds were known for the extensive amount of time they spent contemplating wisdom, not the speed that they produced it. Perhaps our modern perspective has been moulded by the consumerisation of society, under contemporary ideas that time is money and money equals happiness.
I hope that my third article in the Dental Education issue will help colleagues to navigate the plethora of postgraduate qualifications and awards in dentistry. I aim to persuade the reader that postgraduate qualifications and awards should be viewed as tools rather than trophies and that the most effective training course is the one that strengthens professional judgement, improves patient care and supports a coherent career direction.
The Dental Education issue is now available online; printed copies should arrive with College members by the end of October.
The Primary Dental Journal is the College’s quarterly peer-reviewed journal dedicated to general dental practice. The titles and abstracts of PDJ papers are available to all dental professionals via the searchable PDJ homepage, with full paper access available to College members through the PDJ Library.
References
- Lingard L. What we see and don’t see when we look at ‘competence’: notes on a god term. Adv Health Sci Educ Theory Pract. 2009;14(5):625-628. Available at pubmed.ncbi.nlm.nih.gov/19856124/
- Biggs J. Enhancing teaching through constructive alignment. High Educ. 1996;32(3):347-364. Available at link.springer.com/article/10.1007/BF00138871
- ten Cate TJO, Snell L, Carraccio C. Medical competence: the interplay between individual ability and the health care environment. Med Teach. 2010;32(8):669-675. Available at pubmed.ncbi.nlm.nih.gov/20662579/
- Moriarty D. Introduction to human factors. In: Moriarty D. Practical Human Factors for Pilots. London: Elsevier; 2015. pp.1-10. Available at sciencedirect.com/science/chapter/monograph/abs/pii/B9780124202443000017
- UK Civil Aviation Authority (CAA). Safety reporting and Just Culture. [Internet]. Crawley: CAA. Available at caa.co.uk/general-aviation/general-aviation-at-the-caa/safety-reporting-and-just-culture