Competence

One of the characteristics that distinguishes the professional from an amateur is the degree of competence they have in performing a particular task.

You need look no further than the world of sports such as golf, tennis and football to see that. Whilst amateurs may attain a high level of proficiency, what marks out the true professional is their ability to perform to a consistent standard.

The standards that are recognised within a particular discipline derive from a blend of formal education and training, hands-on experience and continued education that is based on a reflective evaluation of events that occur in daily practice (peer review and audit), and finally on further education.

When looking at the preservation and maintenance of these standards (they are defined in Ethics module 3 - Professionalism) there are three areas that every professional needs to consider;

• Maintaining basic standards
• Keeping up to date in your chosen field of expertise
• Acquiring and developing new skills

Maintaining basic standards

Lifelong learning is the cornerstone that supports every profession, and reflecting this fact most dental associations and Dental Boards/Councils expect dentists and their teams to keep up to date. Some have very specific mandatory requirements both in terms of the number of hours prescribed as well as the subject matter that should be updated in order to maintain registration. Core subjects may include topics of universal importance to dentists in whatever sphere of clinical practice they work, such as basic life support and managing dental emergencies, infection control, ethical and legal matters and complaints handling. They may also include communication skills and more specific legal and ethical issues such as consent and confidentiality.

When clinicians make choices about what courses to attend they often choose subjects they enjoy.

This rather defeats the object of postgraduate education since this self-perpetuating cycle of attending courses only because you enjoy them, will result in an ever-decreasing spectrum of knowledge.

It is best to carry out a trainingneeds analysis based on clear educational, career or practice objectives. In this way, it is possible to select courses that will remedy any skill-gaps and help to meet those objectives. The list may well include subjects that do not have the automatic appeal of some others, but which are still necessary in order to fulfil the required objectives.

Keeping up to date in your chosen field

Whilst many dentists develop an interest in general practice, which might be regarded as a specialised way of working, other dentists specialise by limiting their practice to particular braches of dentistry such as orthodontics, periodontics, implantology or endodontics. All these fields have a highly developed academic base of knowledge to which new research and information is added all the time. Standards are constantly evolving in the light of new knowledge and the development of new materials and techniques.

Any dentist who specialises in a particular field would be expected to keep up to date in that area. Although they might not have read everything that was ever written on a particular subject, a patient and indeed a court of law would expect the practitioner to have a reasonable grasp of current concepts and ideas as well as any controversies within their specialist subject. This means reading the latest peer reviewed journals, from both home and abroad and attending postgraduate meetings and conferences organised by specialist societies.

A dentist has a duty to provide care of an appropriate standard to avoid allegations of negligence. The progressive upward revision of the required standard of treatment to be provided is based on the evidence base that is constantly evolving and is also influenced by the local culture and, laws as well as patients' expectations. As a result, the skills and techniques for delivering dental care have changed dramatically over the past ten years. In addition, clinicians face greater demands from patients who want more information about the benefits and risks of any treatment they undergo.

With the passing of time, the use of some materials becomes outdated (eg. silicate restorative materials and the use of silver points in endodontics). Obstinately persisting in using outdated techniques contrary to recognised opinions and evidence is both unprofessional and unethical, especially when those techniques have been shown to cause demonstrable harm in the past.

Maintaining competence

A clinician may be perfectly competent and capable at one moment in their career, only to find their competence being challenged at some subsequent time. This may be due to illness or deterioration in your physical health. It might follow a temporary (or extended) absence from clinical dentistry, or reflect psychological or emotional problems. In all these cases, it is a clinician's responsibility to ensure that at all times they are able to carry out dentistry safely, and to an acceptable standard. Where there is any doubt that this is the case, the clinician has an ethical duty to seek appropriate (eg. medical) advice, and to act upon it.

Acquiring and developing new skills

Part of the pleasure and enjoyment of clinical dentistry derives from the challenge of working with new techniques and materials. But there are other tangible benefits in this; improved quality of care for the patients, and practitioners who are stimulated to achieve even-higher standards in a more predictable and consistent way.

There should always be a benefit to the patient in any changes you make to your technique or the materials you use. It is important to recognise that when using new materials, especially an improved version of an existing product, that very little long term in-vivo data will exist. To a certain degree your patients will become the test beds for these products but the risk of failure will be borne by the patient and yourself rather than the manufacturer.

It is important that the patient should be made aware of this and their agreement obtained with this in mind.

It is generally prudent to use materials from reputable companies with quality controls for producing that type of material, equipment or product; this is particularly relevant in rapidly evolving fields such as implantology where there are numerous manufacturers selling widely differing components all claming to be the best on the market.

When adopting new skills or new materials, sufficient training should be obtained before working on patients. This could be on phantom heads, extracted teeth, animal models or study casts. It is important, having acquired the relevant skills to introduce them gradually to patients if this is possible. You might even want to advise the patient that you have not used a particular technique or material before, in order to obtain their consent for the procedure. If you consider this to be a material fact (ie. One to which they might attach significance when considering whether or not to undergo the proposed treatment) then the patient should be made aware of it.

Mentoring

A useful approach when trying to develop new skills and integrate them into your everyday practice is to duplicate the way in which you probably learned and practised new skills when you were a dental student. Once you have learned the scientific basis for the technique(s) and observed them being carried out by someone who is competent and experienced in them, you should ideally perform the technique yourself in the presence of a suitable mentor, who can guide and advise you while you are building up your own competence and experience.

Referrals

A professional recognises their limitations. These may be based on the realisation that a particular patient's needs cannot be met; either because of the complexity of the treatment or the demands of the patient. It is neither a sign of weakness nor incompetence to seek the advice or assistance of a more experienced colleague in such cases. There is a balance between accepting a challenging case over which you have a high degree of control, even if the outcome may be less predictable, and foolishly taking on a case either for financial reward or because of undue pressures placed on you by the patient or other parties. Those other parties could be an employer, colleague, payment agency or commissioning body.

The paradox of postgraduate education is that the more you know, the less you do. When you know the risks of invasive treatments and understand the limitations of various options it becomes harder to justify some treatment modalities. It is this insight and honesty that makes you a professional whose advice patients seek out and trust.

Patients expect professional integrity when you offer choices and treatments and they expect that their best interests will be foremost in your mind.

Part of making an appropriate referral is deciding what is in the patient's best interest. It may be that you find the patient difficult to deal with, or have a personality clash but that is no reason to offload them on to a colleague unless you genuinely feel that treatment outcomes will be significantly improved if you do so.

As a professional you are expected to deal with both easy and challenging situations and to accept patients from all backgrounds.

It is important, however, to know who you are referring your patient to and to understand their limitations at the same time.

When joining a practice for the first time, a dentist will usually refer patients to the same colleagues that other dentists in the practice refer to; the pathways may have been established over a period of time. Take time to contact, speak to and preferably visit the practitioners to whom you may wish to refer your patients. In due course you might require their services for a patient with an emergency such as oral surgery complications and it would be useful to know how best to contact them urgently or out of normal working hours. Find out the range of services they offer or indeed if they would come to your practice to carry out consultations or treatment at your practice.

Specialists tend to focus on their own speciality and if you have made a decision about treatment that requires specialist input you may feel that the person to whom you refer the patient should provide the necessary care.

However, anyone accepting a referral has an ethical and a legal obligation of their own to assess the patient to establish the suitability of the procedure for which they have been referred. They may well come to a different conclusion to your own following their own diagnostic tests and in the light of their greater experience.

An endodontist for example may be able to root fill a molar tooth but if it is badly broken down and the predictability of the final restoration may be in doubt, he may well advise against the root canal therapy, suggesting an extraction instead. It is important that you have a good working relationship with the people to whom you refer patients since in this situation you would expect the other dentist to commend the appropriateness of the referral to your patient but then go on to offer his or her own professional opinion without undermining the patient's confidence in your own diagnostic or treatment planning skills in any way.

Equally when thing do go wrong and you require the services of a colleague you would expect them to be sufficiently professional not to criticise your efforts or make subjective comments which may aggravate the situation further.

There is an old adage that if the only tool you have is a hammer; everything will look like a nail. A person who provides implants exclusively may be less likely to offer the patient a denture or a bridge. An oral surgeon faced by a periapical lesion under a root filled tooth is less likely to suggest retreating a root canal than an apicectomy.

When things go wrong

One important aspect of being a professional is having sufficient knowledge and expertise to recognise when things are not going according to plan. In some cases this will be quite obvious; an endodontic instrument separated in a canal, a root apex in the maxillary antrum.

In some cases it may be less obvious; loss of anchorage control in orthodontics, over-preparation of a root canal leading to perforations, failure to respond to periodontal therapy.

All these situations require a response based on three elements;

• The knowledge, experience and training to know that something is not quite right.
• The integrity to discuss it openly and honestly with the patient.
• A willingness to acknowledge that you are getting out of your depth.

Such a discussion is often the hardest part for anybody since nobody likes to admit to failure, getting things wrong or making avoidable mistakes. But that is all part of being a competent professional person and the patient is entitled to an honest appraisal of their situation.

Learning from mistakes

An integral part of the educational process is learning from experience how to develop and improve your skills; we can all learn from our mistakes. A careful reflective analysis of how an error arose is the key to preventing its reoccurrence. In risk management this analysis is called root cause analysis. This is the process of finding and eliminating the fundamental cause which would prevent the problem from recurring; only when the root cause is identified and eliminated can the problem be solved. The purpose of root cause analysis is to ask:

• What happened?
• Why did it happen?
• What can be done to prevent it happening again?

A formal approach to recording these incidents is known as significant event audit (SEA).

This technique can be used to celebrate good practice as well as improving suboptimal practice. Take for example a patient who is a regular attender and has been with the practice for 10 years. She arrives in pain one day and on taking an x-ray, a large carious lesion is discovered which requires root canal therapy. How had this been missed on previous visits to the practice? When looking back at bitewing radiographs taken two years previously the carious lesion is seen to be present. Why was no action taken?

• Was it a system error-the radiographs were processed but never actually seen by the clinician and stored back in the record card?
• Did the clinician see the lesion but an appointment was never made (another system failure)?
• Did the clinician see it but did not feel it warranted investigation?
• Did the clinician fail to see the lesion?

With an open-mind the different possibilities described above could translate into a procedural rethink or possibly training need for the dentist ie. Diagnosis and management of early carious lesions.

Getting and maintaining the best education

We started this exploration of the ethical aspects of professional competence with the important principle that continued postgraduate education is the way to maintain competence in your chosen sphere of practice. The clinician is presented with a daunting choice numerous courses offered by a multitude of providers. Some will be run by national dental associations, some by Universities and Colleges and others by dental faculties and specialist groups.. You will also see private courses run by companies who have a vested interest in selling their range of products and this can be seen particularly in the highly competitive worlds of implant dentistry and cosmetic/aesthetic dentistry.

Whilst it is important that the clinicians who deliver these courses provide an independent view of the subject in a non-biased and objective way, they may be sponsored or paid by companies to deliver postgraduate education to dentists and so it is important that you distinguish between what is a thinly-disguised sales pitch and what is fact or genuine scientific opinion.

Be prepared to challenge speakers who appear to favour one technique, material or system to another to offer up objective evidence based reasons for their choice. It may just be personal preference but it is important to realise that what works in their hands may not necessarily work in yours.

Summary

Being a professional requires competence. It also requires a great deal of critical self analysis and evaluation. You have accepted a great responsibility to deliver oral healthcare to your patients and you owe it to yourself, the patients and your professional colleagues to meet that responsibility fully prepared and trained by your experience and ongoing education.

You need to recognise when your own competence in a given situation is compromised and you must also be able to recognise suboptimal performance in others and be prepared to take action if the well being of patients will be compromised. That is what being a professional is all about.