Working within ability

Dr David Cross questions whether regulatory demands for ‘clinical competence’ are explicit enough when it comes to complex dental treatments 

THE GDC recently published its Standards for the Dental Team – a revised version of the document that governs behaviour and provides guidance that all members of the dental team must adhere to. These standards are divided into nine main principles that could all be said to flow from Principle One which is “Put patients’ interests first”. Throughout the Standards document the term ‘must’ is used where the duty is compulsory.

The clinical standards laid out in the GDC document under Principle Seven require that: “You must provide good quality care based on current evidence and authoritative guidance. Work within your knowledge, skills, professional competence and abilities. Update and develop your professional knowledge and skills throughout your working life”.

Further help in interpreting the guidance can be found in note 7.2.1 which states: “You must only carry out a task or type of treatment if you are appropriately trained, competent and indemnified. Training can take many different forms. You must be sure that you have undertaken training which is appropriate for you and equips you with the appropriate knowledge and skills to perform the task safely.”

At first glance this seems reasonable and appropriate. After all, the aims of the GDC are to protect patients and regulate the dental team. However, on reflection, problems exist with the GDC’s wording of the clinical standard. Whereas the use of the terms ‘must’ and ‘should’ are clearly defined in the standards document, there is no definition of clinical competence.

Rigorous training in complex skills

According to the Standards, it is left to the individual practitioner to decide on the appropriateness and level of training that establishes clinical competence. It is therefore up to the individual to decide on all aspects of the training, for example the duration, content and whether clinical or non-clinical. Finally, it is also up to the individual to decide upon what method of assessment, if any, will be used to establish their clinical competence.

This approach is appropriate for minor skills and refreshing every day clinical techniques but is inadequate to establish clinical competence for more complex skills. In order to be deemed competent at any particular complex clinical task, such as orthodontics, dental implants or IV sedation, a more prolonged period of clinical training under supervision followed by assessment is necessary to adequately ensure competency has been achieved. The clinical knowledge required to use these new skills adequately in complex cases can only be achieved through clinical practice and experience over time.

For example, in higher specialist training in the UK the trainee first has to gain entry to the specialty, which is increasingly competitive. There then follows three to five years of training under close clinical supervision with assessments throughout before a final examination is undertaken at one of the Royal Colleges. These examinations undergo rigorous standard setting to ensure fairness and validity.

This training is often linked with a higher degree at university so that research training is undertaken at the same time. This has the benefit of introducing the candidate to skills in critical appraisal, enhancing the newly qualified specialist’s ability to continue life-long learning through reading the latest research and studies. The practitioner can then make a judgement on newly published scientific information for the benefit of their patients. These postgraduates have learned the necessary clinical skills and have been assessed competent by an external examining authority.

This rigorous training has to be compared to that provided by short courses in some areas of special interest. These can range from a single day or weekend courses, or extended tuition over several weekends throughout a year. The majority of such courses are an essential part of life-long learning and can stimulate interest and invigorate practice, allowing the practitioner to develop new skills and interests. However, some of these courses promise more than they can deliver and encourage the general practitioner to undertake more complex treatments than they otherwise might. More often there is no assessment of competence of these new skills and little or no local support if things go wrong during subsequent treatment. With no assessment of competence how can practitioners claim to be competent in these complex skills?

Progression to competence

According to the Conscious Competence Learning Model, there are four stages in progressing from incompetence to competence in a skill.

The Four Stages of Competence (after Clive Shepherd)

 

The ‘unconsciously incompetent’ stage is where everyone starts with regard to a new skill. Although the person is bad at the new skill they are completely unaware of how bad they are. Indeed, it is not uncommon for them to think they are actually pretty good at it.

The next stage is ‘conscious incompetence’, where they have realised that there is much more to what they are trying to do. At this stage the person may become overwhelmed by what seems to be a vast area of knowledge that they were previously unaware of.

Then comes the stage of ‘conscious competence’, where the person has started on the path of learning and their skills improve but they are slow at tasks. Eventually the individual reaches the stage of ‘unconscious competence’ where they possess all the necessary skills and can utilise these with ease and speed. From the figure it is clear that short courses on complex clinical skills can inspire and inform but leave the individual at the unconsciously incompetent stage with regard to these new skills.

Risk to patient and dentist

The GDC will not act unless a complaint is made but patients could be at risk from ill-judged and over-confident treatment planning. Meanwhile the over-confident unconsciously incompetent practitioner is also at risk from litigation as a result of negligence if things go wrong. The standard of care in any resulting claim for negligence will be judged against what any reasonable practitioner of equal knowledge, skills and experience would provide. If specialist treatment is being provided, the standard of care would be what a specialist would provide. It is likely to be easy to prove that this standard was not met if clinical experience is limited and the practitioner has embarked upon an over-ambitious treatment outwith their skills and experience.

The GDC Standards also states in paragraph 7.2.2: “If you are not confident to provide treatment, you must refer the patient to an appropriately trained colleague”. This means that if you refer a patient for treatment you have a duty to refer them to someone who has had the appropriate training and 1.7.6 states: “you must make sure that the referral is made in the patients’ best interests rather than for your own, or another team member’s financial gain or benefit”. In the eyes of the GDC, the incompetent practitioner and the referring practitioner will be at fault.

The number of clinical negligence claims and referrals to the GDC is on the rise with an increasing cost to the profession. The MDDUS has observed a 16 per cent increase in civil negligence claims year on year for the past five years, and the number of cases brought before the GDC has increased 39 per cent year on year for the last five years. These trends are unlikely to change whilst the clinical standard with regards to competency, set by the GDC, remains vague. Can the defence societies continue to afford to provide indemnity for everyone regardless of skills or experience?

Currently MDDUS provides a scale of indemnity for members depending upon their procedures undertaken. In the future, it may be necessary for practitioners to declare their training and experience each year to allow their risk profile to be accessed and an appropriate subscription applied. High-risk practitioners with little or no experience may find it costly to find indemnity with any provider and very high-risk practitioners may find they have to reply upon insurance policies at high cost. The prohibitive cost of such insurance policies may mean high-risk practitioners are unable to practice in these more complex areas, but on the plus side patients will be protected.

Dr David Cross works part-time in specialist orthodontic practice and is a senior clinical university teacher at the University of Glasgow Dental School and an honorary consultant in orthodontics