I wrote back in 2012, for Dentinal Tubules, “RIP the Specialist Practice” (original article below) and over the years there has been a slow (OK, much slower than I thought) decline in Specialist Orthodontists working in their own practice. Why? well it could be due to the NHS contract change (you can’t simply open a NHS squat). May be an increase in number of Orthodontic Therapists undertaking the NHS workload and leaving less for new Specialists.
Or could it be Specialists choosing to work in a more peripatetic way? Or, more and more GDP’s undertaking proper Orthodontics (and I refer to “comprehensive” or “idealistic” treatment plans as opposed to “STO” or ‘Compromised’ treatment plans suggested by many manufacturers or laboratories).
So, could this a reduction be about to accelerate?
In a recent article written by J Sandler (Orthodontic Update, Volume 14 Number 4 - October 2021) made me think change could be coming. In his Article, “Race to the Bottom”, Dr. Sandler describes how the three year Specialist training pathway contains a research element to help develop the trainee’s critical appraisal techniques and, help prevent them form being fooled by ‘snake oil charmers’ or, as I would describe ‘Dick swingers’ / ‘Titty teasers’ aka KOL’s on social media (with many ‘supported’ by the manufactures).
And, I do agree with his views and those of Mills & Houston to the “added value of undertaking a postgraduate research degree as part of orthodontic training has been long established” (1 & 2).
He then delivers the news that the General Dental Council has decided to remove the Masters degree from Orthodontic training, which was quite a shock. Unfortunately, I am unable to find out more. No doubt with time the details will become apparent.
So, will this see an acceleration in the decline of Specialist Practice? possibly. Will it see a reduction in standards? hmmm maybe. Will it reduce the number of people entering ‘Specialist Training’ as ‘Orthodontic training’ can be provided from other sources? I think so.
What can be done about this? Well, I know we have to ‘follow the GDC’ despite what we may think (and you all know my thoughts about the GDC). However, we can still maintain our personal values and standards despite whatever ‘they’ may do. Just because Specialist training doesn't have a ‘research component’ any more doesn't mean we should ditch it. For those wishing to pursue an MSc then we at Assure / Academy Clinical Excellence can offer this.
So Orthodontic training, with exceptional mentoring and coaching - no problem.
A research component as well? again no problem.
Hands on, no not ‘practicals’…..I mean treating ‘live’ patients - watch this space!
Its all about your ethos and values …. Strive to be the best….#ridewithus
References:
Mills JR. The place of research in orthodontic education. Br J Orthod 1982; 9: 67–69. https://doi.org/10.1179/ bjo.9.2.67
Houston WJ. The evolution of a postgraduate training programme in orthodontics. Br J Orthod 1982; 9: 71–72. https://doi.org/10.1179/bjo.9.2.71
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Original article for Dentine Tubules, 2012.
I would like to stress that this is merely my opinion - it is how I feel the future of Orthodontic Specialist Practice is un-folding. I am shaking the tree so to speak - it will be interesting to hear others thoughts.
The traditional route for the Orthodontic Specialist Practitioner was to undertake post graduate training culminating in an M.Orth. This was a three year course with academic content as well as treating patients, from start to finish of orthodontic treatment, hence why the course was 3 years long. The experience of treating 150 or so patients was invaluable, although I know some courses where the students only get to see and treat 40 or so. Interestingly we had to show 5 cases for the exam. The focus was very much on treating children and working in the NHS environment. On qualification, the clinician would either stay in the hospital system and become a Consultant or, as many did, end up in Specialist Practice. From talking to those who have qualified recently, it would appear little has changed. They have very few adult patients, virtually no experience of mini-screws and zero lingual patients.
With Specialist practice it used to be the case that one could either slide into an established practice or, set up on their own. Sufficent work was never a problem, until 2006 that is. This was when the New Contract was established, placing a ceiling on the number of patients the Orthodontist could treat. The issuing of new contracts was virtually zero so those recently qualified had to apply to existing practices where colleagues where retiring.
To make matters worse for the recently qualified orthodontists, along came therapists. The established practice could employ therapists to do the same work at a fraction of the cost. This, in my opinion, was simply a act of greed by established practitioners to earn more money and thereby shooting their newly qualified colleagues in the foot. As with everything, there is the flip side, that is cheap labour for the NHS so they can reduce the cost of the service.
So what happens to the newly qualified practitioner? Well they can either go into the hospital system, open a purely private squat or, hang around until someone retires in an established practice (but in competition with the therapists). The other alternative is to go and work in a General Dental Practice one day week at several different locations. The GDP’s are looking to increase turnover, so what could be better than a Specialist Orthodontist coming one day a week to cream off all the private work that used to go to the Specialist Orthodontic Practice.
And so we, the Specialist Orthodontic Practice, find ourselves in a position where all we receive is NHS referrals. Any private work is that we have generated ourselves. But with the ‘race to the bottom’ with the NHS and ‘how low can you go’ then there will be a move to large poly chair clinics employing therapists. Many can not adapt their buildings to accommodate several chairs in one room and, an interesting aside, I have heard the CQC raise concerns about protecting patient confidentiality when inspecting large open plan clinics. So is this the death for the small/medium Specialist Orthodontic Practice?
And whilst shaking the tree, why not turn and shake the training pathway tree. Why is training undertaken in hospitals. Why aren’t trainee’s undertaking more adult/lingual/miniscrew orthodontics (which I feel is the future). Why do trainees only show 5 cases for the exam? Just a suggestion, but why not have a in-practice training pathway, this could be combined with mentoring/distant supervision and show a minimum of 50 cases (warts and all, not just your best 5). Why not throw in some electronic learning to create a blended learning experience over 5 years?
The above is just my thoughts but after going through the ‘system’ and observing what is coming out of the ‘system’ and where Specialist Practice appears to be headed then may be we should consider some changes?
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