COVID-19 and Postgraduate Dental Training-A commentary.

In this commentary, we discuss the short-term and long-term implications of COVID-19 on postgraduate dental training in the UK, specifically Dental Core Training (DCT) and Specialty Training. Although this commentary focuses on the authors' experiences within Guy's and St Thomas' NHS Foundation Trust (GSTT) in London, we hope that our viewpoint will resonate with dental postgraduate trainees across Europe and may guide further discussion in this area. We also reflect on adaptations that may be required if there are any future disruptions to dental postgraduate training in the UK.

INTRODUCTION

After completing undergraduate dental training in the UK, dentists are required to undertake a mandatory year of Dental Foundation Training (DFT) in a National Health Service (NHS) general dental practice. After completion of DFT, the majority of dentists continue to work in primary care; however, for those interested in gaining hospital‐based experience, or wishing to pursue dental specialty training, there are additional training years (Figure 1). Dental Core Training (DCT) occurs in a predominantly hospital‐based environment. This training pathway is up to 3 years and allows the acquisition of additional broad‐based competencies, before returning to primary dental care services, or pursuing specialty training. There are 13 dental specialties in the UK, including Restorative Dentistry, Oral Surgery and Oral Medicine.

Figure 1

NHS dental training pathway

Following the global spread of COVID‐19, the World Health Organization declared a pandemic on 12 March 2020. NHS services were advised to postpone all elective procedures, and accordingly on 18 March 2020, all routine dental appointments including elective surgical procedures, assessment clinics and student treatment clinics were cancelled. Dental departments at our hospital were transformed from delivering specialised services into a regional urgent dental care centre. Concurrently, some postgraduate dental training programmes, such as DCT and specialty training, were suspended to allow trainees to support the national effort against COVID‐19.

The purpose of this commentary is to describe the personal impact of COVID‐19 on individuals enrolled in DCT and Dental Specialty Training. We also offer suggestions that may help to mitigate future disruption to dental postgraduate training.

Our commentary is based on the personal reflections of two current dental core trainees working in a multi‐specialty post, two specialty registrars in Oral Medicine and a consultant service lead in dental education and training, following their experiences of redeployment.

SHORT‐TERM EFFECTS FOR DCT

The UK DCT Curriculum outlines 4 key domains in which trainees are expected to develop competencies. These domains are as follows: (a) professional behaviour and trust, (b) communication, team working and leadership, (c) clinical safety and quality, and (d) good clinical care. Redeployment was a key component to the preparedness and response to COVID‐19. We outline how DCTs have developed new skills and continued to meet the competencies within the UK DCT Curriculum throughout this process.

Professional behaviour and trust

DCTs were redeployed to a range of departments including community renal dialysis units, critical care units and inpatient COVID‐19 wards. This was supported by formal and informal teaching sessions to expand learning opportunities. These learning experiences enabled redeployed DCTs to perform successfully in their new roles. However, throughout redeployment, recognition of professional limitations was paramount to ensure that DCTs worked within their competencies.

Communication, team working and leadership

As DCTs integrated into large multidisciplinary medical teams, there was scope for developing competencies in communication and team working. DCTs worked alongside doctors, pharmacists, occupational therapists, specialist nurses such as dialysis and diabetic nurses, ward clerks and patient co‐ordinators. As staff sickness and shortages increased, DCTs offered their skills where appropriate to reduce the workload for the rest of the team, without compromising patient safety. This approach required DCTs to demonstrate personal agency and take the initiative to integrate within a team that was largely unaware of how dentists could support the wider healthcare team.

Communication skills were also developed through interactions with patients and their relatives. External visitors, including relatives, were banned from the wards to reduce the risk of disease transmission, and DCTs were able to provide extra support for patients and to update family members by telephone. These conversations were often challenging but provided valuable opportunities to reflect upon and enhance communication skills.

Clinical safety and quality

Supporting the care of inpatients allowed DCTs to gain exposure to patients with complex medical conditions. In addition to gaining greater understanding of specific medical conditions such as diabetes mellitus, chronic kidney disease and acute kidney injury, DCTs developed greater understanding of the holistic assessment of patients with multiple co‐morbidities and improved knowledge regarding polypharmacy and prescribing. These skills are directly transferrable to a dental setting and will facilitate higher quality patient care.

Within the dental hospital, DCTs supported senior staff members transform existing services through reviewing and adapting local policies, trialling new systems of working and creating local standard operating procedures. DCTs supported the introduction of streamlined patient care pathways to minimise the number of hospital visits. By engaging in these initiatives, trainees were able to contribute to a growing body of national recommendations on providing effective and safe dental care for patients in all settings across the country.

Good clinical care

Some DCTs were redeployed to maintain oral hygiene for ventilated ITU patients under the “Mouth Care Matters” scheme. This experience offered trainees the opportunity to actively promote oral health in a medical setting and share their techniques with non‐dental colleagues.

SHORT‐TERM EFFECTS FOR SPECIALTY TRAINING

Dental Specialty Training was not suspended in the same way as DCT. Specialty trainees were advised to identify development opportunities in either their existing environment or their redeployment. Clinical contact time which was lost paved the way for completion of quality improvement projects, research, leadership courses and ongoing knowledge development.

Health Education England (HEE), the body responsible for healthcare education and training in England, indicated that consideration for redeployment of trainees was appropriate in exceptional circumstances. Many trainees were redeployed to inpatient wards and through these placements, gained the opportunity to develop medical competencies invaluable to their clinical practice. This opportunity assisted trainees meet the challenges facing the future dental workforce and identified in HEE Advancing Dental Care, in particular, meeting the needs of an increasingly elderly and medically complex population.

Clinical skills and knowledge

Specialty training enables clinicians to develop the clinical skills and knowledge expected of a specialist. For trainees within specialties such as Oral Medicine and Special Care Dentistry, this includes medical competencies. , Redeployment to medical specialties or intensive care units enabled specialty trainees to immerse themselves with the clinical management of inpatients, often acting as the first point of contact for medical issues on the ward. Redeployment specialties included Head & Neck surgery, Ear Nose & Throat, Obstetrics and Gynaecology contributing to the acquisition of these medical competencies.

Teaching and training

With the suspension of many non‐essential services within healthcare, courses and conferences were also cancelled. Specialty trainees rely on these courses for ongoing development of their clinical knowledge and as a platform for presenting research and quality improvement projects. The presentation and defending of a trainee's output not only provide the opportunity to develop critical communication skills, but are also an important networking opportunity.

Trainees with suspended upcoming professional examinations had their training extended beyond their planned completion date, with the agreement that their training would complete when examinations resumed. Whilst this provided some certainty, trainees with pending examinations had little guidance as to when examinations would restart which has implications on trainee preparations and more general well‐being.

Specialty trainees are often heavily involved in teaching, and acquiring teaching competencies is an important component of specialty training. The suspension of traditional face‐to‐face teaching might have negatively impacted on trainees' opportunities to gain teaching skills; however, this threat has been mitigated by the use of innovative digital teaching methods such as video conferencing.

Research and quality improvement

With the suspension of many dental specialty clinics, clinicians were afforded a unique opportunity to pursue research and departmental quality improvement projects. Those redeployed were able to engage with projects within other departments giving them insight into other research/quality improvement methods that could be brought back to dental specialties. Nevertheless, there may have been a deleterious impact for some academic trainees, with the cancellation of training opportunities, and the temporary suspension of non‐COVID–related research within most university biomedical departments in the UK.

Management and healthcare delivery

The COVID‐19 pandemic has required drastic changes in the way in which healthcare is delivered. During specialty training, it would be expected that trainees obtain insight into the structures of the NHS and healthcare delivery. The pandemic has provided a unique opportunity for trainees to engage in addressing the challenges of healthcare transformation: trainees worked alongside senior clinical colleagues to remodel current systems and evaluate these new ways of working.

LONG‐TERM EFFECTS ON TRAINING

The COVID‐19 pandemic has accelerated the pace of adoption of the NHS vision set out in the long‐term plan, in particular, the reduction of outpatient visits by a third over five years. This must be recognised when assessing current trainees’ progress and importantly should lead to a more rapid review of specialty training curricula.

In the long term, it is likely that the current cohort of trainees will have broader healthcare skills and knowledge following redeployment—it is our hope that this will foster more multidisciplinary working in both a clinical and research setting. This should be captured and embedded in future training experiences.

FUTURE CONSIDERATIONS

We recognise that the lack of meaningful curricula, desirable competencies and assessment frameworks could have impacted trainees’ capacity to maximise potential training opportunities throughout this period. However, we acknowledge that due to the pace of redeployment to a vast range of services, it would have been nearly impossible to develop a competence framework of knowledge, skills and behaviours within this time period. Moving forward, it would be useful to develop a framework as part of our preparedness for a potential second wave or future virus pandemics. This will encourage trainees to engage in opportunities they should find themselves in a role outside of their dental capabilities and structure their learning.

Consideration should also be given for alternative methods for hosting conferences and presenting oral and poster presentations. Holding these virtually via e‐posters, pre‐recorded oral presentations and a showcase of clinical content on an online platform allows trainees to present their work at a national level and continue to build upon their experience without hindering their training.

Similarly, access to expert learning resources through online webinars, quizzes and conference calls has minimised the disruption created by the pandemic and allowed for continuing education remotely. The adoption of digital learning in this way may continue to provide benefit post‐pandemic, by allowing further flexibility for trainees amongst their existing timetables. More use of simulation training for both clinical and non‐clinical competencies is also an area that will require further development.

The COVID‐19 pandemic whilst hugely challenging also has the potential to accelerate positive changes in dental training; however, this will require engagement from diverse stakeholders and a shared vision.

CONFLICT OF INTEREST

The authors have no conflicts of interest to declare.

ETHICAL APPROVAL

Not required.

PATIENT CONSENT

Not required.