17 Professionalism and communication

‘The occupation which one professes to be skilled in and to follow. A vocation in which a professed knowledge of some department of learning or science is used in its application to the affairs of others or in the practice of an art founded upon it. In a wider sense, any calling or occupation by which a person habitually earns his living.’

How different from this broad definition is medical and dental professionalism? Do we individually profess special skill and knowledge? No—that is transparently defined by our peers by assessment, qualification, and registration to effectively prove that we have these properties. In the UK, the GDC holds registration lists for all dentists and certain specialists (GMC for oral & maxillofacial surgeons) and similar legal structures exist throughout the world. Royal Colleges, Faculties, and Specialist Associations all see a major part of their role as ‘standard setting’ for their areas of expertise. Again, this is repeated throughout the world. It is this concept of a universal sense of commitment to a role that defines medical and dental professionalism, not any individual country’s legal definition of it (which is why professions often constitute the major opposition to dictatorships or other extreme political systems).

A useful definition of medical and dental professionalism for our purposes is international and based on the work of Swick.¹ They:

Individual and collective professional self-regulation lies at the heart of the concept of medical and dental professionalism. That is based on the precept that society trusts us with certain privileges by virtue of the job (in all its aspects) that we do and we maintain that trust by individual high standards of behaviour and collective regulation and remediation or censure of those who fail to live up to those standards. I suspect for many of you this concept is self-evident although you may not have considered it in quite these terms. Why does ‘professionalism’ now need to be transparently and didactically taught?

Although the concept of the doctor (and latterly the dentist) as a ‘healer’ goes back into antiquity, the concept of a dual-role ‘healer’ and ‘professional’ is relatively new with the emergence of the ‘learned professions’ in the middle ages. Until the 1960s the role and commitment of the healing professional was largely implicit, evolving and supported by the majority of society. During the next 20 years an increasingly critical view of the professions developed among the social sciences, managerial echelons, and politicians, documenting failures and questioning its relevance to society. In the 1980s and onward an increasing dominance of either state or corporate sector employers and a diminishing influence of the medical professional was seen. This tended to increase the value of systems to state or corporate sector over the values of healthcare professionalism. However, more recently it has been widely recognized that ‘neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism’.² We therefore give more ‘bang for their buck’ by committing to being professional than any externally imposed system. Given that we, as healthcare professionals, have been disrespected and disenfranchised by these influential groups why should we adhere to the notion of professionalism? Clearly the great and good of the medical and dental political world see it as important—is this just to protect their own status?

Probably not. Individually or collectively we cannot do our jobs without a functioning system to work within. The best way to influence that is to wield the power that comes with the trust afforded by society in general in an organized, unified, and responsible fashion. Society needs healers, we are still far and away the most trusted of groups in society. The general public is not happy with their leaders. The bureaucrats (state or corporate) control the marketplace and are blamed for defects in the system. Being a professional is the best way to improve the system and genuinely being professional is what makes you want to improve it—for the betterment of all.

Therefore a better definition might read ‘An occupation whose core element is work based on the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some aspect of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These commitments form the basis of a social contract between the profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society’.³

is a term derived from Gough:⁴ ‘the rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract’. It is a complex mix of the explicit (written, legal or paralegal codes, rules, and regulations) and the implicit (unwritten, individual and collective senses of obligation and purpose reflecting personal and group codes of ethics and morals). It can have universal and local components (i.e. those applicable internationally and those that are country or locality specific). Importantly it is constantly evolving and seeks to balance society’s expectations of medicine with medicine’s expectations of society.

is the basis of dentistry’s contract with society. In common with medicine it requires placing the interests of patients above those of ourselves (within reason), setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.

For professionalism to have any effective basis in reality the public must trust in us individually and collectively, this depends on our integrity both individually and collectively. The fact that annual polls consistently place doctors and dentists at the very top of lists in which the public place their trust bears out the fact that this has been the case since the origin of our professions.

This in itself can create problems.

The patient, individually or as a community, is not the customer who is always right. Politicians elected or unelected do not always have the best interests of the population at heart. In situations where we as professionals see this to be the case we are obliged to speak out. This can carry with it accusations of paternalism or politicization.

It is illogical to believe that health is not a political issue—it affects the public good and is a right in most civilizations. It is therefore part of being a professional to express both concerns and potential solutions at systems that fail to deliver what they should for patients. What is counterproductive is the descent into party or partisan politics which is the rightful quagmire of the politician.

Equally, a desperate avoidance of the appearance of being paternalistic in the name of political correctness becomes counterproductive if we fail to advise patients what we feel is in their best interests. They are entitled to ignore that advice (providing they are competent to do so) and go elsewhere but they are not entitled to demand that we provide a treatment we genuinely believe is not in their best interest.

The fact remains that, as healthcare professionals, we are trusted and society needs us. The continuing commitment to the role of the healthcare professional is key to that.

The principal standard setting bodies in the UK for dentistry are the GDC, the Specialist Dental Education Board, the Committee of Postgraduate Dental Deans, the Dental Faculties of the Royal Colleges of Surgeons, the Specialty Associations, the British Dental Association, and the dental degree-awarding universities. Each of these has a different and sometimes conflicting role and each can be influenced to a greater or lesser degree by government. Each country has its own bodies with variations on the same functions.

All these bodies claim to seek to uphold standards and all to a greater or lesser degree speak for a constituent group. This has the inevitable problem of creating a potential conflict of roles. Each organization has to manage the conflict between altruism and self-interest, professional representation and state or corporate control, public good, and a union function.

It has been mentioned that self-regulation is a key principle of professionalism and one which is regularly attacked by state and corporate bodies. The preservation of collective self-regulation carries with it certain obligations on the individual: maintenance of competence, participation in the process of self-regulation, support for the relevant bodies, and behaviour that reflects integrity. The collective must demonstrate that individuals falling short of their obligations are corrected.

will require a renegotiation of the social contract. There are legitimate worries on both sides and advantage is taken of serious failures in professional behaviour to disproportionately undermine the healthcare professional’s viewpoint. The repeated use of Shipman (a GP serial killer), or Karadzic (a psychiatrist mass murderer) as examples reinforces this even though these individuals’ monstrous personality disorders could not have been contained by conventional medical self-regulation. Because of these failures in self-regulation, the GDC is looking to follow its medical counterparts by introducing revalidation for dentists in four key domains. One of these key domains is ‘professionalism’. Because of this, it is clear that dentists need to have an understanding of what professionalism entails.⁵

Society wants (and needs) healers with a professional mindset. It has to have healthcare professionals using their knowledge and skill to heal, cure, and relieve suffering. It wants individuals’ competence in discrete areas guaranteed. People want to be involved as patients. They want to see that those they trust behave to high ethical (and arguably moral) standards. It also needs accountability. Professionals want (and need) trust and respect and the acknowledgement that some failings are inevitable. Their expertise should be recognized and made appropriate use of. They should be sufficiently autonomous to act in the best interests of patients (politicians dictating and lawyers second guessing helps no one). They need reasonable, reliable, validated, and trusted regulatory and training processes which they have ownership of. They need adequate resources to care optimally for patients. They need to work in a system which transparently promotes the values society wishes to see in its healthcare professionals: caring, altruism, courtesy, and competence.

is to ensure the balanced role of competent healer and caring professional in all training and practising dentists.

The GDC has issued a document called ‘Standards for Dental Professionals’.⁶ This document is centred on the principles of practice in dentistry. The subject matter is frequently asked about in interviews for postgraduate positions. It states that as a dental professional you are responsible for doing the following:

The Royal College of Physicians and Surgeons of Canada have been involved for many years in a project, known as CanMEDS,⁷ designed to describe the competencies required of a physician. As you can see these include the role of ‘professional’ although their definition is narrower than that already used as it overlaps with the other CanMEDS roles. This descriptive system has been used extensively by the Royal Colleges in the UK in designing higher training curricula, the Modernising Medical Careers group and the equivalent group for basic postgraduate training in dentistry in the UK.

It comprises:

Most of us never actually took a Hippocratic Oath although many think we did. The statement you read out at graduation will have been a modern-day version outlining your commitment to professionalism. It was none the worse for that because at the time it was a marker of how you felt about the profession you were entering. The genuinely wonderful OHCM (8e) includes both the old and a new version (see pp. 0, 1) so rather than repeat it (go and buy the book) I’ve included a synopsis of principles and commitments based on a physicians’ charter.

It should by now be becoming obvious that many groups are saying similar things about both the nature of professionalism and the perception of professionalism. The primacy of ‘doing the right thing’ for your patients, your colleagues, your society, and yourself is the key principle that shines through.

As we all work in systems of greater or lesser complexity we need to learn how to cope with, redesign, or overcome systems that prevent optimum outcome for our patients. In a general dental practice (a very small system), considerable power and autonomy is placed with the dentist and system design is important. In huge environments, like hospitals, many aspects of the system may be out of our control so learning how to overcome or adapt existing systems becomes crucial.

describes the individual steps that constitute each point in a journey through a system from start to finish. The easiest way to understand this is to imagine a patient’s journey in great detail. This is the process view and it is essential when implementing an error avoidance strategy. The first step is to identify the high-level view—an overall stepwise progression of the journey that highlights 15–20 key steps. Next, detailed process mapping takes place inviting the views of all the staff involved in the process (remember it is looking at the system first and individuals only if there is a defined problem with one individual’s behaviour). Avoid rarities and personal anecdote. Look for waste in the process: of time, money, effort, goodwill, etc.

This includes: bottlenecks which may be real (a step performed by one person, at one time that takes longest) or functional (trying to do multiple non-consecutive tasks which waste time between each task). Demand/capacity mismatch, the failure to understand these terms are a root cause of much of the mismanagement of the UK health service. Demand is the need plus want for the service, i.e. all requests for the service, activity is what has been done (always retrospective), capacity is what the system could do under optimal conditions, backlog is cumulative unmet demand. Carve-out is where overall capacity is reserved for particular demands (e.g. fast track cancer referrals).

is a core underlying problem in most systems and the major source of stress in most hospital environments—the person held responsible (i.e. blamed when things go wrong) does not have the necessary authority to prevent them from going wrong.

Understanding that a patient’s journey is a system allows you to improve it and use the techniques for error avoidance outlined in ‘Human factors’ ( Human factors, p. 700). In the microcosm of a dental practice the most difficult thing may be simply accepting this concept. In the huge, highly complex, externally interfered with hierarchical systems within hospitals the emphasis has to be on adapting the aspects of the overall system so that you have authority over it to improve it, even if this effectively subverts imposed aspects of that system.

Sometimes referred to as ‘ergonomics’ this consists of a group of subjects concerned with human–human and human–system interaction with a particular relevance to the prevention of error. Popular over the last 20 years or so in so-called ‘high-risk industries’—aviation, nuclear, petrochemical, and military—they have recently become recognized as being of potential value in healthcare, particularly in the Anglophone world.⁸

A longstanding tradition of managing when things go wrong is to find out who is to blame and punish them. That’s it. It is astonishing that it has taken so long to accept that this is not the most useful way of going about things.

We all make mistakes, this is inevitable and inescapable. What is important is that the potential for serious harm coming from those mistakes is minimized and that we and others learn from those mistakes. In order to do that a move away from the blame culture has to take place. In some industries this has been achieved to a large extent (aviation). In healthcare there have been some notable attempts. These have been successful where the system is trusted, usually anonymized, and reliable feedback is given. They have largely failed where a system has been imposed by an outside body which is not trusted (government or corporate body), league tables devised, and feedback has been minimal or useless.

The recognition that humans make mistakes (that are usually non-malicious) but that things go disastrously wrong only when these mistakes are compounded, led to an approach where the system was analysed for failure rather than an individual being blamed.

This is an analogy for systems failure and error occurrence.⁹ For something to go seriously wrong (e.g. a patient dies from taking the wrongly prescribed drug) multiple failings have to happen. Think of trying to thread a straw through multiple layers of Swiss cheese. It will only pass through if all the holes, which are in different places on each slice, line up. One slice out of place and it won’t pass (i.e. the error won’t happen). In the patient analogy, the wrong drug might be prescribed, but the dispensing pharmacist might recognize this or the patient might realize they were allergic to it.

This is the term given to the signs and symptoms of an error in progress. Recognition of a ‘red flag’, e.g. a change in the order of an operating list, should make everyone more aware of the potential for an error to occur.

This is our capacity to be aware of multiple aspects of our immediate environment. A simple example would be driving behind a car which is travelling slower than you in the inside lane of a 3-lane motorway at the point of a junction which has another car travelling at the same speed coming on the motorway. The calculation you make to position yourself safely without losing speed is your situational awareness. Stress massively reduces this and effectively blinkers you to potentially important outside influences.

Is the post-mortem and coroner’s report of the events around a significant event. This is supposed to happen after ‘clinical incident’ reporting, the idea being that the areas of system failure are identified and measures put in place to prevent failure at that point in the future. Obviously this requires feedback and resource for change going to the people and places affected.

As mentioned before, individual personalities and learning techniques exist for all of us. If we are put in a position where we have to work or learn in a way that is at odds with our preferred approach we become, to a greater or lesser extent, stressed. The effect of stress on situational awareness is described. If situational awareness is decreased, the potential for error increases. This is one logical reason why certain types of professions have to be assessed under stress—we have to be competent and able to function under levels of stress that would cripple others.

If you are working in a hierarchy how do you tell the boss he is doing something wrong? One excellent technique is the PACE approach.

‘Is it me? I don’t understand why we are doing (the wrong thing) this.’ This is usually enough and saves face all round.

‘I’m sorry but I don’t think this is right. I’m not happy.’ The ante has been raised but it is still non-confrontational. It takes real bull-headedness to press on in the face of this.

‘Look, this isn’t right. I know you’re the boss but I am sure this is not what should be happening.’ This is a point of no return but you are doing the right thing.

‘Stop. I am not going to let this happen.’ An extreme situation where you intervene (possibly even physically) to prevent harm to a patient.

The concept of leadership is often that of someone who is always in control, always knows what to do, is always right, and carries all the responsibility. Just reading that should make everyone realize it is nonsense. True leadership is about keeping things together, using the right people in the right place at the right time to achieve an agreed goal. Followership is acknowledging this and the leader who gives way (and becomes a ‘follower’ temporarily) to allow someone with a more appropriate skill set to lead is enabling that to happen.

We are all different. That seems self-evident but the fact that different personality types exist and that they have a direct bearing on the way we learn and act does not seem to have permeated training structures or workplace management.

While no human being is completely stereotyped into a category with regard to both personality and learning preferences, most of us show tendencies towards various behaviour types. It is important to realize that no one type is better than another but that certain types are more suited to certain roles in life and certain ways of learning new information, skills, or behaviours and that being forced to act outside that type can lead to significant stress. We might not be able to change the environment we work, teach, or learn in but understanding that someone may be of a personality type where that environment produces counterproductive stress may help us modify the situation or them to accept that this is not a role they are suitable for.

This is one (there are others) way of assessing personality types. This is a quite lengthy questionnaire which categorizes ‘preferences’ in 4 main categories:

Essentially this reflects the extent to which you engage the world in your head or the ‘real world’.

This is about how you gain information; do you rely on the 5 senses (are heavily factual) or have a 6th-sense feel for things?

Do you prefer a critical/analytical approach to decision-making or rely on instinct more heavily?

Do you seek order, sense, and predictability or are you happier to take things as they come?

This is a gross simplification of the process but gives you an idea of how people can differ, no one ‘type’ (indicated by the letters allocated to the different sections) is better than another but certain types cope better in certain situations, jobs, roles, and in interpersonal relationships. Just going through the process aids in personal insight and reflective capability.

Just as there are 4 distinct personality traits which flow into each other so there are equivalent learning types. These also match the stages of learning and reflection and development of what has already been learned. The distinction between people is that they tend to prefer one stage more than another and can feel uncomfortable or even stressed if forced into an area they are less comfortable in.

Reflective observation (thinking about buying a computer, reading all the magazines).

Abstract conceptualization (reading the manual after buying it).

Active experimentation (bought it, chucked the manual away, plug it in, and start pressing buttons).

Concrete experience (got one that works and going to stick with it).

Is an inevitable and ongoing process in our everyday lives and the workplace and is certainly no bad thing in itself. The intense resentment felt by most professionals towards change has come about by imposed change, with no or facile consultation, no evidence base, and no internal motivation for that change. The fact that most of these imposed changes fail, often due to the incredible power of healthcare professionals’ inertia even in the absence of tacit opposition, is a lesson that those who would impose change continually fail to learn.

Is a useful concept both because we may wish to change practices, systems, or treatments within our control for good reasons and because we may wish to oppose change where we feel it is potentially harmful, wasteful, lacking in evidence, or just plain wrong. To do that, it helps to understand a little of the processes.

In terms of our professional environment, three basic groups: individuals (ourselves, patients, colleagues), groups of individuals (nurses, trainees, those who are sharing a common experience), and organizations and systems.

There are 2 which are not mutually exclusive but tend to have different emphasis: changing attitudes in the relevant individuals and hoping that behavioural change will follow (‘hearts and minds’) and a more punitive approach emphasizing the legal and business reasons for change. While the latter has become increasingly popular it is unsurprisingly less effective with highly motivated and educated healthcare professionals.

There is an unfortunate tendency for many trying to implement change to stick with conventional management theory which looks on organizations as machines with staff as components of that machine. This leads to the folly that a detailed plan for change can be worked out in advance (often by outsiders), people are told what to do and will both do it and do it consistently, and that this process will be automatically replicable from one area to another. A much more useful concept is that organizations are complex evolving ecosystems functioning on a series of interdependent nested systems.¹⁰ This concept believes guidance from a few simple rules will allow permanent effective change generated by internal motivation. It is the theory behind ‘brainstorming’ and ‘post it note’ exercises—although all too often these are corrupted by those ‘in charge’ falling back on conventional practice.

need leaders but leaders do not have to be the font of all knowledge ( Understanding personalities, p. 702) acting as enablers or facilitators they can earn the support of the group by active listening, designing a plan of action, facilitating that plan (rather than doing it themselves), seeing what happens and giving feedback ( Feedback use, p. 711).

to function effectively with change need to develop emotional intelligence: ‘the capacity for recognizing our own feelings and those of others, for motivating ourselves and for managing emotions well in ourselves and in our relationships’.¹¹ Discovering what motivates ourselves and others is the key technique in ensuring people feel they ‘own’ the change and the change process, the key aspect of successful change management.

God gave us two ears and one mouth, but they are rarely used in those proportions.

Hard to do but hugely rewarding. Try to cultivate an active listening style; don’t interrupt unless it is essential and if you do always give the opportunity to come back to a point that may be vital to them at some time in the future.

is needed to learn these skills, to use them in imparting news (especially bad news) to people, and to allow people to absorb that news. Allocate it, allow it, and stick to it.

When communicating, it is helpful to be sure of the information you are imparting and that you want to impart it. Prepare what you want or have to say as well as how you will say it.

Saying ‘sorry’ can be taken as an admission of guilt or as a sincere form of empathy. Timing, intonation, and body language influence how the same word is understood by the person hearing it.

is best but does not mean burdening someone with extraneous detail which clears your conscience but unnecessarily harms someone else.

People will have questions but may need time to refocus to ask them—suggest they write them down for next time. They will also have a legitimate need to have some answered—if you can do so, but don’t be afraid to admit you don’t know. If you can’t, but know someone who can, then that is a fair response. Equally you may ask questions; the most useful after breaking bad news, perhaps surprisingly, is ‘How do you feel about that?’. The number of different response will astonish you and it is of huge importance to let people express themselves at this point.

Few things are more disorientating than being told different things by different people about the same subject, especially if that subject is your personal health or that of a loved one. Be sure of what has been said before—ask the person you are talking to as it is what they remember or understand that is important to the conversation. Try to ensure all team members do this before launching into some detailed explanation which may be at odds with what has gone before. If previous information is incorrect it must be corrected but include an explanation of how that ‘misunderstanding’ arose.

are important components of communication but this does not mean you are a limitless source nor does it mean you are an emotional punch bag for upset individuals. Having boundaries in your role as a professional communicator is essential to prevent burn out.

Neurolinguistic programming (NLP) was first developed by a psychologist, Richard Bandler, and John Grinder, a linguist, in the 1970s. NLP is often referred to as the ‘art and science of personal excellence’.

It is a set of interpersonal skill techniques to improve the impact and effectiveness of communication.

When communicating with others, build rapport—this can be done through matching body language, eye contact, tone of voice (pace and leading), and active listening. Understand the situation from the other person’s perspective, ‘Seek first to understand, then to be understood’.¹²

Know the outcome you want, ‘Begin with the end in mind’.¹²

Use all your senses VAKOG to interpret and make sense of the world around you. Be aware we all see, hear, and feel things differently.¹³

Be flexible in your approach. Others may interpret situations/the world differently. The more flexible you can be the more options you create.

is not teaching, but it can be a useful tool in teaching. It can also be a nerve wracking chore (job interview presentations) or a rite of passage exercise in survival at a national scientific conference. Regardless of its intended purpose it can be made better and more pleasant (for you and your audience) by following some simple rules that are based around preparation, planning, and delivery.

What are you trying to say—this is essential, if you don’t know what you want to say, how can you say it? No one wants to listen to you work it out on the spot—that is boring and embarrassing. It is also vital that you understand whether what you want to say agrees with what the audience wants to hear and what the organizers want you to say. It is not always the same thing. Why do they want you—do you have or have promised some special expertise or are you a replacement? Who are you speaking to and who has asked you to speak, are their agendas the same (some attendances are ‘mandatory’ which tends to produce a hostile audience which needs to be defused), what are their backgrounds, ages, degree of knowledge of the subject you are asked to speak on? What would they like to get out of it? How many people will be there? This has obvious implications for the choice of media—PowerPoint to 5 people is dull and ineffective, a flipchart to 100 is impossible. What is the context of your presentation, is it a 10-minute talk with 5-minute questions wedged into a plethora of others; part of a structured course with experts before and after you; or just you with relative flexibility? This is essential for timing considerations; if you are allocated a finite time you must stick to it, which means starting and finishing to the minute. If you are allocated a vague time (‘40 minutes to an hour’) set yourself a specific time and break it into 20-minute chunks (the attention span of most people for listening). Work out how you get to the venue, a backup plan, and who to contact if things go wrong, get there early, and ensure all audiovisuals are working before the audience arrives (getting your presentation to work while the audience sits there growing restless is a cardinal sin).

Now that you have an idea of what is going to happen you can plan the presentation. It is crucial you know your subject and are up to date for the level of your prospective audience. Once you have a good idea of the relevant content, work out what is feasible to deliver (in the allocated time and to that particular audience). More really is often less in presentations. What sort of language are you going to use? What sort of dress style will be right for that occasion? What technique are you going to use to deliver the presentation?

is the defining aspect of your presentation. Media include: blackboards, whiteboard, flip chart, overhead projector, visualizer, 3-D objects (for smaller groups) and microphones, computers/LCD projectors for larger groups. Video and handouts can be used for both. Be familiar with what you are actually going to use (it often won’t be your own computer, many a video clip disaster has stemmed from this). Mastery of the older presentation techniques, which are often more suitable for smaller groups requires greater skill and confidence than slide-based approaches which explains their popularity and overuse. Many presentations will use PowerPoint, while this has many advantages the misuse of the technology has created the well-recognized condition of ‘death by PowerPoint’—too many flamboyant slides, rushing through multiple slides that contribute nothing and give the impression of bad preparation, and freezing of the system if multiple lines and pictures are added to the slide. Do not become obsessed with the media, it can distract the audience from what is important—your message. Design this like a story, know what the end is going to be then work out a way to get there. Now you know where you are going work out the start—an interesting title and an outcomes slide coupled with a short, friendly introduction helps. Build into the bulk of your talk, avoiding abbreviations, keeping it short and simple, and re-emphasizing important points and why they are relevant to the audience. If your talk is longer than 20 minutes build in ‘energizers’, these can be literally breaks where people move about and do things (for the brave and experienced) or interjecting questions into the audience.

using the set, dialogue, closure approach for teaching helps structure every presentation ( Structure of a learning episode, p. 710). Start on time, ensure your non-verbal communication ( Verbal and non-verbal communication, p. 706) is positive and open. Engage the audience and introduce yourself in a way that gains credibility, tell them what you are going to talk about and why it is important to them (or why they might enjoy it). Ensure text slides or OHPs are clear and legible with no more than 7 words per line and 5 lines per slide. Do not read your slides to the audience, it’s insulting, they can read too! It takes a minute to read a text slide. Use good quality pictures and diagrams that are relevant, don’t just show off. Avoid extra logos and pictures on a slide that will simply distract the audience. Ensure you have an aims and objectives slide at the beginning and summary slide at the end. Practise so that you know which slides are where and how far into the presentation you are.

When allowed by the structure of the environment try to ask questions at the end before you summarize what you’ve talked about. This enables you to check the audience has understood you and to build anything missing into your summary and creates an opportunity for a definitive termination of the presentation (which prevents things dragging on and the audience remembering some daft question rather than your summary).

Remember: perfect practice prevents piss poor performance.

In order to teach effectively you have to ensure others are enabled to learn.

In order to learn you have to participate actively in different styles of teaching.

This is the term given to what can be learned. Usually three are described—cognitive (knowledge), psychomotor (skills), and affective (attitude). Some would argue (and I agree) that a 4th domain exists—interpersonal, as this is a group of abilities (verbal and non-verbal) that can be used for good and bad reasons. Each of these domains has more appropriate ways of teaching, learning, and assessing them (e.g. you don’t assess operative skill with an MCQ).

The current term for aims and objectives. Basically this is working out what you are trying to learn or teach before you start trying to do it. From a teacher’s perspective it is useless to start trying to teach something unless it can be feasibly learned in that episode. It helps to state what you are going to do in whatever period of time and with whatever learner(s) you have. From that you can work out how to do it. Think of it as knowing where you want to go, then working out the best way to get there on any given day and in any set of circumstances.

Set, Dialogue, and Closure. This structure allows the efficient construction of any high-quality teaching episode.

This is the initial preparation of the episode, ensuring the environment is the best it can be, introducing yourself, discovering your audience, and agreeing your roles. Establish what you are going to do and how you are going to do it.

This is the bulk of the teaching, the information imparted or the skill taught. Interactivity with your learners is crucial and achieved by questions, eye contact, and direct involvement. Skills teaching involves a 4-stage procedure during this phase:

The end is important as it is often the aspect best remembered by the learner. An effective closure consists of questions with explanations followed by a summary followed by a termination. A definitive stop prevents the process from becoming messy and the last (strongest) memory of the learners from being something irrelevant.

Books, journals, lectures, and the Internet are all sources of knowledge. Retention is improved by repetition and application. Simple acquisition of facts is only the first step in possessing useful knowledge. It is the integration of data and its application to variable information, i.e. working out a treatment plan from a series of signs and symptoms that is essential in a dentist.

The 4-stage technique works but has specific challenges in carrying out procedures on conscious patients (need to agree code words) and in long complex procedures (which have to be broken down into smaller steps).

The ability to relate effectively to other people can be taught and learned in a variety of ways, although the most effective is watching people in action and analysing what they are doing and what impact their words and actions are having on the people around them.

Attitudes are the essence of professionalism, they govern what drives us and are defined by what we do (not what we say). The only really effective way of teaching appropriate attitudes is by acting them out as role models who are valued by those who are learning.

‘Pendleton’s rules’: ask what went well, if they struggle tell them or if in a group ask others, then ask them how they would improve or do things differently the next time, ensure they are told about any significant points for improvement if they miss them (either personally or using others in a group).

Given that what we do is the most crucial aspect of assessment and the workplace is the most real life environment these tools have been created to get as close to real life as possible.

These consist of 2 observational tools—mini clinical examination exercise (Mini-CEX) and direct observation of procedures (DOPS) or procedure-based assessment (PBA) (the names will change again but the principles are valid)—an interactive tool, case-based discussion (CBD), and a peer assessment tool (Mini-PAT).

This assesses an interaction with a patient using either a checklist or a global rating scale (depending on level of the assessment) and can assess, knowledge, interpersonal skills, examination skills, and, to a certain extent, attitude.

The latter is a similar idea but intended to assess technical skills. There is a generic checklist built into the proforma but it is important to understand that this tool was primarily intended to assess physicians carry out relatively simple technical skills (it originated from the Royal College of Physicians). The PBA adapted from DOPS by the Royal College of Surgeons of England is designed to assess more complex technical skills; however, the checklist approach is less appropriate in assessing higher skill levels than a global rating scale.

is an interactive discussion between assessor and assessee around case notes picked by the assessee, designed to assess a wide range of hard and soft thought process and skills (i.e. from technical quality of note keeping to ability to reflect on a mistake).

(aka 360-degree appraisal, multisource feedback, etc.). Assessee chooses 8–15 relevant people to complete a structured questionnaire. Statistically valid results achieved if at least 8 completed returns. Sceptics should try this one and it can be extremely useful in helping self-reflection and improvement on a range of subjects. Originally developed by the Royal College of Physicians and Surgeons of Canada (see CanMEDS CanMEDS, p. 696).

an in-workplace tool for general dental practice developed by NHS Education Scotland.

Clearly all the domains of learning or the subdivisions of these described in the CanMEDS document have to be assessed and a range of techniques are needed for this. While basic facts can be tested by rigid, simple tools like single best answer MCQs, assessing the higher levels of function demanded of a healthcare professional needs much more. A combination of the in-workplace assessment tools and externally validated conventional examinations (incorporating rigid but reliable assessments like MCQs and OSCE as well as the more flexible and valid interactive techniques like structured vivas, moulages, and scenario-based assessments) are clearly necessary to ensure what both dentistry and society need—the competent healthcare professional.