“SAFETY IN THE PRACTICE OF DENTISTRY” by Dr Victor H. Eastmond
I would like to enter the debate on dental registration in the hope that I can provide an element of clarification after reading what I consider to be misleading comments in the printed press on Monday 8th October 2012. In my capacity as a registered dental practitioner in Barbados, I would like to support the current president of BDA on his comments pertaining to registration of local dentists in general but with special emphasis as it pertains to the Caribbean especially since the BDA is not acting in an autocratic manner in disallowing Barbadian dentists an opportunity to practice in their country of birth. Nothing can be further from the truth as there are quite a few UWI trained Barbadian dental graduates who have already met the required stipulations and have been registered to practice their profession in Barbados by our Dental Council.
It is essential to define the term “Profession” as per the Webster’s dictionary which states it as any occupation or vocation showing a sound work man’s command. I looked further and found a more a detailed account (no pun intended) from The Chartered Institute of Management Accountants (CIMA) which stated that their members should:
- Have a common body of knowledge.
- Have benchmarked performance standards.
- Belong to a representative professional organisation
- Have a code of ethics that you work within.
- Have undergone the required training credentials for entry and career mobility.
- Undertake continuing professional development (CPD).
- Have a vocation requiring knowledge of some department of learning or science.
- Have a fear of those in authority.
CIMA’s statements are in keeping with the mandate of other professions (including BDA) and further states that it is committed to upholding the highest ethical and professional standards while maintaining public confidence in management accounting. I have picked on the accountants’ professional dictates as it appears to be very well outlined without bias and has universal acceptance with other professions in what is expected and also because many Barbadian accountants are familiar with these dictates. I therefore cannot see why the aforementioned article highlighted the BDA in such a derogatory non-professional light when it is necessary to monitor ethics, expertise and academics within all professions by trying to ensure and regulate standards to ensure public safety.
There is an old saying in Barbados that it is not good to air your dirty linen in public and the BDA has avoided doing this for many years but this topic need to be addressed if we are to attain much needed balance and a true perspective. We have reached a point where some items should be exposed to enlighten everyone without going into excessive detail. The BDA continues to work with the Government of Barbados to ensure standards have been maintained to provide safe improved services in both the public and private sectors to the benefit of our people. In the regional forum, the BDA is concerned that Caribbean Governments have been dragging their feet in making provision for the enactment of a regional structure that would encompass an accepted and safe standard for dentistry throughout the Caribbean. Such has been implemented for the by The Caribbean Association of Medical Councils (CAMC) that ensures doctors coming under their authority, have reached an accepted standard as competent medical personnel http://www.camcweb.org that will then allow them to practice within our English Caribbean Region. A similar provision is now needed for dentistry to ensure that all dental practitioners practicing within the Caribbean come under similar scrutiny. This proposal has been requested by various Caribbean Dental Councils but is yet to be realised. Such a Regional Council is now required with some urgency in an effort to thereby ensure that successful practitioners have equivalency that will gain them registration to practice dentistry within the CARICOM Region especially in light of the impending free movement of labour within the proposed CSME. I would personally propose that the UWI Dental School in T&T be used for logistical purposes to administer Council Exams where/when required as this the remove the national perception of protectionism within the profession. Please note that within this proposal, I have not stated that registration within any one country is automatic as each country should still retain its autocracy for registration protocols (police records; proof of qualification; etc.).
The BDA is not only the representative of the dental profession but is constitutionally mandated to be the professional representative of the people of Barbados and must not appear to favour any single entity or dental institution. The BDA has and continues to carry out its mandate to maintain and improve the standard of dentistry in Barbados while ensuring that the public of Barbados is provided with universally accepted treatment modalities that will protect All Barbadians in general. Such action started with Dr. Henry Fraser who qualified in dentistry in 1882 to become the first qualified dental practitioner in his homeland. In an effort to ensure safety to the general public he was thereafter requested to review incoming practitioners to ensure that they also met the required proficiency standard on par with his. It was noted by his grandson, Senator Professor Fraser, that some of those practitioners would have done a longer course of three years (compared to his two) but that did not matter because his two years of training and his ensuing years in practice enabled him to know the difference between good and bad as well as between safe and dangerous treatments. This reviewing process continued in a rather ad hoc manner for many years after his passing.
It was later decided that such overseeing of the dental profession should be legislated and this was enabled by the Government of Barbados with the Dental Registration Act (Cap 1973) that formulated a Dental Council whose duties are multiple but can be précised as the administering professional requirements with the aim of protecting the public. The Act is very clear on its provisions and any dentist wanting to practice in Barbados must meet a minimum standard as dictated within the Act. The Dental Council is constituted of
- Three registered BDA members who would have undergone undergraduate and/or postgraduate training.
- One dentist who is appointed by the Minister of Health
- The Chief Medical Officer (or representative).
- A secretary who is an employee of the Ministry of Health.
It therefore seems odd that in the article, a statement attributed to the current Minister of Health, refers to his desire to place laypersons on Council in an effort to get more UWI dental graduates (with two years experience within another jurisdiction) registered. I do not believe that statement is true. Such a statement is disconcerting as it implies he will go to any length to have persons registered without knowledge of the individuals’ standard when in fact they are currently three members of the BDA and three representatives for the Ministry of Health who can ably exercise that duty without interference or prejudice. I ask for realistic objectivity so that the end result will benefit our country and people of Barbados. The Dental Council has also disagreed with the alleged statement for a variety of reasons and has questioned whether placement of laypersons who have no knowledge of what takes place in both the academic and the clinical professional performances are able to provide a service that will ensure future public safety? As much of this public debate has now become a political issue, I would state that the BDA has always been managed in an apolitical manner in an effort to be the representative for all of the Barbadian public.
The Mount Hope Dental School is a much needed institution within the English speaking Caribbean and has been supported by the BDA and its representatives at local, regional and international forums. The school started in 1989 when the General Dental Council (GDC) of the UK was the body responsible for accreditation of the institution. As a consequence, the GDC was requested to perform an accreditation exercise on two occasions in the 1990’s but the school failed to reach their required standard. This practice by the GDC was discontinued when UK came under the European Common Market regulations. This gave rise to The Caribbean Accreditation Authority for Education in Medicine and Other Health Professionals (CAAM-HP) which comes under the jurisdiction of CARICOM. This Accreditation Authority was registered in Jamaica under The CAAM-HP Act-2006. This was a historic moment in light of the Caribbean now managing its own destiny. The mandate and guidelines of this body are well defined and its inaugural Chairman was Prof. Walrond has been showered with much praise for a job well done. CAAM-HP examined the Mount Hope institution and results can be viewed at http://www.caam-hp.org. The Minister of Health stated in another forum that it is the duty of anyone entering a university health programme to first check the status of such medical, dental, veterinary or nursing schools to determine the feasibility for practice within their homeland after graduation. Currently, the dental school is not fully accredited.
In 1994, the first graduates of the school were subjected to an examination by the Dental Council of Trinidad and Tobago in like fashion to what takes place in the USA and Canada where graduates MUST pass a required State Board exam which would then enable them to practice within that State. In the UK, it is slightly different with the GDC supervising the examination continually to check clinical competence but in essence concludes in similar fashion to the State Boards in the USA & Canada. Such integration of Caribbean Registration Councils does not pertain during the entire UWI dental course to provide assessment of the competence. It is imperative to note that the attainment of a health degree and/or diploma demonstrate that one has completed the course as laid out by the individual’s university (College) but is not representative of clinical competence. When accreditation is done and the course meets the requirements of the Accreditation body, then accreditation will be granted to that institution because they have provided the course as stipulated within their curriculum. The degree/diploma does not give graduates the right to work until they are registered by the State when their competence is examined by the authorities (in the USA & Canada) to guarantee public safety within that State. A similar scenario abides in Barbados under the Dental Registration Act which gives provision for an examination in like fashion to those of the USA’s North East Regional Boards. I would make mention here that we currently have a dentist who qualified in Costa Rico. She is fully understanding and accepting of the need to take the exam in like-fashion to any dental professional from UWI or elsewhere. She is doing so with confidence and with acceptance of the required protocols that will enable her to practice dentistry in Barbados.
My queries are: “Why is it that this matter only pertains to a limited number of UWI dental graduates? Why would graduates from anywhere in the world (not just UWI) accept and abide without objection to the stipulated exams in the USA if they want to practice there? Why would a few UWI graduates keep noise when requested to do so in Barbados? Does our national Dental Council not have a duty to ensure the Barbadian public is protected?”
I would also state that there is a big difference between the word accreditation and registration. In the words of the Dean of the Mona Campus Faculty of Medical Sciences quote: “The accreditation process is not intended to prescribe curriculum content nor the time devoted to particular courses. Rather, curriculum content and time devoted to courses and subject areas will be judged in terms of achievement of the stated aims of the programme rather than conformity to a standardised pattern.” End of quote. The accreditation exercise examines the stated curriculum as outlined by the institution at the end of which a degree/diploma is granted to say the course was completed. The Registration process however is usually a legal requirement which follows the laws within the jurisdiction in which it abides, in an effort to ensure that the standard of clinical skills, ethics and academic performance meets a minimum standard to ensure patients’ safety.
An examination for persons wanting to be registered within the dental profession is not new. Following my earlier comments about Dr. Fraser in the 1920’s, it became expedient and acceptable for unqualified persons to be remunerated to perform similar duties to qualified dental practitioners in the mid-twentieth century. In the early 1980’s the then Minister of Health, (now Dame Billie Miller), realised that these unqualified practitioners were a danger to the public of Barbados with an increase in iatrogenic diseases such as hepatitis and Mitral Valve Prolapse etc. The Dental Council was then requested to look into the matter of improving the skills of these persons and with the assistance of the Pan American Health Authority (PAHO) and endorsement from the Ministry of Health, the BDA administered a course with PAHO’s guidance and an examination was given to all nine participants at the end of the course. Eight were successful and became known as “Dental Licensed Persons” (DLP) while regrettably the ninth one died shortly afterwards. These eight persons were termed a “dying breed” as no other unqualified person would thereafter be allowed to practice dentistry under this legislation. This process was also earlier implemented in Scotland to arrest their practice of illegal dentistry. The successful Barbados Licensed Persons (BLP) were allowed to carry on with their service to the public in the construction of dentures and doing simple extraction with local anaesthetic.
So ended the first Council exam which was followed in the mid-1980 with examinations for Swedish and German technicians. Only the German technician was successful and continues to practice in Barbados. The essence of those exams under Council’s guidelines included the provision of proof that candidates could not only perform their technical duties but that they could also read, write speak and understand English. Those exams were instituted using the International Dental Federation (FDI) curriculum.
The situation with the UWI Dental School followed after the 1994 graduates took the National Board Examination by the Dental Council of Trinidad and Tobago. Unfortunately, there was a continual high failure rate and this coincided with the failed GDC appraisal of the school. In 1998, the Ministry of Education in Barbados pulled its students from attending the Trinidad School and sent them to other recognised dental schools overseas. The solution to that problem was for the Government of Trinidad and Tobago to then legislate that any graduate from the School will be granted immediate registration to work in T&T without having their competencies assessed by the Dental Council of T&T. It is recognized that any dentist with questionable qualification will still be examined by the Dental Council of T&T. Barbados has not (as yet) taken that position and still continues to assess any graduate with questionable qualification in relation to the Dental Act. It should be noted that the first dentist to take the exam was not a UWI graduate but a non-Bajan. Other dentists from the Dominican Republic and Venezuela were also subjected to the exam. Such action demonstrates, as stated earlier, that our Dental Council has been consistent throughout its history and I sincerely hope that the general public will acknowledge, appreciate and support its important duty for the profession and all Barbadians.
In retrospect, instead of vilifying the work of the Dental Council I thought the article to which I earlier referred, should have congratulated Dr. Henry Fraser who reviewed the safety of dental practice in the early twentieth century along with all others who have unselfishly served on Council to ensure the safety of our Barbadian public. This ongoing debate demonstrates that it now becomes necessary for all parties concerned to unify in a common goal to ensure our regional dental school (UWI) excels par excellence with the production of well trained graduates whose clinical expertise will be unquestionable. In my opinion this can be best achieved through the utilisation and involvement of the Caribbean Dental Councils within the University examination structure or with the development of a similar structure to that of the CAMC.