Estimated read time: 9 mins
The balance between gaining skills and applying them with confidence is essential to career progression. The ideal scenario is where skills are matched with confidence through the nurturing of a supportive network of educational supervisors, mentors, and peers.
In real life, however, the Dunning-Kruger effect often comes into play.1 This phenomenon, highlighted in a previous edition of Riskwise2, describes how we are often over-confident during the initial phases of learning a new skill (see figure 1). As we realise how much there is to learn, our confidence declines before bottoming out, and eventually returning to previous levels. This final phase, when we become both confident and knowledgeable, is known as the “Goldilocks Zone” – because it is just right.
Most of us have experienced the Dunning-Kruger effect first-hand. But what is not always appreciated is that a new career phase may cause the curve to restart, even for an established clinician.
For many decades in the UK, we have questioned whether new graduates are ‘prepared for practice’.3,4 Given that graduates from the 1990s are now in their 40s and 50s, most must have been at least adequately prepared to not only survive, but thrive in general practice.
Over time, there have been significant changes in the following:
In the early 2000s, concerns were voiced by the Council of Postgraduate Dental Deans (COPDEND) about the communication skills of new graduates undertaking vocational training. More recently, however, the focus has been on undergraduates’ lack of clinical experience.
New graduates are not a monolithic cohort. Many of them recognise that they have relatively little clinical experience, and they consequently underestimate their skill sets due to a lack of confidence.
They also tend to remember their most challenging cases and forget those that went well. Due to the resultant loss of confidence, some graduates have underestimated their clinical experience when entering Foundation Training (FT), in an attempt to ensure that their educational supervisor gives them more support.
More worrying, however, is the (thankfully very low) proportion of new graduates whose confidence greatly outweighs their experience and competence. This latter group may well blunder into situations where they don’t have the necessary experience to redeem their position, leaving behind a disgruntled, or potentially harmed, patient.
For most graduates, a complex set of interactions come into play as they enter practice. The Dental FT year offers support in the shape of training, mentoring, and peer review, and during this period confidence and competence increase to a high point.
However, when graduates successfully complete FT and enter practice as an associate, one or more of the supporting structures can be absent, and the balance between confidence and competence is lost.
The move from FT to independent practice can be daunting. It is often in a new geographical area, with a new principal, and usually with a new financial arrangement that expects the new dentist to perform more efficiently.
At this stage of life, many young professionals aspire to a lifestyle that wasn’t available to them during their undergraduate years or FT, and often they will broaden their skills to pay for it. In the absence of a mentor, confidence will often fall as pressures increase, so treatments are ‘over-promised’, and performance may suffer. It is often at this point that complaints arise.
Even though it is unlikely that this age group will have a fitness to practise (FtP) concern raised against them to the GDC,5 the psychological and emotional effects of receiving and managing patient complaints should not be underestimated. These factors often contribute to the deep trough seen in the Dunning-Kruger curve, that lasts until confidence grows slowly with a re-established focus on performing a reasonable range of skills well. We probably inherently know that working to our strengths is often a more successful strategy than overstretching ourselves.
As we mature clinically and climb back up the Dunning-Kruger curve, the ‘Goldilocks Zone’ tends to run for a long time while skills and confidence are restored. The value of strong social support from peers and professional networks cannot be overstated.
When problems arise, the established practitioner usually has a good mix of experience, confidence, and humility to access their own, and others’, resources to help reduce complaints. Treatment options tend to be more realistic, and the dentist knows their own likelihood of success, so gains a more valid consent, leading to improved performance.
The ‘Goldilocks Zone’ tends to extend from a dentist’s early 30s until their late 50s. This phase of improved performance and higher confidence in the unconsciously competent, proficient practitioner is where clinicians are more often able to experience ‘flow’: the lack of effort associated with a well-running process (see figure 2).6
Very large datasets from NHS dental practice in England and Wales suggest that with simpler forms of restoration, younger dentists’ restorations tend to have very good longevity.7 Indeed, with posterior crowns, the greatest longevity is associated with dentists older than 30 and younger than 60.
There appears to be some form of ‘drop-off’ in performance in later years, despite high self-confidence (illustrated by the red line in figure 1).7 The reasons for this will be undoubtedly complex, but could include:
Fitness to Practise (FtP) referrals are a very blunt tool from which to draw nuanced conclusions, but, looking at the GDC FtP data for 2021 (see figure 3),5 there is some evidence that older registrants are at increased professional risk. It must be recognised that increased FtP referrals could simply reflect a longer time spent in clinical practice, where there has been more time for ‘historical’ problems to come to light, rather than an event occurring in the year of the GDC report. But, even with this caveat, if ratios of percentage of cases raised are plotted against the percentage of dentists within each age range, we can see a change in the relative risk for different cohorts. (Table 1)
In their 50s, many clinicians start to plan for retirement. These dentists may also be well-served by planning for clinical support prior to retirement, by focussing on their existing strengths and using their mature professional networks to refer more complex cases, rather than undertaking these themselves. Available data from various educational papers would tend to suggest that newly graduated dentists are not as experienced as they used to be – but from GDC data, perhaps most dentists are (eventually) not as good as they were when they were younger. It could be that there should be as much emphasis on mentoring systems to help one retire from clinical practice as there is when we enter it.
As our personal and professional circumstances change throughout our careers, we need to consider how these could affect our performance and, during transitional phases, find job satisfaction in excelling at using our skills to do what we are good at, and staying within the ‘flow channel’.
Professor Youngson is Chair of the Dental Protection Board
If you enjoyed this article, why not join Dr Noel Kavanagh and Dr George Wright as they discuss 'exiting practice' – looking at some of the potential risks associated with retirement and selling a practice.