From Volume 14, Issue 3, July 2021 | Pages 119-122
A run-through training pilot has been conducted in orthodontics during which trainees completed 2 years of higher training in the same units in which the first 3 years of specialist training was conducted. This article outlines a trainee and trainer's experience of run-through training in orthodontics.
The General Medical Council (GMC) defines a run-through training pathway as one that guarantees that doctors, after a single competitive selection process and satisfactory progress, will receive training covering the whole specialty curriculum.1 This is opposed to uncoupled training pathways that require a second stage of competitive recruitment following the first 2 or 3 years of core training for an individual to progress to higher specialty training. Within the surgical specialties, cardiothoracic surgery, neurosurgery, and oral and maxillofacial surgery have GMC-approved run-through training pathways. In August 2018, a run-through training pilot in general surgery in more than 21 trusts started. This was followed by urology and vascular surgery in 2019, and in 2020 trauma and the orthopaedic surgery cohort joined the scheme.2
The Dental Gold Guide states that there are run-through training posts of 5 years (three core training + two higher training years) in orthodontics and paediatric dentistry.3 Our specialty has been leading the way in piloting run-through training for dental specialties. In 2016, I was invited to participate in a pilot of run-through training. The following will outline a trainee and trainer's experience of the positive aspects and potential difficulties of run-through training in orthodontics.
This is an undeniable advantage of run-through training. I was able to complete treatment for all of my cases that were started as a registrar. Of equal benefit was my ability to follow up the stability of my treatment outcomes during the 2 years of higher training (Figure 1). This not only helped to foster a healthy habit of reflecting on my cases longitudinally, but it allowed me to successfully apply for provisional membership to the European Board of Orthodontists (Figure 2).4 One could argue that a non-run-through training post would miss out on this aspect of higher training.
Anecdotally, patients and clinicians prefer to complete treatment without mid-treatment transfers. The British Orthodontic Society (BOS) factsheet on ‘Moving and transferring children during treatment’ states that ‘research shows that treatment takes an average of six months longer in transfer cases’. While, a mid-treatment transfer within the same unit might not have as severe consequences as inter-regional transfer, I believe that patient care is optimized by run-through training.
It is well known that many higher trainees in Orthodontics do not manage to ‘treat out’ all of their orthognathic cases. Run-through training meant that I was able to start treating my orthognathic patients in my third year of specialist training. I was able to fully treat and debond 27 orthognathic patients as well as provide pre- and post-surgical management for 15 transfer cases from my predecessor (Figure 3).
Another positive impact of run-through training was that I was able to continue to contribute to work on developing a lab-made mesializer. Two of the major facilitators of this were: (1) an already established relationship with the laboratory technician; and (2) being able to follow up patients to test, develop and modify the appliance.
Audits, research and quality improvement projects require time, and knowledge of, and familiarity with the local landscape and personnel is hugely beneficial. I was able to complete three cycles of an audit started in the second year of my registrar training, become chair of the local Sheffield and District Orthodontic study group and participate in service improvement projects, such as applying for a cone beam CT scanner. The quality of my non-clinical training experience was greatly enhanced by staying on in the units in which I trained. Run-through training allows relationships with the administrative team, dental school, IT, clinical effectiveness unit, and managers to flourish, and would benefit any trainee trying to pursue any type of clinical governance project.
I vividly remember being told as a young dentist that, if I was truly committed to the specialty, I would sacrifice living with my husband and accept an orthodontic training job anywhere. Suffice to say, I did not heed the advice and put family first. My husband was then a trainee in Oral and maxillofacial pathology in Sheffield, and so run-through training gave me security of job progression in the region without the worry of upheaval in any future benchmarking processes. There have been reports in the medical literature that ‘trainees place significant importance on location of training and partners' job prospects’5 and that ‘location of training is the second most important job-related factor’. 6 Indeed, a report on the Orthodontic run-through training pilot highlighted that the potential need to move post, or to move to a different geographical region, was a barrier to trainees applying for higher training posts.7
In 2019, I went to a BOS educational and clinical supervisors course where Dr Rye Mattick provided an interesting account of how the generations were changing, and how this could impact on trainers and trainees alike. Most of our future trainees will be centennials (Generation Z). It has been said that this generation will require organizations to truly personalize career experiences. While there is an argument that perhaps we are fostering a ‘snowflake’ generation, run-through training does allow for better family and personal planning, and may better suit the needs of our upcoming centennial trainees.
On the flip side of support from home, is the support from staff members. I derived a huge amount of personal support from the lovely nurses that I worked with. They saw me through many of life's big events (house buying, renovating, new dog, and two babies) and without their support my training would have been so much more difficult.
The avoidance of a hiatus following the first 3 years of orthodontic training allows for more certainty with planning maternity leave. This may improve gender equality and family-friendly career planning. Run-through training allowed me to plan for my first child to be born just after MOrth and my second just after my ISFE examination.
The BOS Consultant Orthodontic Group is currently undertaking a workforce review including filled/unfilled senior registrar posts. Anecdotally, national recruitment for senior registrar posts in Orthodontics is a significant barrier. A survey in 2018 of core and higher surgical training trainees reported that 18% of trainees were completely satisfied with national recruitment versus 37% of trainees who were recruited outwith national recruitment were completely satisfied.7 In a letter to the Specialty Advisory Committee from the Association of Surgeons in training, it was expressed that trainees for whom run-through training is not an option may avoid surgery and chose specialties more compatible with personal circumstances.8
Working and living in an area over an extended period of time helps strengthen professional and personal ties to that area. Run-through training may help with retention of workforce, which may be of particular benefit to those areas that struggle to recruit. The report on the Orthodontic run-through pilot states that run-through training is an effective method of increasing the proportion of trainees undertaking higher training. Based on data from 2016 to 2019, run-through training has seen 19 out of 22 trainees continue through to higher training. This compares to 44 of 99 trainees not in a run-through training pilot who have then continued to higher training through the national recruitment process.7
There is the argument that a trainee in run-through training could experience less diversity in their clinical experience. It is important that any post that is marked for run-through training can deliver a fair breadth of training, including cleft care, joint restorative/paediatric/orthodontic and orthognathic clinics. Indeed, some units have access to sleep apnoea clinics and autotransplantation clinics. Increased diversity of clinical experience, however, does not necessarily equate to improved quality. I would argue that the ability to treat a patient to a very high standard is more valuable. I would also argue that the ability to be mentored by the same clinical supervisors can really help to hone skills. The trainee–trainer relationship that has been built in the first 3 years of training is a great foundation for being able to push the trainee to fulfil their potential.
Inequalities have inevitably been introduced by this pilot because only certain deaneries adopted the run-through approach. I was fortunate to be a trainee in the right place, in the right deanery, at the right time. It may be that I occupied a senior registrar national training number, which could have been taken by someone more abled. Further, it is possible that the careers of those trainees in the run-through training pilot have been unfairly accelerated compared to their non-run-through counterparts.
There have been concerns raised in the surgical specialties that run-through training introduces an element of complacency with the lack of pressure of an interview after the first 3 years of training. The annual ARCP process, however, should be sufficiently robust to ensure that all trainees are keeping pace.
From both perspectives, run-through training in this circumstance may be difficult. It is inevitable that certain personalities work better together than others. Professionalism, should mean that it would still be possible for run-through training to work even if there was some discord between the trainee and their trainer. It is possible for a trainee to opt out of run-through training if they notify the deanery 2.5 years into the programme. This then allows the post to be entered into national recruitment.
Run-through training has a lot to offer compared with switching units after 3 years to find a senior registrar job in some completely new unit. Those final 2 years are enormously beneficial in giving the trainee time to develop and perfect their clinical skills on the more difficult clinical problems; the ones that weren't all finished in the first 2.5 years. An enthusiastic trainee will learn all the skills and techniques that maximize the chances of achieving a high-quality result for as many of their personal cases as possible. They will also have the chance to review their cases 1, or even 2 years after treatment has ended. This unique opportunity will not be available until most consultants are 5 years into their substantive job and, even then, they may not necessarily have a more experienced colleague with whom they can have in-depth discussions about the pros and cons of a particular treatment, or approach to retention.
Management training is also a large part of the higher trainees ‘curriculum’. If they have been working as a junior trainee within a unit, they will have an idea about the strengths and weaknesses of the current hospital management team responsible for their department, and in their 4th or 5th year of training, they are well positioned to make a positive contribution to management meetings, or to become involved in ‘management’ projects, such as putting together a business case for a new intra-oral scanner or a CT machine for the department. As a ‘newbie’ in a unit, recently appointed as a post-CCST trainee, they will be in a far weaker position to contribute effectively, not knowing any of the characters with whom they have to interact. Having worked in one hospital for an extended period, they will also have a better idea which of the managers they might like to shadow to gain a feel for what their contribution to the smooth running of the health service actually is.
The advantage to the orthodontic unit of a run-through trainee, is that all of the staff are completely familiar with the trainee and therefore, there is none of the usual time wasted in the early few weeks where people are often getting used to new techniques and systems. Run-through training also means that the trainee can be front loaded with more complex clinical cases in the knowledge that they will be around for 5–5.5 years, allowing them to complete a substantial amount of the work involved. Additionally, as they finish their simpler cases within the first couple of years, they can be allotted surgical and hypodontia cases during their third year of training in the knowledge that they may be around for another 3 years to see them through to completion. The clinical experience gained is, therefore, potentially far superior to anything that can be realistically offered within the normal 3-year training.
Another problem with moving to a new unit is that the trainees are sometimes expected just to pick up a whole group of transfer cases. These are often the cases where treatment is dragging on and on, and they might not necessarily be the second, but could be the third or even fourth clinician involved in the actual treatment. It has been demonstrated that when multiple operators are involved in orthodontic treatment, the outcome can be compromised, and this kind of experience is disheartening to the trainee.
Research is also an important part of the trainees' experience and if they are centred in one department for 5 years, there is the possibility of them contributing in some meaningful way to one of the research projects that are being undertaken in the department.
The only possible downside to run-through training is if the trainee is ‘unteachable’ (we all know who these trainees are), but we are stuck with them right through to consultancy. We all have to have sufficient confidence in the ARCP process that it will identify these particular trainees at an early-enough stage in their training, and that the members of the committee will have the resolve to do something about the problem in that such a trainee might be redirected along another career pathway, better designed to benefit from their abilities. Luckily, such trainees are very few and far between, and as a rule, we attract the best of the best to our chosen profession, who are usually a pleasure and a privilege to teach.
