The pleasures and pitfalls of life as a new consultant – an Anecdotal review part 1 Dental Update 2024 13:2, 707-709.
Abstract
This first of a two-part article aims to provide a road map to the budding clinician wishing to take on the role of a Consultant Orthodontist. Part 1 suggests what to consider when taking up a new post and how to create an ideal unit. Part 2 will provide the author's personal insight into the first 18 months of a consultant post. Hints and tips from other newly qualified consultants are also provided, to enable future consultants to avoid the pitfalls and enjoy the pleasures of an immensely rewarding job.
CPD/Clinical Relevance:
To provide first-hand, real world knowledge of life as a new consultant orthodontist in the 21st century NHS.
Article
Andrew MC Flett
Woo hoo! You have now passed the ISFE. No more compulsory exams … ever! For me, and I suspect all my colleagues who pass their ISFE, the feeling is one of immense relief coupled with utter exhaustion. Many of us have spent at least 10 years of our lives getting to the finish line … so what next?
In the current climate there is of course a wealth of possibilities open to you. There are currently a healthy number of consultancy vacancies throughout the country, unlike in recent times. If you decide to follow a hospital career, all you have to decide is in which part of the country you would like to live and where in particular you wish to ‘hang your hat’ and hopefully make your mark (Figure 1).
Figure 1. You ‘have arrived’ when your name is finally on a door!
Where to go… what to do….?
The typical job description often goes like this:
‘Exciting opportunity at fantastic unit… ‘State of the art facilities, stimulating place to work with a committed team of colleagues’
‘A fabulous place to live with amazing recreation opportunities, great transport lnks and fantastic schools and housing … so what's not to like?’
There are many considerations when deciding where to become a Consultant. The best place to start is to think about exactly what motivates you to go to work in the morning. Is it purely the clinical work? Or perhaps you are attracted by the opportunity for teaching, or possibly research? The two main environments you can choose between to work as a Consultant are a District General Hospital or, alternatively, a Dental Hospital. Each has its own merits and you have to decide which place may provide the most professional fulfilment at the end of the day.
You may also want to consider the location, surrounding geography and possible places to live. For others, schooling may be a major consideration, so you should also look carefully into this aspect of your future life before committing. Being close to family and friends could also be a ‘deal breaker’. Hopefully, you should also be able to look forward to far more completely free weekends in the near future, so finding a place that meets all the requirements to fill your leisure time is extremely important.
In terms of applying and securing a consultant job, I would wholeheartedly recommend reading about the experiences and advice that can be gleaned from this paper before completing an online job application.1 To summarize, this article provides you with all you need to know about applying and securing that dream job. Don't be fooled into thinking that a post is won at the interview. All interview processes are transparent and robust. If you put in an abysmal performance, against other highflyers, your name is unlikely to make it above the unit entrance. However, this paper suggests the key people you should identify and meet before the ‘big day’ to facilitate a favourable opinion of you being created. The interview process itself is focused on, as this is unlike the now universal national recruitment process that most trainees have endured. When you are successful in your application, insight is given into job planning, standard consultant contract arrangements and orientation into your new role.
What to consider?
Here are some general points to consider when visiting your prospective place of work which could possibly be your professional home for the next 30 years.
Staff
Irrespective of how you may feel after the exam, you will still be relatively ‘green’ to the nuances and wider working practices of the NHS. In order to drive your ‘vision’ forward you need to find a group of people with whom you can work well. In the NHS, each member of ‘your team’ will have his/her own line-manager and appraiser. This makes complete control of any member of staff by you virtually impossible.
I suggest you visit your preferred unit at least 2 or 3 times to get the feel for ‘the politics’ working in each department. It is also worth ‘sitting in’ on a clinical session or two to see the dynamics of the clinic. You would expect all future colleagues to be showing you their best side when you arrive, but you may be sorely disappointed. What you experience, in these few short preliminary visits could well sway your decision one way or the other.
Gaining an insight into the staff turnover rate may help you decide if the unit is a stable and happy place to be, or more likened to the proverbial ‘lunatic asylum’! Try and identify the key members of the team that you will be working alongside. We have all witnessed, during our training, many a personality clash, which gets in the way of a team working effectively and efficiently. There are, of course, no hard and fast rules and it is impossible to offer any science to help with this potential dilemma. Ask yourself ‘does it feel right?’ and ‘do your potential colleagues seem honest and genuine?’.
Your future consultant colleagues are also another extremely important aspect to consider. Their reputation in the region can only take you so far; it is sometimes conjecture and often opinions that are misguided and ill- informed. Identify the consultants you will be working alongside for the foreseeable future. Ask them how they see you fitting into the team and what particular plans they have for the future of the unit and service. Every consultant will certainly have his/her own pressures and personal goals to achieve. Ask yourself if your areas of interest align with his/hers, fuelling future collaborations, publications and research projects. Collaborative work will raise the profile of your unit generally, and will also help you progress further on in your career.
Office space
Having your own private space for administration, study, research, diagnosis and treatment planning is sadly becoming a luxury in the NHS. You may not have an issue with ‘hot-desking’ or working in a shared office, and for many medical specialties in the NHS, like anaesthetics, this is the norm. It should definitely be something you ask about pre-interview. You may have a personality type that allows you to be completely tolerant of others' noisy dispositions and unusual habits and, of course, you may have some of your own. If you do need your own space, bearing in mind that this could be your working environment for over a quarter of a century, this can be a point of negotiation. If your ‘new office’ is completely dilapidated, you may want to consider ‘a lick of paint’ and some updated office equipment in your bargaining as part of the deal to take up a post (Figure 2).
Figure 2. DIY consultant moving (circa 2016).
Secretarial support
Despite being the consultant you will not be omnipresent; nor should you try to be! Attempting to do everything, and to please everyone, will likely burn you out within a couple of years.
Some of the best clinicians and consultants I have worked with have learnt the art of delegation. By learning this skill, you can focus your time and effort on the really important areas of your practice, whilst others assist you with general duties. At my unit, I share a secretary with my Consultant colleagues. This allows her to be fully informed about others' workloads and pressures. My secretary is absolutely invaluable when patients or dentists ring up with problems, or for advice. Having a secretary who can competently field these issues whilst you are otherwise engaged is fundamental for effective working. Using her experience, she can deal with most problems over the phone. If the issue is outside her comfort zone, our ‘open-door policy’ ensures that, in most cases, a response is given by the end of the week.
Once you take up your post, it is worth setting aside some time with your new secretary to gain an understanding of his/her level of experience in relation to orthodontics. It is also useful to establish how you would like things to operate and when he/she should come to you for advice. Do not assume people completely understand your specialist field and be willing to spend time explaining processes to all your future colleagues and staff.
Practice profile
When considering the merits of each potential unit, you should assess the variety of cases you will be expected to treat and the profile of the unit. There are some units in the UK where there are up to eight orthodontic consultants working for the same trust. The advantage of this is the obvious ‘safety in numbers’, which can be put to good use when applying for additional trainees, equipment and contracts. Any problems that arise, especially of a clinical nature, can be shared if you have the right team around you for support. Setting up and completing larger research projects may be easier as many hands will make light work, especially if the skill set is varied. However, in a relatively democratic set-up, your individual voice within a large unit may be diminished. This could make achieving your individual wants and desires less likely. Annual leave rotas will be needed to be negotiated in the pursuit of fairness, and your patients should always be covered in the event of you being away.
Conversely, other units exist where there are only one or two, all powerful, consultants. Obviously, if you want it all your own way, and want to be responsible for all the decision-making, then this type of unit may be the place for you. No one is going to ‘divide and conquer you’ if you call all the shots. It requires a special type of individual to run a unit single-handedly. Every decision you make is yours and the buck stops with you. A unit like this is usually smaller than others and so, in an era of NHS efficiency targets (read: cuts to funding), a unit such as this may have to amalgamate with larger ones nearby or cease to exist if the NHS decide to centralize services regionally.
Each person will have an area of orthodontics that interests him/her and so, ideally, find a unit that aligns with your area of interest and expertise. Larger units with a plethora of trainees will allow you to have exposure from the relatively mundane to the complex orthodontic case. The drawback of this is that your unit may be the ‘catch all’ when it comes to referrals. This could mean that you will be constantly fighting your 18-week target. Whilst this isn't essential for all orthodontic cases, or as Simon Stevens recently commented,2 most trusts still have to report any 18-week breach. This can get management into panic mode, requiring an ‘action plan’ to reduce the wait. The threat of fines and loss of money for the unit development is something to consider. If you want to provide higher quality care by investing in newer techniques and equipment, there is little argument if you are ‘in the black’ with no management worries.
Personally, I chose a unit where there was one other Consultant, who I felt I could get on with for many years. He has 11 years experience as a Consultant at the trust and also works in specialist practice. This gives us immense insight about orthodontics inside and outside the trust. Before I applied to the trust, Steven and I had many conversations about what we would like to achieve together to ensure that we were on the same page. We liaise about leave and have managed to collaborate on some projects already, utilizing our complementary but different views and skill sets when tackling problems.
Future plans for you and the NHS
The job
First and foremost, I enjoy the clinical aspect of the job. For that reason, I decided to work at a District General Hospital. I still try to contribute, where possible, to the training programme at the local Dental Hospital in Sheffield. This keeps your thoughts fresh on topics as you prepare lectures, preventing you from just switching into autopilot. From a personal point of view, I can still remember being a trainee, and recall all the hours other consultants put into me, when I was training. All of them have lives outside work, be it family commitments or hobbies to pursue. Nevertheless, all the consultants I have come to respect, go way beyond their 9–5 job plan to deliver a fantastic training. It is this altruistic behaviour that really does provide added value to training courses across the country. I hope to be able to emulate this attitude in the coming years and continue to help provide excellent training across the region. I urge you to consider the same thoughts.
Honeymoon period
Before and shortly after you start, expect to be gently eased into your new role. You should have taken the time to visit the unit on at least one occasion before deciding this is the place to forge your career. Recognize this small window of opportunity as your ‘honeymoon period’. During this time, and possibly before signing your contract, consider a ‘wish-list’ of what things you would like in place before you start serious clinical work. For me the ‘deal-breaker’ was a new dental chair and some software to store photos and review and trace radiographs. Review the instrument kits and decide if there is enough there to make things work. You may have some unique pieces of kit that you just can't do without. Now is the time to order them!! Once you are firmly in post you will be subject to the current cash constraints that all departments are under. Acquiring additional expensive items later will be problematic.
Systems in place
I think it appropriate to establish your working pattern and work ethic early. You are now the leader of a team, and when problems arise, people will turn to you to put things right. I wholeheartedly embrace the notion of leading by example. The standards by which you measure yourself should be the standards that you expect of other staff members. Whilst not every member of staff will arrive one hour before the start of a clinic or stay late working on a crucial patient, by showing your dedication to the cause, you will hopefully win some hearts and minds for another day.
Kits and essential equipment is something you should establish early as well. If you are working at the unit with fellow consultant(s), like me, you should get together to discuss kit collectively. Again, having a new consultant on the block does give you some latitude for ordering some new equipment. Try to buy the highest quality you can, so that you won't be replacing your ‘new’ kit regularly due to the purchase of a substandard product.
If you are ordering any new equipment, ensure that all checks and balances are satisfied before pressing the order button (Figure 3). Trusts have a multitude of paperwork to complete on new equipment. Make sure that you know the local sterilization guidelines in your hospital and that any new equipment has a transparent guide on how to achieve this. A CE mark is paramount for most reusable instruments.3,4
Figure 3. Before buying new kit, ensure that it complies with trust cleaning procedures and medical devices directives.
Capacity and waiting lists
Transfers
These are a necessary part of starting new as an orthodontist. In my experience, the transfer case is rarely a good thing, unlike the excitement some seem to get when the football transfer window opens. The other complication is that, as a trainee, you may have had limited exposure to transfers, especially ones that aren't going according to plan. I have known some colleagues get into difficulty with transfers and not feel confident enough to continue treatment.
The first port of call is to treat any transfer as a ‘new patient’ as that is what they are to you! Take a new medical history, reassess that case and ascertain how long they have been in treatment. Review the motivation of the patient. This is usually closely linked to the level of oral hygiene exhibited intra-orally. Rule out any pathology that may make continuing treatment impossible, justifying any radiographs you take. Obtaining the start records with complete notes is essential to understand the progression of the case, as well as best practice. If unsure about transferring patients yourself, as some trusts seem to be, refer to the British Orthodontic Society's general guidance.5
In the event that you really do not think that the treatment goals originally set out are achievable, you should discuss this with the patient honestly and openly. Get advice from colleagues if you are not sure and consult your protection society if you have any concerns about any cases. If you think that the case is lost and it is not safe to continue, consider cessation of treatment as soon as possible. You can't be accountable for previous decisions made, but you could be called to account continuing treatment where further harm can arise. Be tactful during these communications and do not point fingers or lay blame. Only report factual information and steer away from opinion and supposition. It will be for others to investigate if systemic failure is suspected. Your role in this event is to escalate to higher powers where necessary and let them take on the decision-making.6
Training
Most orthodontic departments are affiliated with a maxillofacial unit which creates a symbiotic relationship between you and your surgeon. As with most surgical units, there is usually a plethora of various trainees wanting help, advice or a work-based assessment completing. As with all things when you start as a new consultant, learn the word ‘no’, and do not take too much on in the early days. Establish your own working patterns before diving in to save others.
Our unit has a range of trainees from post-CCST orthodontists, orthodontic trainees, StRs in maxillofacial surgery and dental core trainees (DCTs). Senior trainees will want viva practice or WBAs completing and so accommodate them if you can make the time. They may be your fellow colleagues in the future!
DCTs are an unusual set of trainees in that they carry out a junior doctor's role, albeit only trained in dentistry. There has been a realization, at deanery level, that these dentists should not solely be learning from maxillofacial surgeons as many will not progress down that career pathway. So, gone are the days of being called a senior house officer (SHO) and welcome to the world of DCTs! Deaneries now expect these trainees to get rounded training during their rotation. Whilst the majority of their time will still be spent doing MFU tasks, there is now an understanding that experience elsewhere is beneficial. I would advise that you try and get involved with providing some training for the DCTs. They are year 2 or 3 dentists, keen to learn, and rarely set in their ways. It has been great to get back to basics and teach them how to diagnose patients from an orthodontic perspective via new patient clinics or seminars. Some are keen to do orthodontics and should be helped in their career by completing audits or case reports for you and your department. This will help them to progress and you to fulfil your job plan on an annual basis.
Research
I do believe that, as consultants, we should be close to the cutting edge of new techniques and thinking. Staying research active during your career will achieve this and replenish your enthusiasm when the monotony of work or a stressful event puts you at a low ebb. Rarely can you produce high quality research single-handedly. Realize your limitations and find others who have different skill sets from you and with whom you can work. Aim to have at least one project active at all times and another one in the pipeline to follow through with when the current one is completed.
This wasn't in the curriculum?
The biggest challenges I have faced thus far are the non-clinical aspects of the job. By the time you secure your consultancy job you should be able to deal with most of the clinical cases that are referred to you. That is not to say that you shouldn't expect some head-scratching, researching and wondering about those cases that you have never seen before. That is part of the challenge of being a consultant!
Managers, clinical leads and fellow consultants all have different motivators and drivers. The skill to people management is to determine for yourself what you think these are. Staff room politics is rarely of use here. In order to move forwards with your grand plans, it is first worth spending some time understanding the lay of the land. Where are the pressures on management coming from? What is the current focus of your clinical lead? Would your consultant colleague be supportive, or at the very least, not be obstructive to your plan to modernize or change practice?
As a general rule of thumb, your supervising managers are happiest when your activity is high, your new patient waiting list is low, compliments are high and complaints are low. If you can prove you are providing a high-quality service then your life should be a little easier. PAR scoring and patient satisfaction questionnaires or quality of life outcomes are things you should incorporate into your daily practice.
In the second part of this article, fellow consultants and I will provide the reader with personal insight into the reality of becoming the new consultant orthodontist.
