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Survey of dental graduates entering medical schools and a comparison with previous surveys
British Journal of Oral and Maxillofacial
Sur,qery ( 1996) 34, 438-445
I
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1
Survey of dental graduatesentering medical schoolsand a comparisonwith previous surveys P. Magennis, T. K. Ong Department of Oral and Maxillofacial Department of Oral and Maxillofacial
Surgery, The Royal London Hospital Dental Institute, London, UK; Surgery, Newcastle General Hospital, UK
SUMMARY. The 169 dental graduates known to have entered UK medical schools between 1986 and 1991 inclusive were sent a questionnaire requesting personal and professional information. A total of 154 graduates (91%) responded, 126 (82%) males and 28 (18%) females, all with a mean age of 27 years. Over the 6 years studied, both the average fees paid and the number of students paying fees increased. During the same period, the average grant received and number receiving grants both decreased. Of the 154 responding, 141 (92%) intended to pursue a career in oral and maxiliofacial surgery at the time they entered medical school, and this had fallen to 120 (78%) by the time of the survey. An estimate of the number of those medical students who may return to the specialty was made based on previous surveys (range of 12-26 trainees/year).
INTRODUCTION
1986-1991 inclusive were obtained directly from medical schools and from the records of the Medical Students’ Group of the BAOMS. A questionnaire covering the following was sent to each of them:
Long before the 1988 Report of the education subcommittee of the British Association of Oral and Maxillofacial Surgeons (BAOMS)’ had recommended that a medical degree was essential, trainees in oral and maxillofacial surgery (OMFS) had been studying medicine. The report simply recognised an earlier trend. In the UK, trainees who wish to pursue a career in OMFS apply individually to medical schools. When they cease to hold full-time dental posts in the specialty they become ‘invisible’ for monitoring purposes such as manpower planning and appear again only when they re-enter the specialty after completing their medical degree, house jobs, and basic surgical training. There have been three retrospective surveys of these doubly qualified people; Henderson et aZ.,’ Langton and Levers et al.;4 two surveys of dental graduates in the process of studying medicine; Gwynne,’ Langtom and one follow-up study by Gwynne.’ The last survey6 was in 1987. Our survey up-dated most of the data presented in these earlier papers and also recorded new information, particularly about the financial aspects of studying medicine as a second degree. To keep our paper as concise as possible, the results of our survey and comparisons with previous papers are combined in a single section.
Personal details: age, sex, marital status at entry into medical school, marital status at the time of the questionnaire, and number of children. Information about the career before entering medical school: the dental school attended and year they qualified, whether they were awarded honours or prizes, further qualifications and year obtained, and the hospital grade reached in OMFS before undertaking the medical degree. Future career plans: career intentions at entry to medical school, intentions at the time of the survey, and whether they have regretted studying medicine and if so, the reason. Work undertaken during the medical course: the type of work and hours worked each week, whether work affected their studies, and how they had found the financial aspect of studying medicine. Details of the medical course: any exemption from part or parts of the course and grants or scholarships obtained. Perceived number of peers: the number of dental graduates that they thought were studying medicine in 1986-1991 and, if the total was more than 150, whether that would have made them reconsider starting medicine. Envelopes, with a ‘Freepost’ return address, were included to encourage recipients to send back the questionnaire. Use of a freepost address avoided wasting money on stamps on unused return envelopes. It also permitted the sending of reminders and
METHODS The names and addresses of every dental graduate known to have entered medical school in the years 438
Survey
return envelopes without a great addition to the cost of the survey. To further encourage replies, a prize draw was offered. Those who failed to reply were sent reminder letters and if post failed, they were contacted by telephone. RESULTS,
COMPARISON
AND DISCUSSION
Because of the nature of the survey, with numerous variables, most of the statistics are descriptive. However, differences between the sexes were analysed statistically by means of chi square test. Response
A total of 169 dental graduates were identified as having entered medical school from 1986 to 1991 inclusive. Responses were received from 154, a response rate of 91X, which was higher than in previous surveys (70’X5 and 65.8%~).6 The freepost return address, prize draw, direct telephone contacts, and persistence probably contributed to the high response rate. Of those responding, 129 replied by post and the remaining 25 gave the information over the telephone. Partial information about nonresponders was obtained from the Dentists’ Register, this included the school and year of dental qualification, and the college and year that they obtained a Fellowship in Dental Surgery (FDS). Some information was also collected through the records of the Medical Students’ Group of the BAOMS. (a) Personal details Sex
Of the total 169 dental graduates at medical school, 138 (82%) were men and 31 (18%) were women. The corresponding figures for the 154 respondents were 126 (82%) and 28 ( 18%). The percentage of female trainees undertaking medicine as a second degree had increased from 9% recorded in 1987.h The percentage of females changed in each year studied from 0 in 1986 to 4 in 1987, 15 in 1988, 22 in 1989, 25 in 1990 and 27 in 1991. As women account for nearly half of the medical schools’ normal intake,* it will be interesting to see if female dental graduate students will approach this proportion.
Table I- Percentage of each marital with previous surveys’.‘,h Marital
status
graduates
71 28 0.6
to
graduates
entering
medical
schools
The mean age was 27 years with a range of 23-39 years. Figure 1 shows the age distribution of the respondents which is similar to previous surveys.2.4-h Fourteen respondents were over 30 years old and of these, six were senior registrars and five sponsored by Her Majesty’s Defence Forces. The average age of women was virtually identical to that of men, but women had a narrower range of ages (25-34 as opposed to 23-39 for males). Marital status andfirmil~
Table 1 shows the breakdown of the respondents’ marital status at the time of entry into medical school, at the time of the current survey, and those given in previous surveys.2.4.6 Of the 34 respondents with children (22X), the average number of children was 2 (range l-6). There were significant differences between the sexes: 22 female respondents (79%) were single at the time of the survey compared with 69 (50%) men (P= 0.016) and 1 female respondent (4%) had children compared to 34 (27%) men (P = 0.017). (b) Information school
about career prior to entering medical
Dental school
There were graduates from all the dental schools in the UK as well as three from Ireland (Trinity), three from the Indian subcontinent (Bombay, Calcutta and Mysore), two from New Zealand, one from Singapore and one from Australia. The average number from each dental school was 7 (range l-20). Figure 2 shows the distribution of dental schools from which UK graduates qualified. Of these, 60 (38%), graduated in dentistry from London schools with 20 coming from UMDS alone. Prizes and honours
Twenty-four ( 16%) of the 154 respondents qualified with honours. Previous surveys had found honours rates of 22%’ and 21X6 Men (15”/0) and women (14%) were equally successful. Sixty-two (42%) achieved one or more prizes during the dental course compared with 33% in 1977. Although a greater
to medical
school.
during
current
survey,
and a comparison
Henderson’ (n= 175)
Levers’ (n=220)
Langton” (n = 52)
66 30
64 21
46 52
At time of survey
54 44 2
439
Age at entry to medical school
at time of entry
Current survey (n= 154) On entry medical school
Single Married Separated
state of dental
of dental
440
British
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of Oral
and Maxillofacial
Surgery
H male
23
24
25
26
27
26
29
30
II female
Jml 31
33
34
I 35
,I 37
, 39
Age on Entry to Medical School Fig. 1 -Age distribution of dental graduates at medical school.
proportion of men won prizes (42%) compared with women (25%), the difference was not significant. Time interval between dental and medical schools
The respondents worked a mean of 49 months before starting medicine (range 6-168 months). This compares with 1970- 19793 (mean of 37 months [range O-156 months]) and 1982-1987’j (mean of 40 months [range 3-125 months]). The mean time interval between attending dental and medical schools had increased by almost 10 months, while the range of the interval remained similar. The preference of most medical schools for candidates with Part 1 or Part 2 FDS may explain the longer mean time compared with previous surveys. There was no difference between the sexes in the time interval between dental graduation and entry to medical school. Grade of last post before medicine
Number of graduates
at medical school
Fig. 2 - Original dental schools of medical students.
Overall, 71 (47%) had reached senior house officer (SHO) grade, 70 (46%) registrar grade, and only 6 (4%) senior registrar grade. There was no difference between the sexes. The predominant grades have changed with time (Fig. 3). In 1982-19876 and in the 1986-1988 subgroup in this survey, the registrar grade was the largest group. In contrast, in the 1989-1991 group in the present survey these proportions were reversed with 34% being registrars and 57% senior house officers (SHOs). The reasons for this change are hard to ascertain as there does not seem to be any other difference between the two groups. It may reflect a
Survey
of dental
graduates
entering
medical
schools
441
80
I 70
t
Registrar
--t
Senior Registrar
1
-Part
1 FDS
-.-Part
2 FDS
0
1977
1969
1982-87
1966-91
Year of Survey
Fig. 3 -Changing
grades
on entry
to medical
Year of Survey
school. Fig. 4 - FDS
combination of the reduction in the number of registrar posts for trainees with only a dental qualification and the increasing importance of Part 2 FDS in obtaining a place at medical school, Additional qualifications Fellowship in Dental Surgery
Of the total of 169 graduates at medical school, 100 (59%) held the Part 2 Fellowship in Dental Surgery (FDS) or had this qualification listed on the Dental Register. Of 154 who responded to the questionnaire, 89 (58%) held Part 2 FDS. Possession of Part 1 FDS is not recorded on the Dental Register, so it was possible to ascertain only the number with Part 1 FDS alone among those who responded to the questionnaire. Of those 154 replying, 40 (26%) held Part 1 only. Figure 4 shows the distribution of the respondents’ FDS qualifications in comparison with previous surveys. 2.5.6 The increase in the percentage of those holding Part 2 FDS at the time of entry to medical school rose from a low of 170/02to 58% in this series, probably because of the advantage that it gives in obtaining a place at medical school. A significantly greater proportion of female respondents gained entry to medical school without any FDS qualifications (8 women [29%] had neither part FDS at entry into medicine compared with 14 men [ 1 l’%]; P=O.O43). Fewer females held Part 1 (6 [21%] compared to 34 [27%] males) and held Part 2 ( 14 [50%] compared to 79 [63%] males) but these differences were not significant. As there is no significant difference between the sexes regarding the time between graduating in dentistry and entry to medical school entry, the lower proportion of females without
status
of dental
graduates
at medical
school.
FDS is not because they enter medical school at an earlier stage in their careers. Timing oJ‘FDS exams
Those who had obtained Part 1 FDS (n = 139), passed it a mean of 2 years after graduating in dentistry (range O-7 years) and 2 years before entering medical school. Graduates with Part 2 FDS passed it a mean of 4 years after their initial dental qualification (range 2-9 years) and about 5 months before entering medical school. The sub-group of 40 who held Part 1 FDS only entered medical school 1.75 years earlier than those with Part 2 FDS. Part I FDS during medical school
Seven respondents passed the Part 1 during the medical course: three in first year, two in the second year and two in the fourth year. Of these, three went on to pass their Part 2 FDS before they qualified in medicine. Part 2 FDS during medical school
21 (14%) students passed their Part 2 FDS during the medical course, eight during first year, four during the second year, seven during the third year and two during the fourth year. Part I-Part
2 interval
The average delay between obtaining Part 2 FDS was 2 years (range O-5).
Part 1 and
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Other qualifications
(d) Details while at medical school
Eight had BSc, seven MSc, one BMedSci and one PhD. One master’s degree preceded the dental degree, the other six obtained their MSc within an average of 3.75 years of their dental degree.
Medical schools at which the dental graduates had places are shown in Figure 5.
(c) Career plans Original reason for studying medicine Overall, 142 (92%) respondents started medicine with the intention of pursuing a career in OMFS. This is the largest ever proportion compared with the other surveys. 5,6 Of the 12 not citing OMFS as their reason for entering medical school, oral medicine was the reason given by six (4%), three (2%) said they planned to enter other medical specialties. One cited ‘dislike of dentistry’ as the reason for studying medicine and two did not know why. Although only one listed a dislike of dentistry as the main reason for studying medicine, a further five said that a dislike of dentistry contributed to their decision. These six (4%) compare with the previous surveys’ figures of 5%3 and 1O%.6 Of the 22 respondents without FDS qualifications, 15 (67%) entered medicine with the intention of pursuing a career in OMFS. Career intentions at time of questionnaire At a mean interval of 3 years after starting their medical course, the percentage of respondents planning to pursue a career in OMFS had dropped to 78% (n = 120) from the original 92% (n = 142). This was comparable with previous surveys’ percentages of 75%5 and 8O%.‘j Of the 22 who changed their minds, 14 said that they did not know if they would return to OMFS, two named other medical specialities; one without either part of the FDS chose general medical practice and another with Part 2 of the FDS chose ENT and five simply stated ‘not OMFS’. None of the 12 who planned a career outside OMFS on entry to medical school had changed their minds at the time of survey and decided to return to OMFS. When those entering medicine with a view to a career in OMFS are sub-divided according to their FDS qualifications, a significantly greater percentage of those without FDS changed their minds (50%) compared with those with Part 1 of the FDS (18%) and those with Part 2 of the FDS (7%). This supports previous findings that possession of Parts 1 and 2 FDS increases the likelihood of the trainee returning to OMFS.2,3
Exempt ions Fifty-six (36%) gained some exemption from part or parts of the course. Some reduction in the length of the medical course was obtained by 44 (29%), an increase from 19% in the last survey.‘j The reductions ranged between 4 months and 2 years, most (38/44) receiving a reduction of 1 year. Exemptions for 12 dental graduates (7%) did not shorten the course but meant avoiding teaching such as practicals, computing, or statistics. It is likely that the proportion will increase as more medical schools in the UK offer shorter medical courses for dental graduates.” Interestingly, 12 women (43%) were exempted from part(s) of the course compared with 31 men (25%), although this was not statistically significant (P=O.O96). Fees Figure 6 shows the increasing trend of the average fees paid/year by the respondents. A recent survey has shown that an increasing proportion of schools are no longer using the ‘fees remission scheme’ for UK dental graduates. ls This increases the fees/year from about &700 to &3000 or more, and it is possible that the fees may approach those paid by foreign students of about &15 OOO/year. Aberdeen BmtS SOlFaSt Sbmlnghrm Bristol Cambridge Chafing Cross D”“dOS Edinburgh ol*sgow King’s P
Led%
i! s
Liverpool
Leicester
3 5 P
Manchester Newcastle Nottingham Royal Free Royal London Shsffild Southampton St Andrew’s St George’*
Regrets about studying medicine Seventeen of 154 (11%) regretted studying medicine; seven had reached registrar or senior registrar grade and eight had Part 2 of the FDS. The reasons given were ‘long pathway in OMFS’, ‘poor career progression’ and ‘waste of time’. Fourteen of those regretting studying medicine still intended to return to OMFS.
Tri”ih, UCH UYDS WNSS 0
5
to
Number of dents1 graduates
Fig. 5 - Dental
graduates
at each medical
school.
16
20
Survey
of dental
graduates
entering
medical
schools
443
Year Fig. 6 - Average
Year of entry to medical school
fees paid per year. Fig. 7 - Percentage
of respondents
with
LEA
grants.
Grunts and scholarships
Seventy-one (46%) of those replying to the questionnaire received grants or scholarships from some source, with 52 (34%) receiving a grant from a Local Education Authority (LEA). The average total value of grant or scholarship over the whole course was &7618, with the maximum of f22 500 (five years full mature student’s grant from an LEA) and the minimum of &300 (a university grant). Grants from LEAS for a second degree are discretionary, and the financial pressure from the government on local authorities is increasing. The percentage of respondents receiving grants fell from 80% in the 1986 intake to only 13% in the 1991 intake (Fig. 7). Not only did the proportion with grants decrease but also the value of grants fell by 75% over the same period. A few respondents noted that persistent application for an LEA grant was rewarded by an award and one determined person obtained grants from LEA, university, and a number of charitable trusts. There was a pronounced geographical variation in the awarding of grants to dental graduates with, in reverse order, 0 in Northern Ireland, 27%) in Southern England, 30% in Greater London, 39% in Northern England, 44% in Wales and 63% in Scotland. (e) Work during medical school Type of work
All 152 answering this question worked as dentists during their medical course; 140 (92%) undertook occasional locums; 112 (73%) worked in dental practice, and 45 (29%) held clinical assistant posts. The average student worked 10 hours a week in practice and spent 42 days a year as a locum (usually at senior
house officer grade). More unusual methods of supplementing income included office cleaning and making jewellery. Langton found only 79%) at work during the course, probably because more grant support was available at that time. Earnings
It can be estimated from the average 10 h a week worked in dental practice that the average annual income from this source would be &5431 (calculated from the target income set by the Dental Practice Board for general dental practitioners in 1993). The average earnings from locum work as an SHO, assuming a 1 in 3 rota, this would be about &1300. Therefore, approximate pre-tax income would be &6731 per annum. Effect qf’tvork on studies
Sixty-six students (43%) felt that working during the course adversely affected their studies. Financial aspect
qf studying
medicine
We calculated the cost of being a student including university fees and allowing for lost earnings (4.7 years on average out of full time work), and the total cost of the dental graduate studying medicine was approximately f67000 at 1993 prices. When asked how they felt about the financial aspect of studying medicine, 68 (45%) thought it was as bad as they had expected, 53 (35%) felt it was better, and 31 (20%) thought it was worse. The financial pressures on trainees in OMFS seem bound to increase. The earnings in dental practice have declined, and trainees qualifying after 1991 who
444
British
Journal
of Oral
and Maxillofacial
Surgery
have not done any vocational training can work only as assistants rather than associates in a dental practice. The introduction of integrated medical courses with greater emphasis on continuous assessments” may mean reduced opportunities for locum work. These changes, combined with increasing fees and decreasing grants, make the financial outlook for dental graduates at medical school somewhat bleak. (f ) Perception of peers Number of peers
One hundred and forty seven responded to this question. Only 29 (20%) were right in thinking that more than 150 dental graduates were reading medicine. Of the rest, 83 (56%) thought there were 100-l 50, 32 (22%) thought there were 50-100, and 3 (2%) estimated less than 50. Overall, only 15 respondents (10%) would have changed their minds if there had been more than 150 dental graduates reading medicine. Six female respondents (21%) would have reconsidered whereas only nine men (7%) would have done (P= 0.055). Predicting the manpower resources It is difficult to estimate the number of trainees in OMFS who return to the specialty after the medical part of their training. Previous studies have recorded the numbers of trainees who successfully returned to the specialty but these figures reflect the number and types of training posts available as much as the number of trainees wishing to return, and become inaccurate as competition for posts increases. The overall rate of return has varied ranging from 42%2 to 57% in the most recent survey.6 Possession of Part 1 or Part 2 of the FDS increases the likelihood of return to OMFS from 46% in those without FDS, to 67% in those with Part 1, and 74% with Part 2 FDS.6 Using these proportions and applying them to the overall figures we have estimated the return rate and listed them in Table 2. Our survey asked if trainees intended to return to OMFS. We have no way of knowing how accurate this is but it is interesting that the figures seem to coincide with calculations based on previous surveys. Alty13 predicted that the number of consultant jobs likely to arise in the year 2000 would be about nine/year. Even taking into account the recent creation of new consultant posts, it is difficult to see all Table 2 -Estimated
these committed current trainees in OMFS getting consultant appointments in the UK. CONCLUSIONS Dental graduates entering medicine between 1986 and 1991 are significantly different from those in groups previously surveyed. They are older, more often of SHO grade, better qualified and more intend to train in OMFS. There are also many more of them. It will be interesting to see if these differences will affect the return rate of trainees to the speciality after they have completed the medical part of their training. This survey and the calculations based on previous return rates show that the trainees in OMFS will face stiff competition on returning to the speciality. Many of the OMFS units in the country have found the demand for their career grade appointments is unpredictable and at times low. If this continues to be the case, in spite of the high numbers of dental graduates entering medical school with a view to a career in OMFS, then the speciality must ask why. There is an encouraging trend towards more medical schools offering more dental graduates shortened courses.i4 On the less favourable side, fewer students were receiving grants and the value of those grants awarded was falling; university fees are increasing and fewer schools participate in the fees remission scheme; rewards in dental practice are declining and newer trainees without vocational training can only work as assistants; finally locum posts are becoming more difficult to obtain. These changes will have serious financial effects on trainees. Lastly, although there are an increasing number of dental graduates entering medical school with a view to pursuing a career in OMFS (up to 36 trainees in a single year), only one fifth of the respondents were right in predicting the number of dental graduates studying medicine. There is clearly a need for prospective medical students amongst trainees in OMFS to be better informed. The Medical Students’ Group of BAOMS now runs half-day seminars aimed at trainees intending to study medicine. These take place on the Saturday after BAOMS conferences held in the Royal College of Surgeons of England and have proved popular with those attending.* It is hoped * Unpublished assessment half-day seminar for dental graduates who are prospective medical students organised by Medical Students’ Group of British Association of Oral and Maxillofacial Surgeons, 1993.
number of trainees returning to oral and maxillofacial surgery
Year
Total at medical school
Number returning questionnaire
Neither part of the FDS (replied)
91 92 93 94 95 96
19 36 26 28 39 19
14 35 22 25 37 19
1 3 2 1 9 5
Part 1 FDS (replied)
Part 2 FDS (replied)
Estimated percentage returning
Estimated return numbers
No. stating intent to return to OMFS
6 11 7 5
10 25 14 13 21 9
71% 68% 70% 70% 66% 65%
13 2.5 18 20 26 12
11 30 17 22 26 16
Survey
that these seminars and this paper will help to redress the information deficit. Acknowledgements The authors thank Financial Analysis, Law Society House, Belfast for allowing the use of their Freepost address for the questionnaires, and the Medical Defence Union and Strautec UK for contributing to the cost of postage.
References I. Report of the education sub-committee of the British Association of Oral and Maxillofacial Surgeons. British Association of Oral and Maxillofacial Surgeons, London. 1988. 2. Henderson D, Liversedge RL. James PL. A study of dentally qualified medical graduates. Br J Oral Surg 1977; 15: 173-184. 3. Langton SG. A career survey of dental graduates who subsequently qualified in medicine between 1970 and 1979 with special reference to oral and maxillofacial surgery. Br Dent J 1988; 165: 174-176. 4. Levers BGH, Scully C, Maclntyre D. Henderson D, Porter SR, Coelho A. Careers of dentists undertaking a medical qualification. Br J Oral Maxillofac Surg 1988; 26: 443-451. 5. Gwynne A. A survey of dental graduates reading for medical degrees in the United Kingdom. Br Dent J 1969; 127: 205-207. 6. Langton Xi. A study of dental graduates at British medical schools in April 1987. Br J Oral Maxillofac Surg 1988: 26: 289-294. 7. Gwynne A. What are they doing now? Br Dent J 1976: 141: 162. 8. Lowry S. Medical education: student selection. BMJ 1992; 305: 1352-1354.
of dental
graduates
entering
medical
schools
445
J. Stress in medical undergraduates and house 9. Firth-Cozens officers. Br J Hosp Med 1989; 41: 161-164. 10. Ong TK, Magennis JP. A survey of the admissions policies of medical schools in the United Kingdom with regard to applications to dental graduates. Br J Oral Maxillofac Surg 1993; 31: 246-249. Undergraduate medical education: Il. General Medical Council. the need for change. London; GMC, 199 I. 12. Frame JW. Oral surgery training in the United States of America. Br J Oral Surg 1980; 18: 86-89. 13. Alty HM. Manpower imbalance in oral surgery/oral medicine. Health Trends 1983; 15: 64-65. 14. Ong TK, Magennis P. Admission Policies of British Medical Schools with regard to Applications from Dental Graduates. Official policies 1994 and feedback from dental graduate students entering college between 1988 and 1991. Submitted for publication in the British Journal of Oral and Maxillofacial Surgery.
The Authors P. Magennis BDS, MBBCh, FDSRCS, FFDRCSI, Lecturer/Higher Surgical Trainee Department of Oral and Maxillofacial Surgery The Royal London Hospital Dental Institute Turner Street London El 2AD, UK T. K. Ong BDS, MBChB, FDSRCS Higher Surgical Trainee Newcastle General Hospital Westgate Road Newcastle upon Tyne NE4 6BE. UK Correspondence
and requests
for offprints
Paper received 11 January 1994 Accepted 13 December 1994
to Patrick
FRCSI
Magennis
Sur,qery ( 1996) 34, 438-445
I
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1
Survey of dental graduatesentering medical schoolsand a comparisonwith previous surveys P. Magennis, T. K. Ong Department of Oral and Maxillofacial Department of Oral and Maxillofacial
Surgery, The Royal London Hospital Dental Institute, London, UK; Surgery, Newcastle General Hospital, UK
SUMMARY. The 169 dental graduates known to have entered UK medical schools between 1986 and 1991 inclusive were sent a questionnaire requesting personal and professional information. A total of 154 graduates (91%) responded, 126 (82%) males and 28 (18%) females, all with a mean age of 27 years. Over the 6 years studied, both the average fees paid and the number of students paying fees increased. During the same period, the average grant received and number receiving grants both decreased. Of the 154 responding, 141 (92%) intended to pursue a career in oral and maxiliofacial surgery at the time they entered medical school, and this had fallen to 120 (78%) by the time of the survey. An estimate of the number of those medical students who may return to the specialty was made based on previous surveys (range of 12-26 trainees/year).
INTRODUCTION
1986-1991 inclusive were obtained directly from medical schools and from the records of the Medical Students’ Group of the BAOMS. A questionnaire covering the following was sent to each of them:
Long before the 1988 Report of the education subcommittee of the British Association of Oral and Maxillofacial Surgeons (BAOMS)’ had recommended that a medical degree was essential, trainees in oral and maxillofacial surgery (OMFS) had been studying medicine. The report simply recognised an earlier trend. In the UK, trainees who wish to pursue a career in OMFS apply individually to medical schools. When they cease to hold full-time dental posts in the specialty they become ‘invisible’ for monitoring purposes such as manpower planning and appear again only when they re-enter the specialty after completing their medical degree, house jobs, and basic surgical training. There have been three retrospective surveys of these doubly qualified people; Henderson et aZ.,’ Langton and Levers et al.;4 two surveys of dental graduates in the process of studying medicine; Gwynne,’ Langtom and one follow-up study by Gwynne.’ The last survey6 was in 1987. Our survey up-dated most of the data presented in these earlier papers and also recorded new information, particularly about the financial aspects of studying medicine as a second degree. To keep our paper as concise as possible, the results of our survey and comparisons with previous papers are combined in a single section.
Personal details: age, sex, marital status at entry into medical school, marital status at the time of the questionnaire, and number of children. Information about the career before entering medical school: the dental school attended and year they qualified, whether they were awarded honours or prizes, further qualifications and year obtained, and the hospital grade reached in OMFS before undertaking the medical degree. Future career plans: career intentions at entry to medical school, intentions at the time of the survey, and whether they have regretted studying medicine and if so, the reason. Work undertaken during the medical course: the type of work and hours worked each week, whether work affected their studies, and how they had found the financial aspect of studying medicine. Details of the medical course: any exemption from part or parts of the course and grants or scholarships obtained. Perceived number of peers: the number of dental graduates that they thought were studying medicine in 1986-1991 and, if the total was more than 150, whether that would have made them reconsider starting medicine. Envelopes, with a ‘Freepost’ return address, were included to encourage recipients to send back the questionnaire. Use of a freepost address avoided wasting money on stamps on unused return envelopes. It also permitted the sending of reminders and
METHODS The names and addresses of every dental graduate known to have entered medical school in the years 438
Survey
return envelopes without a great addition to the cost of the survey. To further encourage replies, a prize draw was offered. Those who failed to reply were sent reminder letters and if post failed, they were contacted by telephone. RESULTS,
COMPARISON
AND DISCUSSION
Because of the nature of the survey, with numerous variables, most of the statistics are descriptive. However, differences between the sexes were analysed statistically by means of chi square test. Response
A total of 169 dental graduates were identified as having entered medical school from 1986 to 1991 inclusive. Responses were received from 154, a response rate of 91X, which was higher than in previous surveys (70’X5 and 65.8%~).6 The freepost return address, prize draw, direct telephone contacts, and persistence probably contributed to the high response rate. Of those responding, 129 replied by post and the remaining 25 gave the information over the telephone. Partial information about nonresponders was obtained from the Dentists’ Register, this included the school and year of dental qualification, and the college and year that they obtained a Fellowship in Dental Surgery (FDS). Some information was also collected through the records of the Medical Students’ Group of the BAOMS. (a) Personal details Sex
Of the total 169 dental graduates at medical school, 138 (82%) were men and 31 (18%) were women. The corresponding figures for the 154 respondents were 126 (82%) and 28 ( 18%). The percentage of female trainees undertaking medicine as a second degree had increased from 9% recorded in 1987.h The percentage of females changed in each year studied from 0 in 1986 to 4 in 1987, 15 in 1988, 22 in 1989, 25 in 1990 and 27 in 1991. As women account for nearly half of the medical schools’ normal intake,* it will be interesting to see if female dental graduate students will approach this proportion.
Table I- Percentage of each marital with previous surveys’.‘,h Marital
status
graduates
71 28 0.6
to
graduates
entering
medical
schools
The mean age was 27 years with a range of 23-39 years. Figure 1 shows the age distribution of the respondents which is similar to previous surveys.2.4-h Fourteen respondents were over 30 years old and of these, six were senior registrars and five sponsored by Her Majesty’s Defence Forces. The average age of women was virtually identical to that of men, but women had a narrower range of ages (25-34 as opposed to 23-39 for males). Marital status andfirmil~
Table 1 shows the breakdown of the respondents’ marital status at the time of entry into medical school, at the time of the current survey, and those given in previous surveys.2.4.6 Of the 34 respondents with children (22X), the average number of children was 2 (range l-6). There were significant differences between the sexes: 22 female respondents (79%) were single at the time of the survey compared with 69 (50%) men (P= 0.016) and 1 female respondent (4%) had children compared to 34 (27%) men (P = 0.017). (b) Information school
about career prior to entering medical
Dental school
There were graduates from all the dental schools in the UK as well as three from Ireland (Trinity), three from the Indian subcontinent (Bombay, Calcutta and Mysore), two from New Zealand, one from Singapore and one from Australia. The average number from each dental school was 7 (range l-20). Figure 2 shows the distribution of dental schools from which UK graduates qualified. Of these, 60 (38%), graduated in dentistry from London schools with 20 coming from UMDS alone. Prizes and honours
Twenty-four ( 16%) of the 154 respondents qualified with honours. Previous surveys had found honours rates of 22%’ and 21X6 Men (15”/0) and women (14%) were equally successful. Sixty-two (42%) achieved one or more prizes during the dental course compared with 33% in 1977. Although a greater
to medical
school.
during
current
survey,
and a comparison
Henderson’ (n= 175)
Levers’ (n=220)
Langton” (n = 52)
66 30
64 21
46 52
At time of survey
54 44 2
439
Age at entry to medical school
at time of entry
Current survey (n= 154) On entry medical school
Single Married Separated
state of dental
of dental
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and Maxillofacial
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H male
23
24
25
26
27
26
29
30
II female
Jml 31
33
34
I 35
,I 37
, 39
Age on Entry to Medical School Fig. 1 -Age distribution of dental graduates at medical school.
proportion of men won prizes (42%) compared with women (25%), the difference was not significant. Time interval between dental and medical schools
The respondents worked a mean of 49 months before starting medicine (range 6-168 months). This compares with 1970- 19793 (mean of 37 months [range O-156 months]) and 1982-1987’j (mean of 40 months [range 3-125 months]). The mean time interval between attending dental and medical schools had increased by almost 10 months, while the range of the interval remained similar. The preference of most medical schools for candidates with Part 1 or Part 2 FDS may explain the longer mean time compared with previous surveys. There was no difference between the sexes in the time interval between dental graduation and entry to medical school. Grade of last post before medicine
Number of graduates
at medical school
Fig. 2 - Original dental schools of medical students.
Overall, 71 (47%) had reached senior house officer (SHO) grade, 70 (46%) registrar grade, and only 6 (4%) senior registrar grade. There was no difference between the sexes. The predominant grades have changed with time (Fig. 3). In 1982-19876 and in the 1986-1988 subgroup in this survey, the registrar grade was the largest group. In contrast, in the 1989-1991 group in the present survey these proportions were reversed with 34% being registrars and 57% senior house officers (SHOs). The reasons for this change are hard to ascertain as there does not seem to be any other difference between the two groups. It may reflect a
Survey
of dental
graduates
entering
medical
schools
441
80
I 70
t
Registrar
--t
Senior Registrar
1
-Part
1 FDS
-.-Part
2 FDS
0
1977
1969
1982-87
1966-91
Year of Survey
Fig. 3 -Changing
grades
on entry
to medical
Year of Survey
school. Fig. 4 - FDS
combination of the reduction in the number of registrar posts for trainees with only a dental qualification and the increasing importance of Part 2 FDS in obtaining a place at medical school, Additional qualifications Fellowship in Dental Surgery
Of the total of 169 graduates at medical school, 100 (59%) held the Part 2 Fellowship in Dental Surgery (FDS) or had this qualification listed on the Dental Register. Of 154 who responded to the questionnaire, 89 (58%) held Part 2 FDS. Possession of Part 1 FDS is not recorded on the Dental Register, so it was possible to ascertain only the number with Part 1 FDS alone among those who responded to the questionnaire. Of those 154 replying, 40 (26%) held Part 1 only. Figure 4 shows the distribution of the respondents’ FDS qualifications in comparison with previous surveys. 2.5.6 The increase in the percentage of those holding Part 2 FDS at the time of entry to medical school rose from a low of 170/02to 58% in this series, probably because of the advantage that it gives in obtaining a place at medical school. A significantly greater proportion of female respondents gained entry to medical school without any FDS qualifications (8 women [29%] had neither part FDS at entry into medicine compared with 14 men [ 1 l’%]; P=O.O43). Fewer females held Part 1 (6 [21%] compared to 34 [27%] males) and held Part 2 ( 14 [50%] compared to 79 [63%] males) but these differences were not significant. As there is no significant difference between the sexes regarding the time between graduating in dentistry and entry to medical school entry, the lower proportion of females without
status
of dental
graduates
at medical
school.
FDS is not because they enter medical school at an earlier stage in their careers. Timing oJ‘FDS exams
Those who had obtained Part 1 FDS (n = 139), passed it a mean of 2 years after graduating in dentistry (range O-7 years) and 2 years before entering medical school. Graduates with Part 2 FDS passed it a mean of 4 years after their initial dental qualification (range 2-9 years) and about 5 months before entering medical school. The sub-group of 40 who held Part 1 FDS only entered medical school 1.75 years earlier than those with Part 2 FDS. Part I FDS during medical school
Seven respondents passed the Part 1 during the medical course: three in first year, two in the second year and two in the fourth year. Of these, three went on to pass their Part 2 FDS before they qualified in medicine. Part 2 FDS during medical school
21 (14%) students passed their Part 2 FDS during the medical course, eight during first year, four during the second year, seven during the third year and two during the fourth year. Part I-Part
2 interval
The average delay between obtaining Part 2 FDS was 2 years (range O-5).
Part 1 and
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Other qualifications
(d) Details while at medical school
Eight had BSc, seven MSc, one BMedSci and one PhD. One master’s degree preceded the dental degree, the other six obtained their MSc within an average of 3.75 years of their dental degree.
Medical schools at which the dental graduates had places are shown in Figure 5.
(c) Career plans Original reason for studying medicine Overall, 142 (92%) respondents started medicine with the intention of pursuing a career in OMFS. This is the largest ever proportion compared with the other surveys. 5,6 Of the 12 not citing OMFS as their reason for entering medical school, oral medicine was the reason given by six (4%), three (2%) said they planned to enter other medical specialties. One cited ‘dislike of dentistry’ as the reason for studying medicine and two did not know why. Although only one listed a dislike of dentistry as the main reason for studying medicine, a further five said that a dislike of dentistry contributed to their decision. These six (4%) compare with the previous surveys’ figures of 5%3 and 1O%.6 Of the 22 respondents without FDS qualifications, 15 (67%) entered medicine with the intention of pursuing a career in OMFS. Career intentions at time of questionnaire At a mean interval of 3 years after starting their medical course, the percentage of respondents planning to pursue a career in OMFS had dropped to 78% (n = 120) from the original 92% (n = 142). This was comparable with previous surveys’ percentages of 75%5 and 8O%.‘j Of the 22 who changed their minds, 14 said that they did not know if they would return to OMFS, two named other medical specialities; one without either part of the FDS chose general medical practice and another with Part 2 of the FDS chose ENT and five simply stated ‘not OMFS’. None of the 12 who planned a career outside OMFS on entry to medical school had changed their minds at the time of survey and decided to return to OMFS. When those entering medicine with a view to a career in OMFS are sub-divided according to their FDS qualifications, a significantly greater percentage of those without FDS changed their minds (50%) compared with those with Part 1 of the FDS (18%) and those with Part 2 of the FDS (7%). This supports previous findings that possession of Parts 1 and 2 FDS increases the likelihood of the trainee returning to OMFS.2,3
Exempt ions Fifty-six (36%) gained some exemption from part or parts of the course. Some reduction in the length of the medical course was obtained by 44 (29%), an increase from 19% in the last survey.‘j The reductions ranged between 4 months and 2 years, most (38/44) receiving a reduction of 1 year. Exemptions for 12 dental graduates (7%) did not shorten the course but meant avoiding teaching such as practicals, computing, or statistics. It is likely that the proportion will increase as more medical schools in the UK offer shorter medical courses for dental graduates.” Interestingly, 12 women (43%) were exempted from part(s) of the course compared with 31 men (25%), although this was not statistically significant (P=O.O96). Fees Figure 6 shows the increasing trend of the average fees paid/year by the respondents. A recent survey has shown that an increasing proportion of schools are no longer using the ‘fees remission scheme’ for UK dental graduates. ls This increases the fees/year from about &700 to &3000 or more, and it is possible that the fees may approach those paid by foreign students of about &15 OOO/year. Aberdeen BmtS SOlFaSt Sbmlnghrm Bristol Cambridge Chafing Cross D”“dOS Edinburgh ol*sgow King’s P
Led%
i! s
Liverpool
Leicester
3 5 P
Manchester Newcastle Nottingham Royal Free Royal London Shsffild Southampton St Andrew’s St George’*
Regrets about studying medicine Seventeen of 154 (11%) regretted studying medicine; seven had reached registrar or senior registrar grade and eight had Part 2 of the FDS. The reasons given were ‘long pathway in OMFS’, ‘poor career progression’ and ‘waste of time’. Fourteen of those regretting studying medicine still intended to return to OMFS.
Tri”ih, UCH UYDS WNSS 0
5
to
Number of dents1 graduates
Fig. 5 - Dental
graduates
at each medical
school.
16
20
Survey
of dental
graduates
entering
medical
schools
443
Year Fig. 6 - Average
Year of entry to medical school
fees paid per year. Fig. 7 - Percentage
of respondents
with
LEA
grants.
Grunts and scholarships
Seventy-one (46%) of those replying to the questionnaire received grants or scholarships from some source, with 52 (34%) receiving a grant from a Local Education Authority (LEA). The average total value of grant or scholarship over the whole course was &7618, with the maximum of f22 500 (five years full mature student’s grant from an LEA) and the minimum of &300 (a university grant). Grants from LEAS for a second degree are discretionary, and the financial pressure from the government on local authorities is increasing. The percentage of respondents receiving grants fell from 80% in the 1986 intake to only 13% in the 1991 intake (Fig. 7). Not only did the proportion with grants decrease but also the value of grants fell by 75% over the same period. A few respondents noted that persistent application for an LEA grant was rewarded by an award and one determined person obtained grants from LEA, university, and a number of charitable trusts. There was a pronounced geographical variation in the awarding of grants to dental graduates with, in reverse order, 0 in Northern Ireland, 27%) in Southern England, 30% in Greater London, 39% in Northern England, 44% in Wales and 63% in Scotland. (e) Work during medical school Type of work
All 152 answering this question worked as dentists during their medical course; 140 (92%) undertook occasional locums; 112 (73%) worked in dental practice, and 45 (29%) held clinical assistant posts. The average student worked 10 hours a week in practice and spent 42 days a year as a locum (usually at senior
house officer grade). More unusual methods of supplementing income included office cleaning and making jewellery. Langton found only 79%) at work during the course, probably because more grant support was available at that time. Earnings
It can be estimated from the average 10 h a week worked in dental practice that the average annual income from this source would be &5431 (calculated from the target income set by the Dental Practice Board for general dental practitioners in 1993). The average earnings from locum work as an SHO, assuming a 1 in 3 rota, this would be about &1300. Therefore, approximate pre-tax income would be &6731 per annum. Effect qf’tvork on studies
Sixty-six students (43%) felt that working during the course adversely affected their studies. Financial aspect
qf studying
medicine
We calculated the cost of being a student including university fees and allowing for lost earnings (4.7 years on average out of full time work), and the total cost of the dental graduate studying medicine was approximately f67000 at 1993 prices. When asked how they felt about the financial aspect of studying medicine, 68 (45%) thought it was as bad as they had expected, 53 (35%) felt it was better, and 31 (20%) thought it was worse. The financial pressures on trainees in OMFS seem bound to increase. The earnings in dental practice have declined, and trainees qualifying after 1991 who
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have not done any vocational training can work only as assistants rather than associates in a dental practice. The introduction of integrated medical courses with greater emphasis on continuous assessments” may mean reduced opportunities for locum work. These changes, combined with increasing fees and decreasing grants, make the financial outlook for dental graduates at medical school somewhat bleak. (f ) Perception of peers Number of peers
One hundred and forty seven responded to this question. Only 29 (20%) were right in thinking that more than 150 dental graduates were reading medicine. Of the rest, 83 (56%) thought there were 100-l 50, 32 (22%) thought there were 50-100, and 3 (2%) estimated less than 50. Overall, only 15 respondents (10%) would have changed their minds if there had been more than 150 dental graduates reading medicine. Six female respondents (21%) would have reconsidered whereas only nine men (7%) would have done (P= 0.055). Predicting the manpower resources It is difficult to estimate the number of trainees in OMFS who return to the specialty after the medical part of their training. Previous studies have recorded the numbers of trainees who successfully returned to the specialty but these figures reflect the number and types of training posts available as much as the number of trainees wishing to return, and become inaccurate as competition for posts increases. The overall rate of return has varied ranging from 42%2 to 57% in the most recent survey.6 Possession of Part 1 or Part 2 of the FDS increases the likelihood of return to OMFS from 46% in those without FDS, to 67% in those with Part 1, and 74% with Part 2 FDS.6 Using these proportions and applying them to the overall figures we have estimated the return rate and listed them in Table 2. Our survey asked if trainees intended to return to OMFS. We have no way of knowing how accurate this is but it is interesting that the figures seem to coincide with calculations based on previous surveys. Alty13 predicted that the number of consultant jobs likely to arise in the year 2000 would be about nine/year. Even taking into account the recent creation of new consultant posts, it is difficult to see all Table 2 -Estimated
these committed current trainees in OMFS getting consultant appointments in the UK. CONCLUSIONS Dental graduates entering medicine between 1986 and 1991 are significantly different from those in groups previously surveyed. They are older, more often of SHO grade, better qualified and more intend to train in OMFS. There are also many more of them. It will be interesting to see if these differences will affect the return rate of trainees to the speciality after they have completed the medical part of their training. This survey and the calculations based on previous return rates show that the trainees in OMFS will face stiff competition on returning to the speciality. Many of the OMFS units in the country have found the demand for their career grade appointments is unpredictable and at times low. If this continues to be the case, in spite of the high numbers of dental graduates entering medical school with a view to a career in OMFS, then the speciality must ask why. There is an encouraging trend towards more medical schools offering more dental graduates shortened courses.i4 On the less favourable side, fewer students were receiving grants and the value of those grants awarded was falling; university fees are increasing and fewer schools participate in the fees remission scheme; rewards in dental practice are declining and newer trainees without vocational training can only work as assistants; finally locum posts are becoming more difficult to obtain. These changes will have serious financial effects on trainees. Lastly, although there are an increasing number of dental graduates entering medical school with a view to pursuing a career in OMFS (up to 36 trainees in a single year), only one fifth of the respondents were right in predicting the number of dental graduates studying medicine. There is clearly a need for prospective medical students amongst trainees in OMFS to be better informed. The Medical Students’ Group of BAOMS now runs half-day seminars aimed at trainees intending to study medicine. These take place on the Saturday after BAOMS conferences held in the Royal College of Surgeons of England and have proved popular with those attending.* It is hoped * Unpublished assessment half-day seminar for dental graduates who are prospective medical students organised by Medical Students’ Group of British Association of Oral and Maxillofacial Surgeons, 1993.
number of trainees returning to oral and maxillofacial surgery
Year
Total at medical school
Number returning questionnaire
Neither part of the FDS (replied)
91 92 93 94 95 96
19 36 26 28 39 19
14 35 22 25 37 19
1 3 2 1 9 5
Part 1 FDS (replied)
Part 2 FDS (replied)
Estimated percentage returning
Estimated return numbers
No. stating intent to return to OMFS
6 11 7 5
10 25 14 13 21 9
71% 68% 70% 70% 66% 65%
13 2.5 18 20 26 12
11 30 17 22 26 16
Survey
that these seminars and this paper will help to redress the information deficit. Acknowledgements The authors thank Financial Analysis, Law Society House, Belfast for allowing the use of their Freepost address for the questionnaires, and the Medical Defence Union and Strautec UK for contributing to the cost of postage.
References I. Report of the education sub-committee of the British Association of Oral and Maxillofacial Surgeons. British Association of Oral and Maxillofacial Surgeons, London. 1988. 2. Henderson D, Liversedge RL. James PL. A study of dentally qualified medical graduates. Br J Oral Surg 1977; 15: 173-184. 3. Langton SG. A career survey of dental graduates who subsequently qualified in medicine between 1970 and 1979 with special reference to oral and maxillofacial surgery. Br Dent J 1988; 165: 174-176. 4. Levers BGH, Scully C, Maclntyre D. Henderson D, Porter SR, Coelho A. Careers of dentists undertaking a medical qualification. Br J Oral Maxillofac Surg 1988; 26: 443-451. 5. Gwynne A. A survey of dental graduates reading for medical degrees in the United Kingdom. Br Dent J 1969; 127: 205-207. 6. Langton Xi. A study of dental graduates at British medical schools in April 1987. Br J Oral Maxillofac Surg 1988: 26: 289-294. 7. Gwynne A. What are they doing now? Br Dent J 1976: 141: 162. 8. Lowry S. Medical education: student selection. BMJ 1992; 305: 1352-1354.
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graduates
entering
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schools
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J. Stress in medical undergraduates and house 9. Firth-Cozens officers. Br J Hosp Med 1989; 41: 161-164. 10. Ong TK, Magennis JP. A survey of the admissions policies of medical schools in the United Kingdom with regard to applications to dental graduates. Br J Oral Maxillofac Surg 1993; 31: 246-249. Undergraduate medical education: Il. General Medical Council. the need for change. London; GMC, 199 I. 12. Frame JW. Oral surgery training in the United States of America. Br J Oral Surg 1980; 18: 86-89. 13. Alty HM. Manpower imbalance in oral surgery/oral medicine. Health Trends 1983; 15: 64-65. 14. Ong TK, Magennis P. Admission Policies of British Medical Schools with regard to Applications from Dental Graduates. Official policies 1994 and feedback from dental graduate students entering college between 1988 and 1991. Submitted for publication in the British Journal of Oral and Maxillofacial Surgery.
The Authors P. Magennis BDS, MBBCh, FDSRCS, FFDRCSI, Lecturer/Higher Surgical Trainee Department of Oral and Maxillofacial Surgery The Royal London Hospital Dental Institute Turner Street London El 2AD, UK T. K. Ong BDS, MBChB, FDSRCS Higher Surgical Trainee Newcastle General Hospital Westgate Road Newcastle upon Tyne NE4 6BE. UK Correspondence
and requests
for offprints
Paper received 11 January 1994 Accepted 13 December 1994
to Patrick
FRCSI
Magennis