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Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2011; 56: 9296

COMMENTARY

doi: 10.1111/j.1834-7819.2010.01306.x

Professionalism: what is it, why should we have it and how


can we achieve it?
JP Fricker,* M Kiley,* G Townsend, C Trevitt
*Centre for Educational Development and Academic Methods, The Australian National University, Canberra, Australian Capital Territory.
School of Dentistry, The University of Adelaide, Adelaide, South Australia.
Oxford Learning Institute, University of Oxford, United Kingdom.

ABSTRACT
In this paper we argue that the terms profession, professional and professionalism provide us with important insights
into the practice of dentistry and the priorities for the continuing development of dentistry as a profession. More
significantly, we suggest that this understanding can assist us in designing continuing professional development (CPD)
programmes aimed at maintaining the professionalism of dentists throughout their working lives.
A CPD framework is required to support both the new graduate to develop from novice to expert as well as support
experienced practitioners to maintain their expertise within a rapidly changing environment. Rather than an onerous task,
CPD should be a positive and enjoyable experience, self-motivated to improve job satisfaction and self-confidence. Research
is currently being undertaken to determine what is good CPD for the practising dentist with a view to recommending
strategies based on sound educational theory.
Keywords: Continuing Professional Development, dental practice, profession, professionalism.
Abbreviations and acronyms: CPD = Continuing Professional Development; PBL = problem-based learning.
(Accepted for publication 21 June 2010.)

INTRODUCTION
In a recent editorial of the Australian Dental Journal,
the Editor highlighted the overwhelming need for
dentists to keep up with all aspects of professional
practice, as well as an obligation to be lifelong learners.1
Continuing Professional Development (CPD) is now
part of professional practice and an important element
of professional attributes of the newly qualified dentist
as described by the Australian Dental Council.2
In this paper, we argue that improved understanding
of the terms profession, professional and professionalism provide us with important insights into the
practice of dentistry and the priorities for continuing
development of dentistry as a profession. More significantly, we suggest that this understanding can assist us
in designing CPD programmes aimed at maintaining
the professionalism of dentists throughout their working lives.
BACKGROUND
A profession is defined by the Australian Council of
Professions as: a disciplined group of individuals who
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adhere to ethical standards and who hold themselves


out as, and are accepted by the public as possessing
special knowledge and skills in a widely recognised
body of learning derived from research, education and
training at a high level, and who are prepared to apply
this knowledge and exercise these skills in the interests
of others.3
Ethics is the concept or code of conduct under which
one lives as an individual and as a society. All health
professionals carry a responsibility to attend to those in
need to the best of their ability and to also represent
their profession in a dignified manner.4 An important
component of dentistry as a profession is the need to
establish trust in the dentist patient relationship.5 The
term patient rather than client is preferred as the
dentist patient relationship implies a duty of care over
and above the provision of a service within a commercial transaction.
Tasks carried out by professionals generally carry
high levels of complexity and also uncertainty. The
diversity of tasks in dentistry means that each situation
is unpredictable, but the professional must take ultimate responsibility for every outcome. Such complex
tasks need to be supported by well-developed skills,
2011 Australian Dental Association

Professionalism: a commentary
knowledge and practices. All professionals need to take
responsibility for the continued development of these
throughout their working lives as the public expects
that professionals provide their services both competently and as experts worthy of trust.6
Once admitted to the profession via the appropriate
educational process, professionalism refers to the
conduct and or behaviour of the individual in upholding the social contract between society and the profession. Such conduct or behaviour is what earns the trust
and confidence of the community and the individual
patient in the profession, e.g. dentistry. Therefore,
being a professional requires a commitment to lifelong
learning and maintaining competence in skills, knowledge and attitudes for safe practice. This paper
proposes that CPD provides the vehicle for ongoing
professionalism throughout ones practising life.
Historical perspective on dentistry as a profession
The learned professions of medicine, law and theology
began in medieval Europe and were developed to
address specific problems in society. Dentistry was first
identified as a unique profession in 1699, when an edict
was passed in France legalising the position of dentists
and distinguishing them from physicians, surgeons and
barber surgeons. The father of dentistry is widely
acclaimed to be the Frenchman Pierre Fauchard. As a
dentist in Paris, he published a two-volume text in 1728
titled Le Chirurgien Dentiste (The Surgeon Dentist),
which was a comprehensive, systematic overview of the
scientific and practical knowledge of dentistry at that
time.7 This served as an instructional text for those
preparing for practice and raised the scientific status of
dentistry. This scientific base was further strengthened
following the publication in 1771 of The Natural
History of the Human Teeth by John Hunter in
England.

Society of London, formed in 1856. This society


published a journal, The British Journal of Dental
Science and, in 1859, drafted a curriculum for apprenticeship training of dentists. Successful advocacy
resulted in governments sanctioning these new experts
when the Dental Act in 1878 registered appropriatelytrained dentists.
The Tripod of Professionalisation
As the various professions developed, there were three
main components in their establishment or professionalisation. These were, the formation of a society, the
establishment of a journal and the provision of
education to the members, thereby creating the Tripod
of Professionalisation.7 These three components are
closely linked, with each dependent on the other. For
example, the association represents the membership of
the profession and sets the rules for such membership.
It is also responsible for the publication of research
through a journal and it provides input into the
education of dentists for contemporary practice. Professional attitudes are certainly major internal motivators to keep up, improve and derive self-satisfaction for
a job well done. Given that entry to a profession is a
voluntary act, it could be argued that responsibility to
keep up is part of the acceptance of the label of being a
professional and the civic identity which comes with
that voluntary nature.9
We argue that the dental profession is not only
responsible for the education of new members of the
profession, but professionalism demands ongoing
education and development of existing members as a
cyclic process (Fig 1).
Dentistry has continued to be identified as a regulated
occupation with a unique set of knowledge and skills
dependent on appropriate training.
DENTISTRY IN AUSTRALIA

Professionalisation
The professionalisation of occupations was an important element in the development of British society
during the Industrial Revolution. Prior to this, society
was characterised by the need for individuals to display
a versatility and variety of skills. Modernisation meant
specialisation and dentistry was an example where a
group of individuals identified a problem in society and
offered itself as a provider of the solution.
The creation of professional associations with established criteria for recruitment related to education,
behaviour and ethics, further enhanced professionalisation of recognised occupations. These organisations
facilitated an exchange of ideas and information that
enhanced the growth of science and technology.8 The
first dental society in England was the Odontological
2011 Australian Dental Association

As one might expect, the dental profession in the


colonies within mainland Australia and New Zealand
followed the English model with the first dentists
arriving into the colony of New South Wales in 1818.
Prior to this, dental treatment was essentially for
emergency services and was carried out by Royal Navy
surgeons.10 The development of dentistry in all colonies
of mainland Australia and New Zealand followed a
similar pattern. With the gold rushes of the 1850s and
the economic boom related to primary industries,
migration to the colonies accelerated. From the 1880s
on, there was an explosion of knowledge in science and
technology following discoveries such as those relating
to bacteria by Pasteur. The discoveries of X-rays,
anaesthetics and new materials, such as porcelain and
vulcanite rubber, as well as the invention of the foot
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JP Fricker et al.

Fig 1. Professionalism is the cyclic process of lifelong learning


through CPD over and above the Tripod of Professionalisation.

drill, further improved the practice of dentistry. As


more dentists arrived, many saw the need to raise the
profile of dentistry as a profession and by the end of the
19th century all the colonies had lobbied their respective governments for a Dental Act regulating who could
be called a dentist.
Unique to the colonies of Australia and New Zealand
(Australasia), the dental boards which were set up
under various Acts, set the examinations for registration rather than under licence from a medical college as
in the United Kingdom. In Australasia, dentistry was
independent of medicine from the outset. This independence was further reinforced with the opening of
dental faculties within the universities of Sydney,
Melbourne, Queensland, Adelaide, and Western
Australia in Australia as well as Otago in Dunedin,
New Zealand. Professionalism within dentistry was
also demonstrated in treating the needy pro bono. In all
colonies, the dental fraternity set up dental hospitals for
the needy, and these also doubled as practical training
centres for the apprentice dentists.
Confirming dentistry as a profession in Australia
In England before the Industrial Revolution, the
professions of law, medicine and divinity, as well as
the armed services, were regarded as occupations for
gentlemen. A profession was seen as a passport to good
society and was conditional upon the professional
behaving like a gentleman which precluded indulging
in retail trade such as advertising.
A major event in the recognition of dentistry as a
unique profession was the First World War of 1914 to
1918. In 1914, the Australian Army rejected 15 773
94

volunteers on the grounds of lack of dental fitness.11 In


1915, the Australian Army appointed 14 dentists as
commissioned officers, elevating the profession to
gentlemanly status and recognising that dental disease
was a significant factor in reducing a soldiers fitness to
deploy. The stated policy was: No man was to be
allowed to proceed overseas unless his mouth was free
of caries or any pathological condition of the gum, or
an insufficiency of teeth for adequate mastication.11
Once overseas, instructions were given that no teeth
should be extracted, which can be saved11 and this
placed a much higher responsibility on dentists in the
management of the overall health of soldiers compared
with pre-1914.
Following the Second World War, there was a further
boom in technology with inventions such as the air
rotor drill, improved surgical techniques, new filling
materials and adhesives. The discovery of the effects of
fluoride in reducing dental decay led to fluoridation
of reticulated water supplies and the transformation of
dentistrys philosophy from repair and maintenance to
prevention. The scientific basis of dentistry also grew
with contemporary practitioners encouraged to base
their practice on evidence.12 Clinical research became
more important with journals publishing more articles
in this area and new journals were created to cope with
the explosion of information.
Contemporary practice in Australia
Dentistry in Australia is a relatively small profession
with approximately 10 000 registered practitioners.13
Professional education of dentists in Australia, for both
general practice and specialist practice (with the exception of oral and maxillofacial surgery) is universitybased leading to qualifications for registration in
Australia upon graduation. Modern professionalism
is shaped by the dynamic interplay between commercialism and professionalism.14 As the consumerist
culture becomes more prevalent, dentistry is increasingly moving to a business model as demonstrated by
seminars and courses marketed to the practitioner to
improve profits and grow rich. An appropriate
balance is needed between satisfying the demands of
the patient and recommending what is appropriate
treatment in the light of financial incentives.15
The majority of practising dentists work in the private
sector with approximately 40% in solo practice.13 The
practising dentist thus faces a potential conflict between
the traditional definition of a professional and the
requirement to run a private practice as a business,
generating a profit to cover overheads and personal
income. However, the interests of the patient must
come first and the dentist must have the appropriate
knowledge and skills to select and prioritise treatment
options.
2011 Australian Dental Association

Professionalism: a commentary
PROFESSIONAL EDUCATION
Dental education in Australia is university-based, be it
undergraduate or graduate, and the graduate is eligible
for registration to practise on the public from the date
of graduation. However, practical wisdom or phronesis
is only acquired after a prolonged period of experience
and reflection on that experience.16 It is suggested that
phronesis, combined with the professionals development of knowledge and skills, is a critical attribute for
dentists. One way of supporting both reflection on
practice and the continuing development of knowledge
and skills is through engaging in CPD throughout a
lifetime of practice.17 The good dentist is a lifelong
learner18 and the introduction of problem-based learning (PBL) approaches into Australian dental schools, in
part, aims to promote and develop lifelong learners.
There is some evidence that PBL can foster the
development of the types of knowledge, skills and
attributes that dentists will need in the future.19
What is Continuing Professional Development?
A recent policy paper by the Dental Board of the
Australian Capital Territory (ACT) defines CPD as:
study, training, courses, seminars, reading and various
other activities that could reasonably be expected to
advance professional development as a dentist. It is the
means by which members of the profession can
maintain, improve and broaden their knowledge and
skills and develop their personal qualities required in
their personal lives and is a process of lifelong
learning which enables professionals to expand and
fulfil their potential.20
An essential component of CPD is lifelong learning
which can be seen as a cyclic process of reflection,
planning, action and evaluation in order to develop
ones practice.21 Professional expertise develops within
a specific domain of knowledge with expert performance in dentistry being a combination of a sound
knowledge base, good reasoning skills and broad
experience with patients.22 As expertise increases, the
individual is better able to deal with more complex
clinical problems and the adaptive expert is able to
utilise existing knowledge and practices to learn when
presented with a new problem.23 CPD is thus a vehicle
for professionalism in the delivery of services to patients
and society (as indicated in Fig 1).
Why do we need Continuing Professional
Development?
As an example of a university-based vocational
programme, dentistry requires a period of formal
education to be completed prior to admission to the
workforce in that occupation. Traditionally, it has been
2011 Australian Dental Association

implied that all learning required for a lifetime of


practice is completed within a university course.
Nowadays, however, newly graduated dentists are
generally unprepared for independent practice and
need support for at least the first 34 years after
graduation.24,25
Skills in management and clinical decision-making
need to be honed early in their careers and new
graduates need to be motivated to seek appropriate
CPD in order to maintain the currency of these skills.26
Likewise, a preparedness to engage in practice on these
terms is required of new graduates, as is understanding
and acceptance on the part of established members of
the profession, that these developments simply reflect
how things have changed (and continue to change) over
their working lives. The Australian Dental Association
and professional indemnity companies encourage
engagement in CPD activities to minimise complaints
and litigation.27,28 Contemporary practice is regarded
as what can reasonably be expected of the average
graduate in terms of recognising, diagnosing and
treating problems that normally occur in dentistry with
an evidence-based approach.18 However, there is a need
for healthcare practitioners to respond to a rapidly
changing environment and this has placed CPD high
on the list of priorities with registration boards, as
consumers have the right to expect that health professionals are practising in a competent and professional
manner. Dentistry is not a static profession and there is
a need for both the experienced dentist and the new
graduate to constantly upgrade their knowledge and
skills.29 CPD should also include the development of
self-assessment skills for both identifying deficiencies in
skills and knowledge, and as a comprehensive system of
ongoing monitoring.30 However, there is little evidence
to support mandatory CPD as a mechanism for the
long-term maintenance or improvement of clinical
competencies.31 One can lead the practitioner to an
educational activity, but CPD demands an active
engagement in the learning process.
Learning new procedures and techniques has an
element of risk and there needs to be a judgement of the
risks involved. While every endeavour may be made to
provide safe treatment, society must accept that there is
human error and there are risks when dealing with a
biological system. The practitioner must strive to
maximise the margins of safety and this requires the
support of the profession to develop the knowledge,
skills and attitudes of the novice to those of the expert.
Professions are group-based social entities and being a
member of ones professional association facilitates
keeping up-to-date through collegial activities and peer
interaction.27,28,32
Professional mastery takes many years of practice
and demands an engagement in CPD over a lifetime of
practice. It can be hastened by involving others in the
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JP Fricker et al.
process. The threat of litigation may motivate the
practitioner to engage in CPD and risk management
aimed at minimising errors is essential as part of the
learning process.
CONCLUSIONS
We have argued in this paper that CPD is the
mechanism for professionalism, based on a cyclic
process of learning and reflection that enhances ones
skills and competencies, and enables the generation of
trust between dentist and patient. The development of
professional life is governed by ethical behaviour and
the continuous updating of knowledge.4 Increasingly, a
CPD framework is required to support both the new
graduate to develop from novice to expert as well as
support experienced practitioners to maintain their
expertise within a rapidly changing environment.
Rather than an onerous task, CPD should be a positive
and enjoyable experience, self-motivated to improve
job satisfaction and self-confidence and to contribute to
professionalism. It is beyond the scope of this paper to
engage in a detailed discussion of CPD. However,
research is currently being undertaken to determine
what is good CPD for the practising dentist with a view
to recommending strategies based on contemporary
educational theory.
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Address for correspondence:


Dr John P Fricker
CEDAM
The Australian National University
Chancelry 10T
Ellery Crescent
Canberra ACT 0200
Email: john.fricker@anu.edu.au
2011 Australian Dental Association