October 12, 2017
by Peter C. Fritz, BSc, DDS, FRCD(C), PhD (Perio), MBA; Carolyn Triemstra, BRLS, MEd.; Amanda B. Longo, BSc, MSc, PhD; Taylor Sparrow, BSc, RDH; Wendy E. Ward, BSc, MSc, PhD
Dentistry in the VUCA World
It is clear that these are turbulent times. From geopolitical instability, threats of war and terrorism, shifting political alliances to resource scarcity and climate change, rising inequality and loss of confidence in information in the world is very different from 15 years ago. This is further catalyzed by technological changes occurring at blinding speeds without an ability to absorb the implications. We live in a world that is more volatile, uncertain, complex and ambiguous (VUCA) than ever before.
Industries are being disrupted at a record pace (i.e., Blockbuster disrupted by Netflix, taxis by UBER, hotels by Airbnb, etc.) and these disruptions are never again going to invade their target market as slow as they are now. The disruption of stable industries by invasive companies is paralleled in nature by the disruption of established eco-systems by an invasive species.
The knee-jerk reaction to control a disruptive invasive species is to focus on how to eradicate and destroy them. There is generalized fear and hatred of invasive species. The status quo is desirable. Invasive species come from the outside and turn everything upside down and disturb our comfortable world.
One of the best risk mitigation strategies to deal with disruption by an invasion, be it a zebra mussel or a technological advancement in your field is innovation. One must purposely develop an ecosystem that is incredibly diverse and unusual. If your perfectly manicured garden is limited to three or four indigenous species it is quite easy for an aggressive invasive weed or insect to devastate it. If however, you create a complex garden with a great variety of species of plants, insects and animals from all over the world in informal and creative combinations, you will create an ecosystem which is much more difficult to disrupt. No one expects to get invaded on an island. In nature, the only way you become resilient is by making sure you remain exposed to the widest and most diverse eco-systems you can find. If you are insular, you can’t adapt well. You must purposely expose yourself to unfamiliar eco-systems and learn from them.
Healthcare and academia are certainly not immune to the changes. To meet the challenges of a VUCA world, strategy needs to change and adapt. We can’t think long- term strategy anymore in a VUCA world.
Dentistry is not immune to these disruptions and is in fact a perfect target for disruption. The reaction among the dental community to this challenge is quite mixed. There is significant effort among dentists to vehemently resist change to protect the traditional model. Some have chosen to compete on price and in fact have fallen into the commodity trap. Some have attempted to create disruption by creating large corporate networks and leveraging the economy of scale to the potential disadvantage of smaller businesses. But most dentists, simply, don’t know what to do.
Building on the shoulders of giants has been the tactic of choice for several generations in dentistry. However, the electric light was not created through the continuous improvement of the candle. That is to say, the continuous adjustment of an old model does not lead to novel and innovative systems and approaches. In a VUCA world, people crave simple and preferably monosyllabic jingles for answers to complicated problems. These don’t exist. Today, there is no one single “all knowing” leader who can guide us through the complexity and ambiguity of challenges facing us today. It takes a high performing team.
Having an industry disrupted in a VUCA world is not necessarily a bad thing. A VUCA world is one of tremendous opportunity for a significant improvement. To be successful however, you cannot simply copy how others in the industry are doing things. One needs to do research and development to reinvent an industry. In a VUCA world, innovation is a matter of survival. The world in which good planning and brilliant execution was enough for success is over. Rather, good planning and brilliant execution is a prerequisite for survival. One must be agile enough to sense and respond along the way. The most successful strategy in a VUCA world is learning and adapting as part of a continuous renewal.
With this idea in mind, this paper describes one ecosystem that has been created to foster synergy between dentistry, dental hygiene, university research and college training as well as industry partnerships to produce the future dental hygienist leaders of tomorrow.
After completing dental school, one option for dental graduates is to gain an additional year of specialized training and experience at an accredited dental residency program such as the University of Toronto Teaching Hospitals or the Western University General Practice Residency (GPR) or hundreds of other GPR programs in North America.
The criteria for selection to these programs include academic achievement, motivation, maturity, professionalism, and the ability to work as a team member. These programs are often the stepping-stone for specialty programs and graduate school. Future leaders in dentistry are often created through these programs. Each program offers a specific niche of dental services through their dental departments. Residents are given supervised clinical experience in hospital dentistry and assignments to other clinical departments. Throughout these programs, regularly scheduled lectures, literature reviews and case presentations are held. The objective of these residencies is to create an environment for learning clinical and intellectual skills, as well as developing teamwork skills in order to better serve patients and ultimately lead a team. In both Ontario residency programs, residents are paid an annual stipend and get two weeks of paid holiday time.
Presently in Canada, there is no comparable program for dental hygienists. It would be advantageous to create and implement such a residency for high potential dental hygiene graduates with the goal to foster the development of future leaders in the dental hygiene profession. One environment for such training would be in a specialty private practice setting, specifically in an orthodontic or periodontal practice while at the same time reinforcing linkages with the college program and developing new linkages with a university program through a research project.
This article outlines the framework for one such residency program, the first of its kind, focused on periodontics and implant dentistry for high potential new graduates of the Dental Hygiene Program. This 12-month Dental Hygiene Residency program is offered in a private specialty practice setting and is designed to build on the many clinical skills and background knowledge the new graduate gains during their tenure. In addition to clinical skills and evidence-based didactic learning, the residency program builds clinician confidence, strengthens communication and leadership ability and imprints the importance of functioning optimally in a team environment. Finally, the program also includes exposure to metrics of dental hygiene including: clinical effectiveness of treatment, patient satisfaction and meeting business objectives through established systems.
This program equips the resident with skills necessary for comprehensive advanced periodontal care, implant maintenance, radiography interpretation including cone beam computed tomography (CBCT), wound care, and providing treatment under sedation for the anxious patient. The resident is also involved in a practical research project and is expected to publish their findings by the end of the program. The mechanism by which the resident further develops skills and knowledge is though mentoring by master hygienists, surgical assistants and treatment coordinators. The resident is also mentored by a periodontist, research scientist, chief innovation officer and academic director. During the program, the resident not only acquires unique and very marketable skills, but also gains access to a wide network developed from exposure to an ecosystem which includes a private specialty practice, a biomedical research lab, global networking at international conferences and participation in industry collaborations. Being a member of an agile team further imprints the importance of stragility (strategic agility) and the responsibility of contributing to a positive work environment to maximize the effectiveness of the team. Furthermore, the development of written and verbal communication skills gives the resident a competitive advantage in whatever environment they subsequently wish to operate. Future pathways include returning to a hygiene college in a teaching capacity, or to further their training in an M.Sc. or Ph.D. program.
The program was launched with the H.A.V.E. competencies of agile leaders: humility, adaptation, vision and engagement. We recognized that to be agile, we needed to accept feedback and acknowledge that others know more than we do. We accepted that change is constant and that changing our minds based on new information is a strength rather than a weakness. Our clear vision of long-term direction (how do we best serve the patient of tomorrow) even in the face of short-term uncertainty guides us. Finally, there must be a culture of willingness to listen, to interact and communicate with internal and external stakeholders, combined with a strong sense of interest and curiosity in emerging trends.
Dental Hygiene Periodontal Residents in Action (A) Residents learn alongside senior and junior periodontal dental hygienists in an on-site, hands-on, hand instrumentation continuing education seminar led by Mrs. Anna Pattison of the Pattison Institute of the University of Southern California; (B) Residents assisting with periodontal debridement on a patient under sedation, all under the supervision of the periodontist.
Residents in action.
To gain confidence and to understand the skills and knowledge required by a dental hygienist working in a periodontal practice, a complete immersion in all aspects of the periodontal practice is required. This is achieved through a full time commitment and an ambition to understand not only the hygiene component of the practice, but also the surgical, sedation and administration departments of a periodontal clinic. Familiarity and proficiency surrounding specialized clinical situations prepares the resident for the inevitable widening scope of hygiene that will support a more efficient and powerful collaboration.
To facilitate this, a number of milestones are defined at which time certain core competencies are measured. Once the required competencies have been achieved, the resident is given more responsibility and new skills are introduced along a timeline. Several of the competencies the resident acquires are unique to the residency (i.e., optimized time spent with each instrument during sanative and recall appointments, post-operative wound care strategies, treatment under conscious sedation and calculus identification using CBCT.
The resident shadows all staff members with rotations (in two week blocks) through the Dental Hygiene, Surgery, Sterilization and Administrative departments. During this time the resident attends all new patient comprehensive examinations and assist the hygienists during these appointments. This includes developing and practicing skills for taking dental and medical histories. The resident learns to use the dental management software and assists in the compilation of data for the radiographic and periodontal reports. They also learn about wound care by observing all post-operative appointments. The resident is instructed and coached on how to maintain and sharpen hygiene instruments and they gain competency in instrument sharpening by the end of the third month. Digital radiography skills and radiographic interpretation are also measured as is the ability to take a full mouth series. Preparing an accurate interpretation of the series is also a core competency. The resident practices half of a day to one-day per week treating well-maintained periodontal patients. In addition, there is a directed reading program and didactic assignments in dental anatomy and pharmacology culminating in a presentation to the staff and local dental society. Presentation skills are developed through practice and feedback. The resident also begins a research program in partnership with a professor at a nearby university with a focused clinical question. For example, the research project for the current resident is to determine if higher intakes of foods, food components and nutrients known to have osteogenic and immunomodulatory effects are associated with improved clinical outcomes: reduce probing depth, fewer areas of bleeding upon provocation, and attenuated expression of inflammatory markers.
New skills during this stage include independent preparation of comprehensive periodontal examination reports and mastering a clinical algorithm for dental implant maintenance. The resident sees well-maintained periodontal patients, post-operative patients for suture removal and implant maintenance patients for approximately one to two days/week. They also see patients with the periodontist for consultations beginning with comprehensive periodontal examinations. Once they have developed an understanding of all aspects of this type of consultation, they are required to achieve competency consultations surrounding muco-gingival grafting, connective tissue grafting, crown lengthening, implants and bone grafting, peri-implantitis management, pre-prosthetic surgery and oral pathology. During the time they are developing an understanding of these procedures they will be expected to be in the operating room and assisting with each type of surgery. Also during this time, under the supervision of a senior hygienist, the resident will be treating patients with sanative therapy (the most difficult and advanced non-surgical therapy a hygienist is able to provide). The resident is expected to work with each of the senior hygienists and by the end of the ninth month have completed a sanative case to a level of competency acceptable to each of these hygienists. Once this has been achieved, the resident will be permitted to see sanative patients without the supervision of a senior hygienist. The results of every sanative therapy are always evaluated by the periodontist.
During this time, the resident is expected to understand all of the tasks of a hygienist working in a specialty periodontal clinic and is coached on the areas they feel they still require the most development. The resident sees patients for periodontal maintenance and sanative therapy four days per week. The resident is also expected to publish the results of their research project and present these findings at an international dental meeting.
At the end of the program the resident will be equipped to enter private practice with a significant competitive advantage. They will also be ready to enter graduate school if they so choose, having already made connections during the residency program. The resident will have also developed skills and knowledge which would be useful to any college dental hygiene program looking for well-trained and networked clinicians as future faculty members.
To survive in a VUCA world, planning well and a brilliant execution is expected but not enough to thrive. We must teach how to sense and respond and subsequently how to learn and adapt. By collectively defining and communicating this strategy and innovating programs that foster the creation of wide and unique eco-systems, we make progress. By leading horizontally and establishing faster collaborations and connections among organizations we will find opportunity in the VUCA world to positively disrupt the status quo and above all, be better able to support the patients of the future. OH
Oral Health welcomes this original article.
Dr. Fritz is a full-time periodontist in Fonthill, ON and is on a mission to redefine the way people think about periodontal and implant wellness. He leads an extraordinary, collaborative, empowered team of clinicians, makers, scientists and artists who are all working together to innovate the dental specialty of periodontics and redefine the patient experience.
As Dean of the Community of Health Sciences department at Niagara College in Niagara, ON, Dean Carolyn Triemstra is committed to the process surrounding the development of students into leading professionals and productive community members. She believes in dynamic, comprehensive and hands-on learning as an approach for transforming students into successful graduates.
Dr. Amanda B. Longo is the Chief Innovation Officer and Director of Strategy of a private specialty surgical centre in Fonthill, ON. Dr. Longo combines deep clinical and scientific knowledge with a vast network of internal and external stakeholders to raise the patient experience, ignite team spirit and redefine engagement in periodontology.
Taylor Sparrow is a full-time registered dental hygienist and the first to complete the Dental Hygiene Periodontal Residency program in Fonthill, ON. She is a recent top graduate of Niagara College with a laser focus on continued learning and improvement. Taylor is currently pursuing her Master’s degree in the Department of Health Sciences at Brock University with long-term goals rooted in academia and knowledge mobilization.
Dr. Wendy Ward is a Professor of Kinesiology and Health Sciences at Brock University. She is a Canada Research Chair in Bone and Muscle Development and mentors an extensive research team of undergraduate and graduate students. Dr. Ward leads her research initiative with foresight and innovation and has graduated a network of professionals who have reached and continue to push the limits of the status quo.
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