Equality,Diversity and Inclusion in Dentistry Needs Leadership

Diversity within admissions

On superficial inspection, it would be easy to congratulate ourselves when thinking about our ability to attract, train and retain a diverse profession. Comparing ourselves to other industries such as financial services, the media or the arts, would give us further cause for celebration. Indeed, in 2017, a report from the policy exchange entitled The Two Sides of Diversity corroborates this. ¹ It reported that dentistry is in fact the second most ethnically diverse occupation in England and Wales, with medicine in fourth place.

The foundations of this diversity are, of course, laid at an undergraduate level. A recent study ² by Patricia Neville revealed that between 2010-2014, an average of 44% of applicants to UK dental schools were British Asians. 37% of those individuals were accepted. Comparing the BAME acceptance rates to those of their white counterparts in the same period is illuminating. Whilst 41.6% of dental school applicants were white in this period, a higher proportion (52%) of this group were accepted. If we delineate the BAME figures further, we see a glaring disparity in the presence of black students. In UK dental schools, they represent only 2% of its intake. ² If we view career progression in dentistry as a leaky pipeline ³ with various checkpoints which individuals are susceptible to fall out from, it is at this admissions checkpoint where minorities are first vulnerable.

So, what accounts for this disparity?

The reasons behind this disparity are multifactorial but can broadly be split into systemic and institutional. Whilst the systemic reasons are beyond the scope of this article, a significant strand to the institutional argument is the lack of diversity within admission committees themselves. The American Dental Education Association (ADEA) explicitly acknowledged this in 2011 when they chose to disseminate national guidance. ⁴ In this, they highlight the importance of having a diverse leadership admission committee to better reflect the diversity of the undergraduate applicants. Combined with the lack of diversity at admission level is arguably an overreliance on examination results and standardised tests (e.g., University Clinical Aptitude Test, UCAT) and not taking a holistic approach. This can exclude or disadvantage candidates from different backgrounds. The dentist and educationalist, Sheila Price, has clearly argued for a more holistic admission assessment that ‘balances the quantitative and qualitative qualities of a candidate’. ⁵ It also emphasises the need to recognise non-cognitive variables such as the ability to ‘sustain academic achievement with competing priorities’ ⁵ that dental schools should take into consideration. Price goes on to argue that admission committees could combine ‘this comprehensive review of candidates into the case for promoting cross-cultural understanding and enhanced competence to provide care to patients from diverse backgrounds’. ⁵

A compounding factor is one of ‘role models’ and their importance in providing the confidence for members of the BAME community to pursue careers in dentistry. Osama and Gallagher ⁶ explored the views of early career dentists on positive and negative role models across key phases in their professional development and the influence of these role models. Although diversity was not exclusively explored in this study, it highlights that early career dentists have benefited overwhelmingly from positive role models. It is not a stretch to imagine that role models of colour reflecting the applicants’ would increase this positive effect. This might account for the disparity in the lack of black students at dental school when compared with Asian and White students.

In an effort to augment the positive effect of role models, UK medical and dental schools have seen the introduction of widening participation efforts with formal outreach programs. Whilst initially relatively limited in their scope, widening participation is now a key element of the majority of UK medical and dental school. For example, at Birmingham dental school, they have a well-established range of activities that bring pupils from all ages onto campus. Significantly, some of the activities and programmes have specific eligibility criteria that prioritise students from underrepresented groups. ⁷ These efforts should be applauded. It is arguable that they should be consolidated across universities with binding commitments from UK vice chancellors.

Diversity within the curriculum

From debates around tearing down statues to the role of Winston Churchill, no aspect has been spared in the UK’s recent conversation about colonisation and empire. This has included medical and dental education. Those in charge of determining the curriculum of medical and dental schools have begun to think about how they can ‘decolonise’ the curriculum. ⁸ Whilst such terms may sound dramatic, they simply acknowledge how the authors of a medical or dental education can affect the teaching and subsequent practise of it. Hartland and Larkai ⁸ suggest that we should reflect on the way we discuss and present race within our teaching. This could include counteracting stereotypes within learning materials or encouraging students to consider racial bias in their critical thinking. This approach is starting to bear fruit. In 2020, Malone Mukwende, a medical student from St George’s, University of London, was progressive in creating a dermatology resource that focused exclusively on the presentation of common skin lesions in skin tones which were not white. ⁹ The introduction of this resource in UK medical schools will undoubtedly improve clinical detections of pathological skin lesions in non-white patients.

UK dental schools could benefit from similar initiatives. A study looking at unconscious racial bias by dentists when making decisions on tooth restorability observed a greater likelihood of extraction for Black patients presenting with a broken-down tooth and symptoms of irreversible pulpitis. ¹⁰ In these situations, it is impossible to exclude a subconscious evaluation of the patient’s race from the clinician’s judgment. By creating explicit resources which focus on the role bias can play in clinical decision, outcomes for patients of all backgrounds will be placed on clinical merit alone.

Diversity within academia

As we rise through the dental profession, we see further impact of the leaky pipeline and underrepresentation of BAME individuals in senior academic roles. BAME clinical academics are underrepresented at both professorial and senior lecturer grades. ¹¹ In 2017, 72% of clinical academics identified as White whilst 25% identified as BAME. The discrepancies between White and BAME clinical academics differ from that of the GDC’s specialist register, with 52% of registrants identifying as White, and 31% as BAME. ¹¹ When looking at ethnic profile by academic grade, the data is more illuminating. It demonstrates that as the level of seniority increases, the proportion of those who identify as white also increases. BAME clinical academics are most under-represented at Professorial and Reader/Senior Lecturer grade (8.5% and 16% respectively). At professorial level 91% of clinical academics identified as White. ¹¹

The effect of underrepresentation is twofold. First, as touched on earlier, a lack of senior academics from BAME backgrounds prevents a future lack of diversity through a dearth of obvious role models. There is an urgent need for further research to investigate why dentists from BAME backgrounds are not making the same progress in academic careers as their white colleagues. BAME dentists have traditionally chosen to pursue a career in general practice; is it possible that one of the reasons for this is their lack of career progression in academia?

Further, if the research agenda is set by a mono-cultural ethnic group, it potentially precludes exploration of research pieces which are relevant to a more diverse patient population. The fundamental way in which dentists in academia lead our profession is by producing research which shapes our clinical guidelines and practice.

Diversity in regulatory boards

In 2017, the GDC published a comprehensive analysis of the characteristics of the fitness to practise (FtP) data for the GDC. ¹² It stratifies FtP proceedings across key subgroups including sex, age, route to registration, primary qualification type and time on register. Its analysis in relation to ethnicity and FtP is revealing. In their subgroup analysis, they conclude that after controlling for all other factors, ethnicities recorded as Asian or Other are more likely to have been involved in FtP cases at all stages of their career compared to their white counterparts. The odds ratio recorded range from 1.05 to 1.40. ¹² Whilst this work is important in highlighting the discrepancies which exist with FtP proceedings, it does not go on to explore the reasons why this might be. Further work needs to be done in order to explore this disparity. Undoubtedly, systemic societal bias, conscious or not, will play a role in the decision to discipline more dentists of colour than white dentists. I would suggest that if those on fitness to practice panels were from a more racially and ethnically diverse group, this might dissipate bias and result in a fairer process for all dentists.

Diversity in executive positions

Interestingly, a recent article on the gender imbalance on UK dental boards ¹³ shows that there is marked variation in the percentage of women on dental boards. The make up the dental registrants is 50 % female. The NHS defines balanced boards as having between 40-60 % representation from each gender. The report found only 9 out of 23 organisations had more than 50% women. The conclusion was therefore that there is gender discrimination in the dental workplace. The authors did not explore the ethnic mix in UK dental boards, however, I believe some of the conclusions about lack of gender diversity in board membership can be extrapolated and applied to the lack of ethnic diversity on boards. Balance can be achieved through the appointment process rather than through election which will be slow and difficult without any role models. This area needs further investigation.

Diversity as a driver of innovation and success

Whilst we should promote a diverse and equitable profession as an end in and of itself, it is worth exploring some of the commercial implications of this as well. McKinsey & Company, a global management consulting firm, have produced a series of reports which make a business case for diversity. In their latest report, Diversity Wins, ¹⁴ their findings emerge from their largest ever data set. By analysing over 1000 companies from 15 countries, they have found a statistical correlation between diversity on executive teams and the likelihood of financial outperformance. ¹⁴ This has only strengthened over time. The reasons for this success are multifactorial but focus on equality of opportunity, fostering an environment of openness and embedding representation of diverse talents. For the dental profession, in which clinical excellence and a commercial acumen are required, the findings from McKinsey should encourage us all to promote EDI within senior leadership positions.

Where next?

If our key institutions have been a little sluggish in recognising the importance of EDI in our profession, 2020 galvanised a robust response. The GDC had already made a public commitment to EDI with the publication of their Equality, Diversity and Inclusion strategy 2017-2020. ¹⁵ In it, they acknowledge that EDI is a driver of standards in dental practice by maintaining the trust and confidence of all interest groups. Notwithstanding the legal requirements of equality legislation (e.g. Equality Act 2010), they recognise the rich diversity of the UK’s working population. In light of this diversity, they argue that it is imperative to have a workforce that mirrors the diversity of the communities in which we operate.

Another key development has been the establishment by the Office of the Chief Dental Officer (OCDO) of the Diversity in Dentistry Action Group (DDAG). ¹⁶ It was created in June 2020 in the wake of Black Lives Matter (BLM) events. Many of its aims refer to the key pillars of dentistry mentioned above. By ensuring a collective commitment to EDI from an institutional body it ‘facilitates a profession-wide commitment to drive positive action towards the race inclusion agenda’. ¹⁴

FGDP(UK) has also committed to inviting dental healthcare representatives from Black, Asian, Chinese and other minority groups to form a task force to identify the areas in dentistry which directly or indirectly disadvantage these groups. In December 2020, FGDP(UK), College of General Dentistry (CGDent) and the BDA launched a survey into discrimination in dentistry. ¹⁷

At board level, it is important that we educate ourselves about the issues that affect the various groups within the BAME community. To progress this, it is anticipated that FGDP(UK)/CGDent will arrange further equality and diversity training for our boards so that we are fully conversant with the issues and can implement positive and lasting change. The intention going forward is to collaborate with external stakeholders to actively promote equality, diversity and inclusivity in general dental practice as well as in the wider community.

Racial inequalities in dental education have already been highlighted and recommendations made to decolonise the dental curricula. ¹⁸ Decolonising curricula may have negative connotations by being misinterpreted as implying that the curricula is in some way inaccurate. I think a better description is widening the curricula to be inclusive as discussed by Sathnam Sanghera in Empire land. ¹⁹ Data from medical schools suggest that students tend to be resigned to accept that their career progression may require them to tolerate intimidation and that ethnic medical students are more likely to experience bullying and harassment. ²⁰ There is no data yet on the experiences of dental students. However, a webinar was held by FGDP(UK) and CGDent on 21 July 2020 and dental students spoke about their experiences of racism at dental school and in the associate positions they applied for.

The need for leadership

This article has considered career progression within the individual pillars of our profession and the ways in which diversity, or a lack thereof, is reflected in them. Diversity is often thought of as representation, but there is a danger that we merely look at numbers and tokenism and consider quotas as a tick box exercise. It is more important to achieve inclusion. This is about including a diverse group of people and integrating them in the organisation. This goes to the culture of an organisation and to achieve it will require robust leadership.

If the dental profession is to continue to enjoy its high standing with the general public and remain an accessible service for the majority, it needs both leadership to drive the EDI agenda and leadership which is itself inclusive, diverse and equitable. If these twin objectives are achieved, and leadership is truly embedded within the drive for EDI, we will continue to see improved patient outcomes for a diverse patient population.