The emergence of the IGen dentist and the implications for the workforce

The I Generation: IGen

IGens have many traits, many of which align with the GDC's findings above. They also possess many positive traits that need to be developed. They want stability, are conscientious, and a potential to earn a high income. Unlike the Millennials before, they have a realistic view of their abilities and are prepared to put the time in to work their way up a career pathway. Finally, they have a refreshing, and automatic respect for others.²

However, IGen are cautious, with a safety-first approach to life; they are not risk takers and they also have a tendency towards anxiety and depression, a lack of confidence, and are very risk averse. Safety in all things is the preferred state. These particular characteristics have caused this generation to be described as the ‘Snowflake Generation’,³ which has a negative connotation, but must be viewed in the light of the particular strengths of iGen discussed later. There have been significant societal influences that have shaped this generation during their formative years, and these should not be ignored or underplayed.

The most transformative factor is the internet. This is the first generation in history to have had instant access to the internet and, crucially, its open-ended availability 24 hours a day through their mobile phone.² This has revolutionized every part of life, including learning, socializing, shopping and entertainment. Social interaction and landmark life events driving relationships through the teen years are all delayed. It is likely that communication skills, often honed and refined in interaction with others during adolescence, essential to general practice, are also delayed as a result.²

Social media sites emerged, with Facebook in 2006 and Instagram in 2010, just as the IGen were reaching their teen years. The idea was to connect people; however, these ‘friendship’ sites became re-interpreted as comparison sites.⁴ The typical IGen will have spent many hours on sites such as Instagram and Facebook. It is this exposure that might well have inspired some of them to study dentistry. A quick scan on Instagram soon demonstrates the appeal; with digital cosmetic makeovers, computerized guided implant placements, facial aesthetics, slick cosmetic ‘workflows’ and much more. It looks like a glamorous, perfect world. With ‘Gurus’ happy to provide all the courses you could ever need to become an expert, just like them. What a person sees of another is a filtered view of how that individual wishes to portray themselves, which does not necessarily represent the truth, and the lens of what is ‘normal’ becomes distorted. Professionally, this use of sites, such as Instagram, is likely to continue; constantly comparing their work against that of others who inevitably appear ‘expert’, setting unrealistic standards that are seen daily.

There is clear evidence that overuse of the internet, specifically social media sites, during adolescence has a deeply profound psychological effect on development.² It is associated with increased anxiety, as well as a tendency to depression, which appears to negatively affect females more than males.² Recent figures show that 63% of the dental student intake in the UK comprises women.⁵

There are high entry requirements to study dentistry at a university within the UK. This is a challenge for all potential students and so, preparation starts in many households from an early age. This is sometimes initiated by upbringing, and the phrases ‘helicopter parent’ or ‘intensive parenting’ have been used within recent years. These phrases describe parents who are overly involved in their child's development – a physical overpresence, but alongside an emotional absence.²·⁶·⁷ In 2016, Hong et al⁸ showed that intensive parenting is related to maladaptive perfectionism, a constant self-criticism of their own work, and in 2020, Colin et al showed that 35% of UK dental students suffered from maladaptive perfectionism.⁹

In the intensely parented environment, there is often a culture of ‘safety-ism’. The child is viewed as fragile and lives in an environment where free play is discouraged. Instead, play is both organized and supervised by the parents. It is generally agreed that this style of parental upbringing negatively impacts upon the child and increases still further both anxiety and depression tendencies, as well as the child becoming more risk averse. ¹⁰

This ‘concerted cultivation’ is expensive in both time and money for the parents.¹¹ Extrapolating from research into university admissions, however, it is exactly this style of upbringing that is advantageous for applicants to be able to truthfully complete a personal statement, and to navigate the entry process successfully when applying for a dental degree.¹² These activities are likely to be more readily available to children of higher social classes and are in alignment with findings from Bedi and Gilthorpe¹³ who found that 80% dental graduates within the UK are likely to be from higher socio-economic backgrounds.

Applicants for medicine follow a similar trend, with applicants from higher socio-economic backgrounds being more likely to apply and to be more successful when they do. Those with a lower socio-economic background are less likely to apply and less likely to gain an offer to study medicine.¹⁴

Cleland et al¹² refer to the ‘criterion problem’ that faces medical schools in the selection of medical students: should selection criteria target likely performance at undergraduate level, or attempt to predict performance as a doctor? It appears that neither are particularly accurate. The same is likely to apply to dental students, but selection criteria definitely include personal statements and ‘A’ level grades.

The unintended consequence is that families tending towards concerted cultivation and helicoptering of their children can ‘manufacture’ ideal candidates to achieve access to a BDS, but who perhaps, once qualified, are not ideal candidates to cope with the stress levels in practice. Indeed, they might be the most vulnerable to stress and anxiety. Recognizing that most graduates enter general practice, and prevention is better than cure, it would seem prudent, if possible, to select for more robust personalities from the outset, recognizing both desirable and undesirable characteristics.

Dental Foundation Training, undertaken immediately following the BDS degree, attempts to prepare the fresh graduate for independent practice, and it is at this point that the new graduate can start to feel the pressures of actually practising dentistry.¹ The traits of the iGen towards stress and anxiety, overlaid with intensive parenting, creates individuals who are likely to have even less confidence and are more likely to suffer from anxiety and depression.^2,7

IGens and general practice

Dentistry is a stressful profession. A study conducted by Baldwin et al in 1999¹⁵ showed that 30% of dentists were stressed. Collin et al in 2019 showed that this figure had risen to over 43%.¹⁶ Alarmingly, 10% had considered suicide within the previous 12 months, an increase from 3.5% in 2008.¹⁷ It is important to remember that these figures relate to previous generations, members of which are generally accepted as being mentally robust.

The BDA reported in 2017 that both community dentists and GDPs are at an increased risk of occupational stress.¹⁸ The top stressors were identified to be fear of litigation and fear of regulation. Further evidence of this was found in a survey conducted by Dental Protection in 2018,¹⁹ which revealed that nine out of 10 graduates feared being sued by a patient.

A cohort of graduates that is innately more susceptible to stress, anxiety and depression is particularly vulnerable. This is concerning when increased stress in the workplace is known to increase still further, anxiety and depression.²⁰

The application of theoretical knowledge to a live, practical and potentially novel situation takes a degree of confidence, and the GDC recognizes this in their preparedness statement.¹ This is particularly so when it is an irreversible procedure, such as the removal of a tooth, or if it is a procedure on a patient who has not been met before. It requires the following belief:

The GDC launched its new ‘Standards for the Dental Team’ in 2013.²¹ All undergraduates will be very familiar with this core information. Section 7 of the Standards states the following:

These above phrases are all eminently suitable for the dentist who has already completed their training, but this can only be at the end of a career of ‘lifelong learning’. Even an experienced dentist attempting a procedure for the first time is unlikely to be both competent and confident. To the inexperienced learner who is neither confident nor competent, and who might be suffering from stress and possible anxiety, these requirements might become potential barriers to further development and learning, and only add to their stresses.

The practice of dentistry requires a very broad skill set that includes, but is not limited to, communication, confidence, manual dexterity and reflection. For any aspiring dentist of any generation, these are all skills that need to be practised and refined in a safe environment. This is particularly pertinent for the IGen dentist where safety comes first; both for the patient and their registration.

Once foundation training is completed, general practice with its overarching threat of litigation and regulation, and the added pressures of a target-driven NHS contract, is not the easiest place to refine skills, and can drive the individual into ‘defensive dentistry’.¹ The stressed, inexperienced and unsupported young dentist might lack the confidence to repeatedly practise relatively basic procedures. Possibly accompanied by flawed, negative reflective processes, this might lead them to a conclusion that they are not ready to move forwards with more complicated tasks and, ultimately, that dentistry is not the career choice for them.

There appears to be a perfect storm developing: a cohort of individuals with a predisposition for anxiety and depression, often selected from homes with an environment that concentrates these tendencies, who are entering a stressful profession that offers little or no support. Throughout, they have been provided with an education system that was designed for baby boomers.

However, there are signs of hope. IGen are also hard working, reliable, prepared to ‘put the time in’ when learning skills, open minded, pragmatic and have an automatic respect for others. These are excellent traits that bode well for patients and the dental team, but before we can develop these desirable characteristics, we need to reduce their stress levels or they will leave the profession.¹ We also need to recognize that the new IGens cannot change and be shoe-horned into the existing system. The profession must review not only how we select, educate and train young dentists, but also review the system in which they work.

Foundation dentistry

Compulsory foundation training in dentistry for inclusion onto an NHS list (Vocational Training) began in 1993.²³ The majority of the graduates at that time had been born between 1964 and 1980, the ‘X generation’, and whose attributes are quite different from the current cohort. They are well known for their ability to take negative feedback, are mentally robust and are strong team players. Useful traits for a dentist in general practice.

The training involved 30 study days of lectures, a weekly tutorial, and close supervision from a ‘trainer’. Both teaching and learning styles were a good fit for the X generation.

Foundation Training is available to all UK graduates automatically upon graduation. It is there to prepare them for NHS practice. There is an implicit assumption that all graduates can be trained to work in general NHS practice, and from the number of places available that all graduates will want to complete it.

However, applications to start Foundation training from UK graduates are at an all-time low, with up to 40 graduates failing to apply for Foundation Training in 2022.²⁴ It seems that either they are so disillusioned with their undergraduate experience they do not want to practice dentistry or that they want to be dentists but have no intention of ever working within the NHS. Hitherto this was never a possibility as there were few openings in private practice for a young dentist. However, with so many practices now pulling out of the NHS,²⁵ it is likely there are empty surgeries and potential employers, keen to provide desirable packages for graduates. At a stroke, for the young IGen dentist, many of their concerns about general practice are gone; namely, compliance with NHS regulations and system.¹⁹

The training that is required beyond Foundation Training depends on the individual, but recognizing their ‘late development’, perhaps the structure of Foundation Training itself needs to be reviewed. An extended period of training accompanied with salaried employment and vicarious liability would likely be seen by IGen as desirable.

IGen drivers for workplace selection

IGen will be likely to want extended training to be available within the practice and at least initially with continuous support. Feedback needs to be regular and in small encouraging portions, an annual review is too far off; it needs to be frequent.

The IGen is likely to expect their education and development programme to be personalized according to their developing skillset within their practice, and the practice needs to take an active role in their development. The organization that offers in house mentoring from trained personnel and recognizes formal development of their younger colleagues is likely to attract IGen.

It is important to recognize that currently a PDP for an associate is mainly ‘self-generated’ and as Kahneman states:²⁶ ‘we can be blind to the obvious and blind to our blindness’.

More than ever, the struggling associate needs professional help in identifying their learning needs, and more than ever, they are likely to grasp the offer.

We might be moving to a world of HR reviewing associates’ development, and tailoring courses and relevant training needs. These would not be limited to clinical issues and include teamworking, stress management, efficiency, communication skills and relationships with both patients and colleagues.

General practice

A central trait of the IGen is recognition that they are individuals, and before an IGen can accept an interview for a job in practice, they need to have seen an advert that appeals to them. Remember you have 8 seconds to get their interest.²⁷ Key words such as ‘tailored’ ‘bespoke’ or ‘personalized’ packages will be desirable.

IGens will be looking for a role that caters to their particular needs, so an interviewer needs to shift emphasis from how wonderful the organization is to exploration of what the applicant wants or needs in the role and then provide it. This will no doubt include further tailored development and mentoring and might form part of their associate agreement.

In business, the organizations that can demonstrate that their values align with those of the IGen will succeed, whether they are large corporates, small practices, employers, labs or even material suppliers.

In their work, the IGen will likely take a cautious approach, referring to senior practitioners or hospital whenever there are higher risks and constantly require reassurance of their decisions from colleagues. This would be borne out with increased referral rates to secondary care. The IGen employer might carry out internal monitoring of referral patterns and provide relevant training and guidance.

Any position that offers a safe supportive environment, especially one that has experienced practitioners willing to share knowledge and help, will be preferred. Long-term mentoring is likely to be desirable.

In practice, they need to be treated as individuals, with their individual career progression path in that particular practice mapped out. Using examples of patients seen at the practice by other colleagues, the IGen needs to be gently led by example, repeatedly visiting the edge of their particular ‘skills envelope’ knowing that they are fully supported if things don't not go as planned. The practice that can offer protracted, trained mentoring and support will attract the IGen.

We are now seeing an unprecedented rise in stress in the profession. This might be attributable to the NHS contract, the susceptibility of the graduates or both. Early detection at undergraduate level and stress management training might help, but prevention is better than cure. Perhaps we need to identify susceptibility to stress at selection?

Interestingly, there is currently no mapping of who qualified where, by what route, and whether they suffered stress later in their career.

The structure of general dental practice

Associates work for independent business or companies that are susceptible to any changes in the NHS contracts that they hold. Their incomes are generally pegged to the number of Units of Dental Activity they can perform and supplemented by any private income generated in addition. Their incomes vary from month to month, and they are responsible for their tax affairs.

The exception to this is at the start of a GDPs career they are employed as foundation dentists and some progress into Dental Core Training in secondary care where they remain employees of an NHS Trust. However, on entering practice they are likely to become self-employed.

Fundamentally the IGen probably do not want to be self-employed, especially in their ‘formative’ years when they feel exposed to the risk of litigation while they are still developing their skills and maturing. The British Dental Association regard self-employment of associates as the default position of dentists, but noted in a recent survey that there was ‘a noticeable level of interest in the benefits of employment among younger dentists.’²⁸

This, coupled with their lack of confidence, the need for further ‘safe’ training along with the perceived shield of vicarious liability offered by ‘employment’, are likely to be drivers to seek ‘employed status’.

If some of the above pressures of general practice were removed, and a welfare and development package offered, there would seem no reason why they would not be prepared to work at similar rates of pay to DCT as a salary with annual reviews and bonuses.

Teamwork

The modern dental practice is a team environment, and this is likely to grow further with the increase in DCP employment as defined in ‘Advancing dentistry.’²⁹

It is interesting that the instantly respectful nature for the individuality of others, is likely to make IGen more open minded to work with DCPs and in expanded teams, but they might initially lack experience of working in groups.

Training in this respect is normal practice in other industries, each employee is expected to work efficiently within the team, conforming to company protocols and values. Dentists, however, are different: once the surgery door is closed they often work to their own set of rules, often learned the hard way and possibly the wrong way. Anyone who ‘employs’ dentists must ask themselves if their dentists are working efficiently with their nurses, and have they been trained to do so or is it just an assumed skill? The profession might have something to learn from ‘Lean Service Provision’.³⁰

Extended training?

It is well established that IGens develop at a slower rate to previous generations, probably by as much as 2 years.² This is a significant difference from previous generations and is likely to be exposed when under pressure in practice.

General practice requires a diverse skillset for the aspiring dentist. Not least is the ability to strike rapport with a stranger in just a few moments. The young IGen lifestyle is generally not one of face-to-face social meetings with highly polished social skills. It is possible that they will be relatively inexperienced in this respect.

Consent is a fundamental of dental practice, and the quick to and fro of information that it involves is central to the process, again skills could be underdeveloped. All experienced dentists are aware of the subtleties of identifying a potentially disgruntled patient, poorly developed social skills might miss the social queues at early stages, allowing complaints to develop. Again, all areas for personalized development that need to be identified by someone for their PDP.

There is no substitute for maturing, the IGens need to develop at their own pace in a safe environment, and this environment needs to be in their workplace. An associate position in a practice with disinterested, jaded colleagues all concentrating on simply hitting targets is not the environment an IGen wants to work in. The IGen's lack of maturity and worldly experience could leave them vulnerable in their early years

Discussion

IGen represent a step change in generational progression. Unlike the millennials that preceded them they will not be able to easily adapt to a pre-existing system. It is for the system to change for them.

The IGen's innate requirements for safety in all things, especially if in an ‘uncaring’ environment could impact on their confidence to try new procedures. However, it must be recognized that although they will work hard, and ‘put the time in’ if they feel their safety-first approach to themselves and patients is threatened, it could drive them from the profession before they have even ‘learned’ it.

An associate position in general practice has hitherto been seen as a self-employed role with the individual responsible for their own professional development and indemnity. Their mental health and personal development is often not even considered by the organization they are working for.

A paradigm shift from each self employed individual having to do everything for themselves might be replaced with practice or company based package of CPD, indemnity, PAYE, mentoring, pastoral support and teamworking and surgery efficiency.

The introduction of the ‘employed status associate’ with bonuses for higher performance would carry with it a responsibility for the mental welfare of the employee.

The GDC recognized that:

General practice might have to change to a point where the organization provides not only a salaried income, but a developmental pathway tailored to the individual with relevant training either in house or external, with staging points, reviews and constructive feedback of development, possibly delivered by a professional HR department. Failure to do so could risk associate retention.

Naturally, this, along with extra time to record notes and gain good consent will soak up precious resources within the practice. In light of the surge in mental health issues in health care workers, these aspects should be part of the metrics for the practice as an unhealthy workforce cannot provide a healthy service for patients.^17,31

In recent years there has been an increase in students attaining access to the undergraduate BDS course without the prerequisite ‘A’ levels. Further research is required to establish whether graduates who have taken a more self directed approach to their attainment of a BDS fare differently from those who progress through the more traditional channel.

Conclusion

With customized training, management change, a policy of nurturing the individual, and recognition that the young dentist is unaware of what they don't know, the innate attributes of the IGen will enable them to become successful and happy dentists able to provide a high level of care for their patients.

If the profession, the NHS and HEE are complacent in their approach, there could be a mental health crisis among young dentists, an exodus from the NHS and a subsequent fall in service provision for patients. The failure of up to 40 UK graduates to take up foundation Training places is a warning.²⁴

There is a paradigm shift away from the attitudes of a Boomer graduate. The IGen graduate will not tolerate disturbance of their work-life balance and will unhesitatingly ‘move on’ from providing services that they find stressful. This will include the avoidance of certain treatments, progression into complementary skills such as facial aesthetics, shorter working hours or even leaving the professional altogether.

It seems that the IGen have surveyed the landscape of Boomer-provided education and service provision and are starting to vote with their feet.

The sarcastic phrase used by IGen in the reluctant acceptance of a Boomer world; ‘OK Boomer’ would already seem to be going out of date, being replaced with ‘no way Boomer’.