The multifactorial nature of dentistry admissions and career progression means that reliable research and tangible suggestions for improvement are limited. Low numbers of Black dental students make it more difficult to identify the specific challenges that affect their progression into the profession, whether this be at the point of obtaining the correct grades, lack of support in admissions or unconscious bias in the interview. A better understanding of the restrictions and barriers comes from those who applied; why were they successful or more importantly, unsuccessful?
Lack of role models
What makes us choose a career in dentistry? A qualitative study looking into the impact of role models in the early stages of a dentist’s career reported positive role models playing a significant influence in their professional development.22 With low representation, it is unlikely that any Black students will: have a family member in the profession; receive a talk at school from a Black DCP; or have a Black orthodontist fit their braces, with only 0.8% of UK orthodontists of Black ethnicity.20 Without professionals that can support and guide students, the continuing cycle of under-representation continues, where young Black British children can’t envision themselves becoming a dentist or DCP in the UK. By breaking this cycle, we can truly show that dentistry is open to everyone.
Training more Black dentists and DCPs will help to tangibly demonstrate to Black children what they can achieve. However, with the current low proportion of Black dental professionals, increasing the exposure of dentistry to children requires help from the majority. My clinical tutor vividly remembers how a ten-minute presentation from a local female dentist strongly influenced her decision to apply. Dentists and DCPs from all ethnicities can make a substantial difference to the diversity of applicants. Presentations to low socioeconomic schools or an online interview with a local school on careers day can help to present dentistry as an option to students interested in healthcare.
The study into role models in dentistry focused on dental core trainee (DCT) placements, where the junior dentists are exposed to more DCPs, academics and specialists than normally found in general dental practice.22 A commonly quoted example of local influences pushing us to aim higher is Roger Bannister’s four-minute mile.23 In the 1950s, it was thought to be impossible for anybody to run a mile in under four minutes, until the medical student Roger Bannister ran an impeccable 3 minutes and 59.4 seconds. Fast forward one year and a further three runners broke the four-minute mile in a single race! There was no sudden leap in human evolution or specialised trainers; merely the proverbial bar had been raised which allowed the collective mindset of runners to change.
As a fourth-year dental student, I have many positive role models in dentistry, from fellow students to dental nurses and dental tutors, some of whom work in general dental practice and have achievements outside of dentistry. I do not know what my career will hold, but meeting tutors who have additional degrees in law, business and other academic fields shows how being surrounded by role models can be incredibly inspiring and can open up your mind to the possibilities.
Aspirational role models can be close to home or distant luminaries. Fortunately, the numbers of BAME clinical dentistry academics has increased over the past decade, from 14% in 2005 to 27% in 2016; however, the under-representation still exists at the higher levels of professor, senior lecturer and researcher grades in the UK.9 On requesting an FOI report, of the 4,376 specialist dentists shown as registered with the GDC, only 74 are Black (1.7%), with nearly half within the oral surgery field (33).20 Interestingly, oral medicine is well represented with 4.3% of specialists identifying as Black, while the majority of specialities show under-representation with endodontists at 0.3%, prosthodontists at 0.2% and restorative dentists at 0.7%.20
Advances have been made in widening participation to dentistry, with a broader mix of students from mature, Asian ethnicity and state school backgrounds.17 However, research shows that measures still need to be focused on broadening the appeal of the career and supporting the admissions process for those who are Black, live outside of London and are from lower socioeconomic groups.9,17 Although dental school applications are consistently higher from London than other cities across the UK, this is not surprising as it has the greatest ethnic diversity with a high density of dental schools, therefore providing schoolchildren with more exposure to dentistry.9,17,21 I am aware of positive action following the BLM protests at my London dental school, where we have an anti-racism steering committee to actively review any racial bias in the curriculum and ensure the welfare of staff and students. However, with 83% of students coming from outside of London and personal reports of students sharing their experiences of racism in dental schools across the UK, it is important that these headlines do not deter potential applicants.21,24,25
Personally, I had limited exposure to dentistry, struggled to gain work experience and did not have any direct connections within the dental community – difficulties to which my Black friends and peers have also attested. Fortunately, when I expressed an interest in healthcare, a friend applying to medicine kindly lent me her book on undergraduate applications, but even with guidance I found on the internet, I was shocked to see other students bringing sculptures and drawings to the dental interview. Many universities do not explicitly outline the specific grading criteria or requirements for the interviews, so I felt intense pressure when asked: ‘Have you brought any evidence of your dexterity?’ On speaking to fellow dental students, this is advice that they commonly received via word of mouth from teachers, family and friends.
My tutor informs me that when I graduate, every dental foundation training and DCT post will have specific criteria for the written application and interview. I feel I would have benefited from this when applying to dental school. Had I known more about the interview, I would have felt less stress and therefore been able to present my true self more confidently. I understand that providing excessive preparatory information could decrease the integrity of the application process; however, the success of recruiting competent postgraduate DCTs and speciality trainee dentists proves that the provision of transparent criteria is viable. Specific essential and desirable criteria are clearly stated on Oriel, COPDEND and NHS Jobs websites, allowing applicants to reflect on their suitability, prepare their CV and collate supporting evidence.26,27,28
Mock interview videos available online are valuable to students who are unable to practise challenging interviews at school or at home. It may be difficult to find a teacher who can guide a student through their application, particularly if they have often moved schools. Videos created for prospective medical students at Cambridge University show that, even with tangible demonstrations, universities are still able to recruit the most high-achieving students.29 The scoring sheet used at interviews can be requested as an FOI enquiry, but it would be beneficial to have an open version on all dental school websites, along with instructional videos, to allow all students a fair opportunity.
Social media is widening the audience and capturing more prospective dental students, with groups such as the African & Caribbean Dental Association (ACDA),30 Budding Black Dentists31 and Melanin Medics,32 to name a few. The COVID-19 pandemic highlighted the growing dependence on the internet to deliver teaching and, unfortunately, increased the digital divide. This prompted the UK government to provide laptops to disadvantaged children, in order to prevent them falling further behind in their education.33 Nearly all UK children should therefore be able to access these online communities, which continue to grow and provide inspiring talks and interviews from Black dentists, which may become crucial in capturing students from minority ethnic groups.
Black students fare much worse in the undergraduate application process; as previously mentioned, low numbers of Black students apply to dentistry but even fewer gain a place, with 81% unsuccessful in 2014.21 In order to remove barriers associated with race, it is important to investigate why these applicants did not gain a place and what they subsequently went on to do. With the proportion of Black DCPs higher than Black dentists, are students underestimating their abilities before applying? Do the unsuccessful Black dentistry students consider other dental roles or instead lose hope with the profession altogether?
My dental tutor was fortunate with her application; her father was a dentist who gave her advice for her interviews and provided opportunities for her to shadow dentists and DCPs. Although guidance from a dental professional isn’t a necessity, it makes a big impact on a student’s application. It would be interesting to know whether the unsuccessful Black students had any qualitative guidance available, such as tips on preparation, past questions or mark schemes for dental interviews.
Correlations exist between university applications and a student’s ethnic, socioeconomic and regional background.21 The UK government states that Black people as a whole are the most likely to live in the most deprived 10% of UK neighbourhoods in relation to housing and services, leading to overlap of these detrimental factors.34 We cannot assume and stereotype students according to their skin colour; on an individual level, a white dental student may be facing more barriers than their Black peer, but it does mean that the chances of experiencing these barriers are higher if you are a Black person.
A scheme utilised by the University of Leeds offers additional qualitative support to UK students who fall under detrimental barriers – such as low household incomes, low-achieving high schools, first-generation applicants, living in areas with low progression to higher education – or those that have lived in public care that show academic potential.35 Students who demonstrate the ability to excel but have been marred by environmental factors are provided with a series of study skill workshops and short assignments marked by a university tutor, with full in-depth feedback on any topic they choose. Successful participants of the scheme who have shown an ability to work hard and have excellent aptitude receive a lower offer of ABB to dentistry, compared to AAA.
A key component of the Leeds scheme35 is the time and support provided by the dental academics. Providing this extra tuition enables a more level playing field for applicants; making the students prove that they are competent avoids positive discrimination. There is a drive to improve the diversity from within universities, but spreading the message and starting to provide this access nationwide has its challenges. It is, of course, unrealistic to suggest that only those who are under-represented hold the responsibility to push for these schemes nationwide, but by recognising that disparities exist and providing unconscious bias training for interviewers, any prejudice in the interview process for staff and students can be eliminated.
Financial constraints and debt are a real issue for many dental students, but with evidence showing that Black students are more likely to fall under previously discussed detrimental barriers, they are therefore more at risk of having financial limitations. To put this into perspective, the UK government reports that Mixed and Black households are the most likely out of all ethnicities to have a weekly income of less than £400 at 32% and 35%, respectively.36 Although application advice is available online, there is a prevalence of additional ‘getting into dentistry’ courses, mock interviews and clinical aptitude test guides, which can exceed £1,000; therefore, those from low socioeconomic backgrounds may find these additional barriers dissuading.
Although it is clear that financial struggles affect all ethnicities, a Black or Asian person under the age of 19 in full-time education is significantly more likely to live in persistently low-income households (16% and 27%, respectively) compared to white households (10%).36 In 2017, the BDA estimated that dental students in England who started in 2017/18 could graduate with £76,055 of debt.37 It has been shown that the increase in student fees to £9,000 in 2012, now £9,250 in 2020, resulted in a reduction of dentistry applicants.38,39 While student loans are means-tested and a limited number of bursaries do exist, a 2017 study highlighted the strong dependence on family financial support, with 77% reporting family contributions towards student expenses.38 Have these financial considerations led to fewer students from low-income households?
With the majority of dental schools in city-based campuses where facilities are spread over a wide area, high living and travel costs rule out studying in places such as London or Edinburgh for some prospective students. Many of my peers at school struggled to afford the travel and accommodation costs for interviews and therefore applied to local universities. Relocating to London from Wakefield increased the challenges that I have faced, from finding affordable accommodation to storing my belongings over the holidays due to luggage restrictions on the coach. Dentistry is an all-encompassing degree; therefore, balancing a part-time job may be unsustainable for some and even more difficult to find with the effects of COVID-19 on the hospitality sector. The sacrifices mean that I rarely visit home, only three times per year, and certainly push those from lower socioeconomic backgrounds away from applying to some dental schools.
High-achieving students from low socioeconomic backgrounds have been shown to underestimate their suitability for selective universities and generally apply to less prestigious institutions than richer peers with similar attainment.40 The Stormzy Scholarship introduced last year awards £18,000 per year to two Black UK students to attend Cambridge University.41 Encouraging and publicising high achievers undoubtedly motivates future applicants, seeing these prestigious institutions as more of an option to under-represented groups (Box 2).
Once at university, statistics on the performance of Black students, specifically in dental school, are limited. However, research in medical education has shown that students of minority ethnic groups, on average, perform significantly worse during their medical degrees, failing medical examinations more than twice as much than their white counterparts.42 This phenomenon is classified as ‘differential attainment’ and persists following graduation, with poorer outcomes seen in UK medical recruitment.42 Medicine and dentistry are competitive degrees, with all successful applicants possessing high cognitive abilities, so why are the students in minority ethnic groups struggling more than their peers in majority ethnic groups?
Further investigation into the specific successes and pitfalls of gaining a dentistry degree will help governing bodies and academic institutions to understand why Black under-representation in the dentistry workforce exists, along with differential attainment.9 Effective policies, guidelines and strategic planning to improve Black representation in dental school and beyond will require input from those of Black ethnicity to gain a qualitative understanding of the barriers. The BLM movement has highlighted the need for people to be listened to and heard; opinions may differ, but by working together, the diversification of the dental workforce will be successful.