Meet Derek, 52 years old. He has spent the past three decades dedicating himself to doing Dentistry. As he distractedly stares at the dregs at the bottom of his lukewarm tea, he despairs. His associate, Maya interrupts his preoccupied thoughts with assumed mundanity. He patronises her with a steely glare and a throwaway, dismissive instruction. He glances back down to the worrying letter of complaint that he holds in his nervous fingers, as his heart sinks into his boots.
The spiral of a dentists life-The sacred geometry of chance
“He deals the cards as a meditation
And those he plays never suspect
He doesn't play for the money he wins
He don't play for respect
He deals the cards to find the answer
The sacred geometry of chance
The hidden law of a probable outcome
The numbers lead a dance”
(The shape of my heart, STING)
I sometimes wonder what life would have been like if I hadn't become a dentist. Right from an early age I was tutored and moulded to champion scientific learning as the pinnacle of achievement. Arts subjects were sidelined in favour of scientific endeavours, being more “academic.” With increasing age came greater opportunity to explore scientific principles. The funny thing about science is that it is not quite what people think it might be. It is merely a way to organise ideas and discover patterns, documenting the sacred geometry of chance.
Dentistry is a mix of operative mechanical procedures to fulfil chance’s geometry with a balance between cost, risk and benefit. In my younger and less experienced view I perceived that dentistry would combine the 3 golden threads of carpentry, mechanics and communication skills. I never realised that dentistry would pose a never-ending trail of building up an evidence base over many years supposedly to contribute to a higher purpose. The most interesting part about this is that the destination is not the most important thing as there is no definable end point. There is no such thing as perfection in dentistry as nature incorporates imperfection and asymmetry. It is as much about the journey as anything else.
Dentistry provides a career path that creates a product of meandering experience rather than a portfolio career. One never knows when that golden nugget of information gleaned from a random source, in an unexpected moment will come in handy and will contribute to a successful treatment. One thing is for sure, sponges absorb and the glut of information that we have at our virtual fingertips, tempts us with its overwhelming volume. We can become enmeshes in a seemingly endless, torrential cascade of data. We learn by experience and piece together techniques and evidence to help us inform our patients’ choices.
I think back to the first time that I did an RCT. I was at dental school and had read up on the procedure and the tools and techniques used to carry it out. I had practised on some in vitro plastic and a handful of preserved extracted teeth. I reassured myself with a pocketful of mumbles such as promises of perching the perca within a professorial whisker of the apex. I had gained a basic knowledge of what I was supposed to achieve and broadly how to achieve it. I was then let loose to achieve gutta percha perfection in a real live patient. Suffice to say, my resulting RCT was not fantastic. I remember thinking that the patients who submit themselves to be experimented on by students must either be masochist, insane, desperate or a combination thereof.
The transition into being a real life practising dentist is a learning curve. How can these mainly academic skills be transformed into a practical livelihood as a dental professional. I am never quite sure whether to call the people that see me patients, clients or customers. Personally I prefer thinking of them as patients, it gives me a definable degree of professional separation.
How much does dentistry cost?
Let’s consider an RCT. We can work out the cost of materials, instruments, a proportion of buying an expensive rotary system and the expense of any specialist courses, training and regulation. We can add on an appropriate profit margin and come up with a cost to the patient for the procedure. Let's not ignore the cost also being, the time that the patient sacrifices to be present, tooth in mouth ready to be drilled.Perhaps most often overlooked ; a cost in terms of emotional turmoil caused by having the perceived worst procedure you can possibly have in dentistry.
Then we come to risk. What is the risk of success, what is the risk of failure? We often like to present the risk of success as a percentage. Is this meaningful? Should we also balance it with the risk of failure or do we shy away from that information as it might put our patients off. What is the risk relative to alternatives? ie. extraction and implant? Can we easily balance the risk and cost against the alternatives?
NO we find it really hard.
How do we express risk ? Should we use percentages? This tooth would have a 93% success rate over 10 years but because it has a curve in the mesial root I give it a 75% chance of survival. What does this actually mean? If we are not really sure what it means to us how can we then expect our patients to understand it? And more to the point, does it have any relevance to that particular tooth whether its successful treatment will be 100% or 0% specifically? Should we do a treatment or refer it out to a specialist where the cost risk benefit ratio will be skewed in a different way?
The last part of the equation would be BENEFIT. What benefit is there to the patient in retaining this tooth over losing it? A good way of explaining RCT is to say that it is the last resort for a tooth. This tooth has been filled, filled again with a larger filling, subsequently had an inlay, crowned and finally the nerve has died. This is now the only option and it's not certain that it will work, oh and by the way you will probably want to have a crown on the tooth afterwards as the tooth will become brittle and need protecting. If you opt for the quicker and cheaper option of a filling over an RCT, you might well lose the tooth anyway after all that hard work and immense effort.
No wonder the patient looks up with bewildered and puzzled eyes and says that their baby stole all the milk out of their teeth which is why, even though they smoke 20 a day, their periodontitis is not their fault, it must be genetic! Oh and root canal fillings give you cancer, I read a book about it once so it must be true!
Nothing can prepare you for entry into working practice. I had looked forward to a natural progression from student to VT to practitioner to associate to practice owner. After all, that is the accepted natural progression just like a dental nurse would expect to one day become a senior dental nurse, a stepping stone to becoming a practice manager. I do question whether our skill sets are universally applicable to such vastly different professional roles with their unique demands. The business processes, compliance and HR skills weren’t taught to me at dental school, maybe I would be lucky enough to drink them in and effortlessly absorb them with deliquescent finesse. Maybe not.
Why is it that I can’t just go to work, provide simple effective and lucrative treatments to healthy, cooperative and motivated patients that won’t ever complain as their expectations are so realistic that anything I do will seem like the best thing since sliced dentine?
Why is it that my patients don’t congratulate me on being clever, educated and knowledgeable about dentistry? Instead they want to lead their own treatment planning with a heady mix of doctor google, mythical health concepts and outdated baseless beliefs passed down from their ancestors harking back to an era where healthcare was largely misunderstood.
Why is it that my nurses and colleagues seem more interested in mostly other things, apart from me and my welfare. I am expected to care about every single one of them without ever making sarcastic, hurtful or any remarks that could even be remotely construed to be offensive in any way shape or form. In return for my caring for all my team, they seem much more interested in a protected lunch break/holidays/EastEnders/pets/whether something is pointedly someone else’s responsibility, in fact anything else.
I ask myself how I find myself here, 30 years on, exploring the sacred geometry of chance on a daily basis whilst looking down at myself flicking through the film script of my life, my clinical practice holds me in stasis. If I were to ask myself what I was doing this time last week, or this time last month, I would find it so hard to remember one detail of the patient I was seeing. What treatment was I doing? What was the apical length or shade of composite? I have no idea as the beat of the stream, of continual patients rolls on relentlessly by.
That is not to say that I don’t treat my patients to the best of my ability. I have taken courses, learnt techniques and purchased a range of equipment, tools and materials. I have decades of years of months of weeks of days of hours of treatment plans of patients and of experience. I have attempted to engage with each patient on a close, personal level, exploring their wants, needs, fears and anxieties enabling me to deliver quality treatment for them.
I have pursued science above all else to build a repository of learnt evidential practice from papers, articles, colleagues and experts. I have also secretly been using my own bank of anecdotal, not necessarily evidence-based, options to offer my patients, who choose to follow my own personal practice philosophy.
I relish the thought of a patient who takes me up on my recommendation simply because they trust me when I express my preference in their best interests. Somehow, even though I know there will be relative risk involvement, I relish the thought of being able to explore the sacred geometry of chance, the true heart that pumps, still alive in the barren wasteland of the everyday experience I have of my professional self, my angle of daily discomfort.
I have put layer upon layer of safeguarding in place to ensure patient safety and compliance to the nth degree. I have written and updated policies about policy updating and policy writing. I have put fences around fences to contain and protect the safety of my modern clinical practice. Is it expected that experiencing fear in a defensively reactive manner will enhance my clinical decision making? I am told that this is the way it should be, by regulators, managers and overseers.
When practising self-protective dentistry, I fear the options that I tend to offer my patients would be curtailed to leave a depleted range for the patient to choose from.
Vibrant experts with shiny faces will sing to a rapt audience about the latest innovations. They soil the megaphone that their on-paper status and flat strings of binary qualifications bring. Titles and silver spoon accomplishments often afford them this privilege. Their gleaming pictures of perfect results make me feel inadequate and I look deeper into the social network feed for results that are more realistic. I search but I can’t find them. How I wish I could view their mistakes and failures, that would certainly be truer and more worthwhile learning.
I look for inspiration and try to inspire my team, the relentless beat, the stream of unending needy patients, wears me down. Emotional exhaustion assassinates my inspiration.
Suddenly and unexpectedly a tooth dies for no other reason than the nerve just flops over and gives up. An abscess ensues. Never let the sun set on pus in the words of Elton John or something like that. Everybody loves the sunshine, but the pressure cooker of an apical infection has no release like crown down obturation. The sweet stench of relief you can recognize from across a room. The acute tang of onions and dead things in equal measure, the patient’s relief, the therapeutic release of trapped anaerobic death.
I want to say to my patient “please be thankful and don’t blame me, it was out of my control as your dentist”. But instead, I unintentionally distance myself from responsibility and my patient leaves feeling like I have provided poor care. I stay silent out of worry that an apology would be misconstrued as admitting liability. I wonder if perhaps, I could have done something to prevent this adverse outcome. I go home with a heavy yoke upon my shoulders, replaying the events of the day over and over again in cyclic PTSD.
When the darkness comes alive, I swear I won’t turn around to relive the shortcomings I have expressed in my quest to provide perfect dentistry. Protective self justification validates my redefinition of error and responsibility. I have never been completely satisfied with any dentistry I have done and can always find fault in whatever I have managed to achieve. The quest for perfection is tempered with the sacred geometry of chance. Dental perfection, my nemesis, the incorporation of nature’s imperfection. So, my skill has become to identify as an optical illusionist in order to create the appearance of perfection whilst incorporating nature’s imperfection.
Somehow this could only make sense to a Dentist.
The darkness descends and much wanted and needed sleep evades me, replaced by the cyclic reliving of how I could have done better, changed the incisal angle ever so slightly or just gone one more degree to the left. I have let my patient down, I haven’t achieved what I could have done and most of all, I am sorely disappointed in myself. It takes until the sparrow’s tweet for my fitful exhausted mind to be overcome by inevitable sleep, only a few hours prior to my 9 o’ clock patient in need, ready to demand my rushed appointment time and my fleeting, exhausted, spent attention span.
I comfort myself in the knowledge that I only have 10 years or so until retirement and my pension is building year on year, albeit slowly. The thought of ending up in a hospital bed, perhaps a cardiac ward seems a relief, the holiday I deserve, just the tonic, maybe with some dancing pink elephants for good measure. I continue to provide treatments for my patients in order to pay off the large sums I have dedicated in the equipment, tools and techniques that I have invested in, the tools of my trade. My professional status is bolstered by the title Dr . Although I sometimes feel status shamed that my doctor friends might see me as a barber surgeon, the saprophytic bottom feeder of the doctoring world.
I receive a letter addressed “Dear Doctor,” I am proud to be able to use that title, although medical surgeons prefer to avoid it as it demeans their status. I read through the letter and my heart sinks into my boots. I experience what is known as a heartsink moment. I have read about it in the dental papers. My patient has made a complaint about me, and I am cordially invited to submit my patient’s records to the regulator and the prosecuting legal acrimonious acronym. I contact my 3-letter acronym professional body for advice and phone my tryptically titled indemnity provider for help.
My mind whirls like a feverish dervish. Whilst skydiving down a steep ravine the only comfort I have is that the sharp rocks below me will eventually break my fall and I will lie battered and broken with nowhere further down to go. I don’t know how I will climb up the treacherous foreboding walls on my own. Luckily, I have built up a bank of goodwill with some of my close colleagues whom I hope will support and carry me back to my grindstone of dental slavery to do my time until I can hope to retire before I have my coronary. At least my heart attack would be mine, I would be prepared to do the same thing for my colleaugues without hesitation, that’s what dental friends are for. Unwavering white coated comraderie.
I often wonder where the week begins and ends. I fall from one day into the next, desperately trying to keep up with myself in a relentless stream of demands. Demanding patients, demanding staff members and desperate attempts despite feeling exhausted, to spend quality, meaningful time with my loved ones.Connecting to family members takes redoubling of effort through the acrid haze of emotional exhaustion and through intensely fragmented focus as a result of compassion fatigue.
I take a break. I can’t continue. I decide that things have got to change. I take time to gather my thoughts. I sit in a double fenced equine arena after the horse has bolted clutching at the shreds of clinical records and minimally protective CQC enforced consent forms. I wonder what I did wrong as I try to desperately recover from the relentless cumulative verbal assaults I have endured servicing my patients to the best of my abilities, navigating and tolerating a broken, outdated system of management.
Pavlovian learned helplessness.
I ask myself what I have done wrong, and I realise that it is more about how long this has been going on. The legal attack will not come for this acute incident but from the omission of the BPE and smoking cessation advice 5 years previous in my clinical records. The case assessor dental colleague has found a chink in the protective armour of contemporaneous notes. Characterization of patients as litigation hungry individuals may fall far short of the truth. Fuelled by the litigation hungry dentist lawyers, the sweet sickly scent of compensation fees, the ambulance chasers will get the firework display they crave, to fuel the Ferrari in the name of patient protection and marginalise the expendable cost of a dentist’s mental health and sacrificial career.
In hindsight, I have changed. Oh the wonders of professional reflection! After I treat my patients I just hope they either emigrate or die suddenly, somewhere remote from my clinic. I hope it will be before their treatment has a chance to fail or they have the opportunity to make a complaint or a claim against me. Let’s face it, sooner or later all dentistry is doomed to fail.
I have also taken the protective step of conscious deskilling. In this way I am ready for tomorrow, protective, catastrophising, anticipatory dentistry at its finest.
I am far from being beaten, my continued survival could be mistaken for resilience but in my heart I know it is just exhaustion coupled with no realistic, conceivable alternatives.
The pulsating beat of the continual stream of patients continues.
I put on my mask and take on my role, ready to greet, ready to listen and ready to treat.
For I am a dentist, that is the shape of my heart.
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