Learning Part III: Clinical Dentistry

This is not a manual on how to do dentistry well. It is more of a philosophical piece on the specific role we all have as a clinician and what it takes to be that person.

Dentistry for most of us is a business. On one hand we have the need to advertise, promote and sell. On the other, we have the need to be self-sacrificing, putting patients’ needs first along with maxims like ‘under promise and over deliver’.

Fitting into the gap that sits between maximising profits (as all businesses should) and being an ethical clinician who ignores financial goals can mean wriggling yourself into quite a small space. For some it’s like squeezing an elephant into a wetsuit.

When we write ‘selling’, do not confuse this with a slimy  salesperson’s demeanour or Machiavellian pressure to make sales. Selling is the exchange of money for goods or services. Patients pay you for your service, which is the deployment of expertise in dentistry over a given time period.

Selling is ok. You just have to make sure what you sell is good value. Companies that sell products that customers value (phones, clothes, cosmetics, food) do well. Those that don’t, go bust.

Value is a key term here. A perception of value is what makes us spend our money, or time or energy. We value something, so we buy it. If we don’t value it, we don’t buy it – or become resentful if we are forced to buy it. The greater we value the item, the more money we gladly spend.

It’s always worth a quick reminder of what dental patients the world over value the most.

Number 1, since the age of the dinosaurs, is painless dentistry. Even if it’s not painless, your demonstrated and explained efforts to reduce or eliminate pain go a very long way.

Numbers 2-8 relate to your personality.

And 9 and 10, bringing up the rear, relate to your clinical work.

I bet many of you know the successful and wealthy dentist who can’t do dentistry very well. I also know many excellent dentists gifted with superb hand-piece skills and delicate light-fingered touch who barely make ends meet as patients don’t ‘feel’ they like them.

A friendly, empathic and just competent dentist will both out-earn and enjoy work more than a glum, monosyllabic expert dentist every day of the week.

But… what about  clinical standards? What is really good enough? I’m afraid I don’t believe all humans are equal. I cannot run as fast as Usain Bolt. So, by definition, ‘good enough’ has to be set at a comparatively moderate level. Remember, most people are average in a normally distributed data set. I guess all we really want from people we depend on is their best. If it’s their best, we can’t really expect any more; and being a patient showing disappointment with a dental result when you have done your absolute best is a simply dreadful outcome to face. I know this from personal experience.

Your best is simply that – the best you can offer. It is worth us noting that our best varies too. Bad  sleep, excess stress, too many inputs, too many outputs, time pressures, disrupted staff, broken A/C… any of these can influence you and what your current best is. There is seemingly a panoply of factors that diminish our best; and as such, our true and absolute best needs to be way better so that even on our worst days we are still good enough.

Am I competent? The answer to this stems from the specific competencies we need, and that means setting a standard for being competent for each one of them.

Humans aren’t very good judges of competency, but our experience is that most graduating dentists have some competencies when leaving dental school but lack many others. Where and when these holes in your clinical skill-book get filled is, as yet, unclear. We are good at recognising the extremes of true expertise and hopeless incompetency; but the middle is a grey area.

Do you think you are a good driver? Most people believe themselves to be better-than-average drivers and more skilful than most others on the road. Whereas in reality you are probably no worse and no better… just average.

What about singing? Again, in reality you are in all probability an average singer; but I expect, like me, you think you are really bad. We only compare ourselves to singers who publicly display their expertise.

So we judge ourselves wrongly for many skills. What about dental skills?

It’s hard to rely on external input – particularly social media, where you only get to compare with that person’s absolute best-ever outcomes. Social media is a pure highlight reel, yet everyone who posts has shameful secrets, bad days, naughty habits and moments they hide… just like you and me.

The truth is that actual competency, like integrity, comes from within.

The internally generated standard of competency we arbitrarily set is this: I believe I am competent at xxx, and, as such, I am happy to carry it out publicly and under the scrutiny of other dentists.

Harsh? Well, your driving is under the scrutiny of all other drivers. Perhaps your cooking. Perhaps your football skills. So boohoo, now show me your prep. Lol.

Are you happy to do that molar endo you did last week in front of me and a load of other dentists? Live? Explaining your decisions?

If you truly believe yourself competent then you may accept the invite. This is competency and this is a public display of ‘what you’ve got’. The reality of what occurs when a patient comes to you for treatment.

If you do not feel this way, then that must be stressful. Wanting to keep it hidden and out of sight.

Admittedly the propensity for dentists to criticise other dentists is a particularly bitter and rancid ingredient in this cocktail. Why the predilection for this unpleasant, judgmental and largely anonymous form of sabotage has come to be so prevalent is a discussion for another day. Perhaps an Aspire blog on the underlying psychology of this is called for, as it is well understood and has been emulated in other sectors.

So we have now our internal standard of competency. We can now choose which competencies we wish to gain. Molar endo? Anterior composites? Soft tissue handling? ID blocks?

There are many, but a ruthless internally generated standard setting is by far the most robust measure of achievement. An internal scorecard where you are a tough judge awarding yourself points.

If you want to get good, the first thing to do is know that you are currently bad and admit it. If you’re not willing to be crappy at something, you’ll never be good at anything.

Then get good by spending time up close with an existing expert. Copy them, practise, repeat, challenge, question, copy and repeat again and again and again. Any expert who isn’t comfortable with your challenges or your demand to see a live demonstration is a fraud and knows it. They react with anger and obscure avoidance as they don’t want to ‘drive in front of other drivers’.

Competent experts will demonstrate time and again and with seemingly no effort. The effort came during their learning process; they had failures and errors, but through steady improvement and ruthless integrity kept going until they felt able to perform publicly.

Most of you reading this are qualified. Make a written list of the procedures you want to do live (we won’t actually ever ask you to) that you currently can’t. This is moving you out of your comfort zone.

Now think about those words. Out of your comfort zone = uncomfortable = painful, perhaps!

So, doing this in an environment where you are supported, supervised and mentored is the best way possible. Once that skill is nailed, pick the next one off the list; and when that list is complete, make another.

Building deep clinical expertise takes time and a willingness to feel uncomfortable. It is worth it, however. Your authenticity in discussing said treatments comes across in your tone and body language to patients.

You can stop referring out. Most importantly, your career becomes interesting and the challenges keep you sharp and focussed. This brings vitality and energy to daily practice life.

Best of all, it means you get to treat and help more people. You can sell more! Ensure that former challenges become effortless victories and difficult cases become easy. You will find yourself forever seeking more knowledge and expert development.

With this approach, your stress goes down. When you receive your post-op endodontic radiographs with confidence as you already know the result will be great (as opposed to ‘hoping the image on screen is kind’), this is a good feeling. Adhesive dentistry is simply brilliant, and deploying it daily with erudite consultations and alacrity alongside a deft touch means your stress levels plummet. Yes, please!!

Key takeaway points for clinical dentistry:

• Be honest with yourself about your competencies
• Seek to be the eternal student – always learning, always improving
• As you gain competencies, broaden your clinical skillset menu
• Become as good as you wish the person treating you should be. Martin Kelleher wisely termed this the daughter test. He relates it more to ethical decision-making, but I know he would want an expert treating his children too!

The Aspire philosophy for dentists has always been to set a simple goal: A happy and healthy patient.

Happy: as they trust you, find you compassionate and kind as well as highly expert and dedicated.

Healthy: in that your dental treatment, be that preventative, elective or reparative, is brilliantly carried out and is predictable over time.

A happy healthy patient is an excellent friend to you.

The problem arises when these two aspirations come into conflict. For example, a patient asks for antibiotics but it isn’t clinically correct to prescribe them, e.g. cold sensitivity (as this would not make them healthy).

Or, for example, a patient wants veneers when ortho is clearly a better clinical option, and you just cannot justify damaging their teeth (unhealthy) to make them happy.

Or a patient doesn’t want to hear about their periodontal disease (and the concomitant treatment that may keep them healthy); they are upset by your mention of hygiene and periodontal care; but if you avoided mentioning these crucial points in order to keep them ‘happy’, this would be counterproductive to their health – as well as their happiness in the longer term.

The happy healthy patient is a balance, and we achieve this by eliminating patients who simply do not want to be both. I would describe such patients as toxic personalities and ‘hateful’ people with a bizarre and non-dental agenda. Through compassionate, clear communication, nearly all patients are keen to be both happy and healthy, and this is an excellent way to describe your intentions to them.

Then expertly deliver your care after you have realised your aspirations for competency. Then we have a fantastic job and are very lucky indeed.