Thursday, 9 October 2014

DF1 Diaries: My First Week in Practice





A bit delayed but I'd thought I would share what my first week was like out practising dentistry in the real world . After almost 5 months off, I was feeling pretty apprehensive the closer it got to September 1st!

I had briefly visited my practice a couple of weeks before starting. I had shadowed the previous DF1 trainee one morning and having a brief play with the computer system. So I felt reassured that at least I knew where to go on my first day and what my surgery looked like!

My practice had recently moved following the relocation of Barts Dental Institute to the Alexandria Wing of the Royal London Hospital, so there was a lot of organisation and unpacking happening around me and a lot of temporary arrangements in place as they adjusted to being in the new place.

The plus side of that was that I was in a brand new dental facility - you could still smell the fresh paint when you walked into the waiting room. I could set up the surgery exactly how I would like it and all  my equipment was up to date.

Not only did I have a new job environment to get to grips with, I was getting used to having to negotiate my way around a new city and not just any city: London.
I convinced myself I could walk to work everyday in order to avoid the tube which I had heard was an absolute nightmare at rush hour so I had worked out a route to work which would take me around 45 minutes.

The first few times I walked to work, I got lost. Even with google maps on my side. So it took me more like an hour to get to work - at least I had left myself plenty of time on my first day!
This also meant that by the time I got home each evening I was knackered and it was all I could do to cook dinner and collapse in bed!
I think 3 months of having no structure to my days or any regular exercise had taken its toll.


My First Day in Practice


Luckily for me, the first couple of hours of my first day was spent familiarising myself with my surgery, the computer system and generally how things were organised at my practice.
Other trainees on my scheme had been thrown head first into things with patients booked all day from 9am! A bit daunting and stressful for a first day!

Computerised notes were something for me to get used to. In Newcastle, all notes apart from those on Outreach clinics were in paper format. And even the computer systems I had looked at were different to the Exact programme used at my practice.
Since starting foundation training however, I have learnt that writing notes in a paper format at dental school had taught me how to write in depth records for each individual patient. Some other trainees who were used to using a computerised system have found it difficult to write satisfactory notes without a template and felt they could often miss out important details.

It was also strange being able to wear whatever I wanted. Well not anything, but at dental school I was used to a strict white tunic uniform policy - I had gone out especially and bought a bright blue tunic to match my dental chair to celebrate (white tunics are such a pain to keep clean!).

All the staff at my practice are super friendly, and were eager to answer even the silliest of questions (why isn't my ultrasonic working? Answer, because it wasn't plugged in!).
One of the best things about being out of the dental hospital is that you have your own nurse! 
And she'll honestly do anything for you - for the first week mine kept telling me off for things like taking off the patient's PPE myself or wiping excess composite on my glove because she had a paper towel there waiting for me.

So it came around to 11am on the first day and my first patient was sitting in the waiting room, ready for her new patient examination.
Nervous was an understatement. But once I had the patient in the chair and the mirror and probe in my hands, the nerves evaporated and it was just another examination like I was used to doing in dental school. The only difference was that I was in my own surgery, not in hospital.

You also have to learn to trust your clinical judgement. Your trainer is always there if you need them, but you've spent the last 5 years accumulating all this knowledge which is fresh your mind, trust it!
It was also hard to resist the urge to say to my patient 'Ok I'm just going to get my clinical tutor' just out of old habits.

Also, having to take your own radiographs.... remember how difficult you thought this was in dental school? When you are taking them for virtually every patient you will become a pro!


Settling In


After a few days I was beginning to get settled, getting into a routine with patients and knowing where things were in the practice.

I also learnt when to ask for help. This again comes down to trusting your clinical judgement but also knowing your limits; as the GDC would say, working within your remit.

For example, I knew that after a couple of unsuccessful attempts with impressions for immediate complete dentures, I needed to ask my trainer for help because the materials available in practice were different to what I was used to at dental school and I was struggling to manipulate them effectively.

My practice is busy, but still pretty chilled out so my trainer doesn't mind me wandering into his surgery to ask questions, or I can instant message him on the computer system. We have lots of little Buddah statues in each of the surgeries and in reception which perhaps promote our chilled out vibe!


One of the many Buddahs dotted around the practice hopefully helping the patients relax a bit!

My first week or so was pretty much just examinations - new patients and recalls, but one day I had to see my first dental emergency. I was expecting the worst.

But compared to some of the things I've seen at the emergency department at Newcastle dental hospital, it was pretty tame. A lost crown which turned out to be a fractured root beneath a post crown.
Feeling brave and after a discussion of treatment options with the patient, I decided to extract the root at the same appointment.
Thankfully, everything went well and the root came out pretty easily, but for those first few minutes my heart was racing and the 2 things that kept running through my head were don't fracture the root and don't shove the luxator into the patient's antrum!

In practice you also learn new perspectives on things and different treatment options which I hadn't considered in dental school.
For example, I observed my trainer placing a silver GIC core for a crown using post and dentine pins to retain it - he had warned the patient of the dubious prognosis for the crown before starting treatment.

I have also learnt you need to be transparent with patients when discussing treatment options and their prognoses especially since the patient is paying for treatment.
In Dental School, you could pretty much try anything and the patient wouldn't mind as they weren't coughing up the cash for it. However, if you are promising a patient you can provide them with a treatment, especially if it's band 3 and it then fails in a short space of time, the patient isn't going to be happy. Especially if you haven't warned them of the risk of it failing.

What I am now doing for each patient is talking through each of the treatment options with them going through risks, benefits and costs and letting the patient come to their own decision. Sometimes this may be against your clinical judgement but as long as you have explained everything to the patient and documented it in their notes then its the right treatment option for that patient.

Getting my head around the NHS banding system was also something that took me a few days and I initally relied heavily on the receptionist telling me what bands my patients fell into - especially if I was providing emergency treatment. One thing that really confused me was the amount of different treatments covered by band 2 - one small GIC that takes literally 5 minutes costs the patient the same as 2 extractions, a root canal and 8 fillings. And if I was working on a NHS contract, I could get the same 3 UDAs for both.

This hardly seems likely value for money for the patient and isn't a reflecting how much (or little) treatment you provide for patients. Whilst the UDA NHS contract does have some advantages over the old fee per item system, from my experience of it so far I'm not certain of how effective or fair it is.
But I won't go on about that much more - take a look at my recent post about NHS rules and regulations

Watch out for future posts from DF1 Diaries about some of the study days I've attended as well as an update in a couple of months time. 
How was your first week in practice as a DF1? Please share your experiences in the comments below!


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