The D-2 Experience V

As I delve deeper into my last semester as a D-2 student, I feel like spurting fourth another opinionated post about the curriculum this spring. My last post on this matter pretty much outlined my schedule – now I can actually give some thoughts on the courses themselves, after about 6 weeks of exposure.

First off, compared to last semester – things feel much less hectic..in certain ways. For example, I feel like we get a lot of random time off this semester. The D-4s have their boards coming up, which also means they practice with ‘mock boards.’ This gives us a few afternoons/mornings off. The midwinter meeting is coming up which essentially grants us a 4-day weekend. Then spring break is thrown into the mix for good measure. Compare this with last semester, in which we had three days off ALL semester (including thanksgiving). Just getting those little breaks helps a lot – although one could also argue that it makes you lazier and less compelled to do school work.

However, no semester of dental school is ‘light’ or ‘easy’ and there is plenty of random crap we have to do. This semester has definitely topped the list of papers/projects required:

Endo case presentation in which we have to make a PowerPoint presentation based off of a patient we assisted with that required endo diagnostic testing/treatment planning.

Patient portfolio: minimum 10 page typed paper answering an assortment of questions in regards to our first COE patient.

Chart audits: we get to audit charts at some point this semester..fun

Clinic and research Day paper: Just a random assignment that takes up time to complete which is supposed to prove we showed up for clinic/research day.

Mid-winter meeting: same as the C/R day paper..another waste of time. I would go regardless..now this just adds another bothersome task.

Business Report: I don’t know what this is..but apparently we have to do one at some point this semester.

Communications Reflection: Tape-record yourself interviewing a patient and then write a ‘reflection’ on the experience.

Two classes also have EBD papers/presentations…sigh.

I’m sure I’m forgetting some stuff..but this is just to give you the basic idea of all these assorted ‘extras’ we have to do. None of it is really that hard…just easy to forget about..which is not good.

Now onto the actual schedule:

Treatment Planning: This course would have been far more useful last semester..or even over the summer. It is going over stuff we have already had to teach ourselves in order to survive in the clinics. Granted it will probably be more helpful once we start tx planning mock cases..but right now it is a very dull lecture-based class.

Comp Care IIC - Implants: I was most excited about this class – but now I am less than thrilled. It is clear that this module has not been done for many years as it is rather haphazard and unorganized. I don’t like courses that rely on blackboard to post all the lecture material and then proceed to not post half the crap..or post it weeks after we had the lecture. It is really hard to take notes on a lecture that is almost all pictures with no reference material to write on. The first quiz we had was really easy; the second one was ridiculously difficult in comparison. They are also unannounced which is the biggest testament to BS. No sane person has enough time to study every course every night to prepare for pop-quizzes. You need to be able to shift focus as necessary…guess that isn’t how everyone thinks.

I think things will get better now because we have ‘all day lab sessions’ which = no lectures. Unfortunately there is no lab manual or reference material as to exactly what we are doing in these labs..so you pretty much go in blind praying you figure things out. They technically did talk about the lab sessions prior to going..but it was not done effectively..and again – not posted online.

I won’t bitch too much though, because I am managing to learn a lot – I just am not enjoying the course layout..but I guess the directors can only work with the time they get.

The other 60% of our comp care grade is decided on our clinic faculty evaluation and patient portfolio. I really have no idea how our faculty will evaluate us…. I really only have one patient willing to show up..and I hopefully will do some basic restorative on her by the end of the semester (crossing fingers).

I did get my patient in again last Monday..but she showed up late and I had to let an upperclassmen check her out for board lesions…so I didn’t manage to get through the entire perio evaluation…she is coming in again in two weeks. I hope to have a basic tx plan ready to go so I can at least give her a cleaning…then amalgam time!

We also have several P/F components (communications, rotations, ect).

Endo – We have two different endo courses this semester (although we won’t register for one of them until the summer). Basically one is clinical and the other is lectures. The clinical one involves us getting ‘endo experience’ points based on assisting upperclassmen/residents. We also have to present an endo diagnostic case scenario in front of faculty and peers. I have my case lined up..I just need to grab the file and make copies of the radiographs…then I can put the PowerPoint together.

The other course is identical to last semester without the lab component. We have the weekly reading assignments along with the weekly 10-questions T/F quiz. Getting old real fast.

Ortho - This class is giving me total nostalgic flashbacks. I had so much ortho tx done as a child, that seeing all this crap in a professional light is pretty cool. I may actually go back to my orthodontist and see if he’ll let me pull out my case file so I can see how jacked up I was (class III with posterior crossbite). Yea, I totally had the expander, face-max, Nance-appliance…not to mention braces. Ahhh those were the days. The course itself is ok…although I cannot stand some of the lab work…tracings cephs is headache inducing…and all the math/guessing involved is quickly turning me off to ortho as a potential career path. Endo still remains the only specialty of interest to me at this point.

Fixed Prosth. II – I actually like this class more than I did last semester. Mainly because we had two weeks off already (random reasons had us off on Wednesdays…it was awesome). The pacing seems more laid back and we seem to have less to do. We really are only learning how to do bridges..not much else. The performance exams have also been greatly reduced in terms of expectations compared to what the current D-3s did. They had to prepare and provisionalize a 3 unit bridge in ONE exam. We only have to prepare the teeth OR create the provisional (one per exam). This makes things much easier..although I can’t take it lightly as my performance exam average last semester was pitiful..gonna have to make a damn pretty provisional.

Oral Surgery – Not much to say..we have one 50 minute lecture each week..no quizzes..just two exams. Sort of interesting stuff…but some of those pictures are a bit too much for me at 8am.

Pharmacology - saving the best for last right? This class is like biochem all over again. Long boring lectures with little relevance to what a clinician NEEDS to know - not to mention how hard studying for this class is. At least during the D-1 year all we had to do was go home and study....now we have to manage patients, get tons of lab work done, write a bunch of papers/presentations, AND study for this horrible, horrible class.

So things seem less stressful at the moment. Fixed prosth I, dentures, and endo was such a deadly combo last semester that nothing really seems bad in comparison.

Time to get back to slacking off.

A Rarity

Yes, I finally am going to put forth a positive post that isn’t chalk-full of bitching and moaning..well, maybe a little. So as my life as the beleaguered D-2 continues, I find the clinics becoming more and more integrated with my routine. And for all my whining, I must admit that the school has done an admirable job at getting us exposed to the clinics bit by bit quite early. I couldn’t imagine diving right in as a D-3 without having any prior experience.

Let me elaborate. Many dental schools follow the strict formula of D-1 = didactic, (SUMMER BREAK) D-2 = pre-clinicals, D-3-4 = Clinical. Our first year was straight up didactic with a few pre-clinical courses. Because we go year-round here, the D-2 curriculum can have a good portion of clinic time while still filling in all the pre-clinical lab stuff. So during the summer of our D-2 year, we had an average of around one ½-day per week in the clinics. Granted, this was limited strictly to assisting upper-classmen, but it still got you exposed to a very different environment from the lecture halls/pre-clinic. How many dental students around the country can say they gave an IAN block to an actual patient before they had even been in school for 12 months? We also got sent on a few rotations (radiology/OS/ect.) I would wager we are in the minority on such experiences. We weren’t graded on anything outside of attendance.

So once we hit the fall semester, we were allocated a very small pool of patients. This is where things began to get quite different depending on the luck of the draw. Some of my classmates were doing all out restorative procedures, while others were stuck struggling to get just ONE to show up for an appointment (like me). We had one full day each week devoted entirely towards clinical activity. So even if we couldn’t get patients in, there was still plenty to do/learn. Even by working with upper-classmen, you start to get a feel for the clinical faculty as well as all the bullshit red-tape one must wade through to get ANYTHING accomplished. We had a few rotations, similar to the summer semester. Again, we were really only graded on showing up.

Finally, the spring semester of D-2 fun is upon me along with my last chance to get as comfortable as possible with how zany the clinics tend to be. We now have 1.5 days of clinical activity. Usually 0.5-1 of those days each week is spent on rotation (namely because there really aren’t enough chairs in the clinics for all of us mixed in with the upper classmen.) The rotations seem a lot more in depth now. For example, I spent every Tuesday afternoon during January on a radiology rotation. I now feel marginally comfortable taking radiographs on real patients. I start my Pedo block tomorrow afternoon…kids..ugh.

The only stress is that we are now expected to accomplish things and are graded on performance. This is scary in that it is still relatively difficult to get patients. However, once the D-4’s get closer to graduation, I’m sure they will start piling in. Adding that strain of grading is good though, because it is just edging us a tad bit closer to how full time clinic semesters will be.

I guess I am so upbeat about all this clinic stuff right now because things have actually been working out the last few weeks. I have been learning a ton (even without my own patients). Although today, I FINALLY got one in. She was freshly screened and had ZERO work done on her at the school. In other words, this wasn’t the scraps from another student – this is my own patient – starting from scratch.

As I was setting up my chair and checking out equipment, things just felt unreal. Here I am, about half-way through my 24th year of life – getting ready to do some REAL dentistry all on my own.

So what did I do exactly? Disclaimer: If you aren’t in dental school, you may really want to ignore the rest of this post although I do try to explain things when possible.

The first appointment for a new patient is known as the complete oral exam (COE). The COE encompasses a full medical history, dental history, clinical exam (extra- and intra-oral), risk factor evaluation, full electronic odontogram charting (marking where decay is for example), photographs, radiographs, and impressions. It sounds like a lot – and it IS..especially for someone who has never run through the entire process solo before. Granted, radiographs are usually taken care of prior to the appt. – but my patient only needed 4 bitewings, so I just did them myself rather than waste time sending her to radiology. I got EVERYTHING done except the impressions. I just plum ran out of time. It FLIES by – which is in stark contrast to the grueling 4 hours of lecture I had in the morning.

I also had to tape-record myself doing the initial medical history for a communications course. That just made me even more self-conscious. Ahhh dental school.

Now my patient was only 19; and very mellow – this is good. Starting with nice patients will make dealing with the crazy ones easier down the road. So I do the med hx. She is anemic, and has a latex allergy – that’s it. This was nice, because I hate looking up all the random meds that most patients are on. So far so good, now move on to the dental history. This portion of the exam seems a bit redundant and stupid at times. A lot of the questions are rehashed versions of an earlier question. For example, “why are you seeking treatment at this school” and “what is the chief complaint” are kind of the same thing. Seeing as this was my first time, I asked EVERY question. Even the useless ‘corah anxiety scale’ questions which attempts to quantify how scared a patient is when they visit the dentist.

So here is where I slow down..because I want to actually face the patient – I can’t sit at the computer (which is where all our charting/history info is done). So I am just writing it down on a pad of paper. Once I finish the med and dent histories..I have to go back to the computer and FILL it all out. If there were more spare chairs in the clinic, I would just have the patient sit in one of those first and I could sit at the computer and still be able to talk face to face.

So I go through risk factors next, such as smoking/alcohol/sugar intake/blah/blah. FINALLY I begin the exam. The extra-oral exam seemed completely normal and I flew through that. Now I get inside her mouth (about 1 hour into the appointment). She has all these text book findings that I am almost giddy with excitement. She had a palatal torus and two mandibular tori (these are bony protrusions that are completely normal – not anything to write about…oops). She also had a ridiculously high lingual frenum (thing that attaches tongue to floor of mouth) which pretty much doesn’t allow her tongue much movement. I still am not comfortable evaluating tonsils…I just don’t know what the hell is abnormal. I hope I’m not missing anything obvious.

So after all this..I have to go BACK to the computer and chart all my findings. Half my time was spent just mindlessly typing away. So now the really long part starts – charting all the findings on her teeth. This includes noting minutia such as rotation, drift, and tilt of the teeth along with restorations, active carious lesions, as well as good old fashioned giant gaping holes. Now this patient also was having pain in her lower left quadrant. I naturally was drawn to the molar with the HUGE amalgam sitting on it. But it seemed stable – and she pointed to the tooth behind it. Because her brushing was pretty bad, a whole mess of plaque had completely filled in the hole that was fairly large sitting on the front side of her 2nd molar. I completely missed it my first time through! I marked it down and called for my instructor to check my progress. She found a spots I had not marked along with the few that I had. Seeing as we get no training in actually feeling for caries, I wasn’t too disappointed in my first honest attempt.

Now before my instructor could really complete her own assessment, I had to get the four radiographs. I prefer using the rings (because they are harder to screw up) but this patient also had third molars. Getting that film all the way to the back of her gullet was no easy task. I still managed to turn out 4 decent x-rays in the first attempt. I didn’t quite get the full thirds, but the interproximals is what we really are looking at. There was also some slight overlapping (indicating my film was a bit angled) but it wasn’t enough to really distort the image.

So now the rays are done, my instructor returns and points out a few more carious lesions to add to my odontogram. At this point, it is nearly 4:30 which is that magical moment when all the clinical instructors vanish into thin air. I quickly typed up my essay-sized treatment note and got everything swiped (electronic signature) by my instructor. I luckily found a D-3 who was willing to quickly help me with taking photographs using the super-expensive camera that I was afraid of dropping the entire time. Basically these photographs are good to have when working on the case when the patient is absent – it also allows other faculty to get a better idea of what is going on. Finally – the pictures are most important when preparing case presentations and patient portfolios. Basically we take a few head on shots, a profile, and some intra-oral pics using cheek retractors and mirrors. After I get the patient on her way, I return to upload to the photos ..but the damn batteries had died. Sterilization closes at 5:00pm, it’s 4:50. I run over to the window, get a new battery – run back. Upload everything, delete the camera photos, and barely get the thing turned back in on time.

Cutting it close I know. So I clean up, and finally get out around 5:15. It was a long afternoon, but a good one. I still need to make some impressions, but other than that – I was pretty satisfied with my efficiency. Speed is one of my main concerns at this point – so at least I can handle the basic crap.

I know this post was pretty technical and boring – but this really was a bit of a dental landmark for me, and worthy of remembrance, if for nobody else but myself. I will probably follow this case with my writing as it is my first stab at treatment planning and performing those treatments from start to finish.

Stay tuned for part II, I have her coming back next Monday for the periodontal evaluation…fun fun.