Monday, February 2, 2009

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.