Rotation Vs Clinic

Another post? Hot damn. So as I’ve just started my fourth (and final) block of rotation, I have decided to follow up on old promises and discuss rotations in general. I participated in what is known in these parts as the ‘2x2’ rotation. Basically I spend about the same amount of time offsite as I do in the school during my final year. This has been an overall wonderful experience. My only major gripe is that I truly don’t want to be gone anymore at this point. Three blocks was enough. Now my presence at the school is pretty important because I have requirements to finish and boards patients to find.

However, the topic here is what’s the point of rotation? Now all the muckiddy mucks up top will say that the primary goal of extramural rotation is to help you develop a sense of how crappy health care is in this country and how many people are lacking dental care. I understand that is important. But let’s be realistic. As a student, all you care about is experience. You want to get as much dentistry under your belt before you get booted out into the real world. Your paying out the ass for it, why wouldn’t you? And honestly, while I have seen a lot of great people on these rotations that truly appreciate what they are receiving, I have definitely seen plenty of the ungrateful dregs of society that are abusing the system for all it is worth. Eye-opening either way.

So have I gotten a lot of experience? Of course. Has it all been as technically complex as some of the things I get to do at school? Hell no. So you still need both. At school, I am pretty much doing all my fixed and removable work at this point (crown, bridge, partials, etc). On rotation is almost exclusively directs, EXTs, exams, emergency. Now I have done the odd endo and crown off-site, but these are exceptions, not the standard.

My stance is that my overall experience is pretty damn well-rounded. I wouldn’t mind some more crown/bridge, but honestly, at the rate things get done at the school, I’d rather just continue to learn with my own materials and getting to choose my own lab.

So here is what I have completed on rotation to date (not everything, but most)

Total patients treated: 330

POE: 101

Emergency: 31

Prophy: 71

Sealants: 62

Amalgam 1 surf: 19

Amalgam 2 surf: 33

Amalgam 3 surf: 2

Resin 1 surf: 120

Resin 2 surf: 41

Resin 3 surf: 13

Resin 4 surf: 5

SS crown: 11

Pulpotomy: 12

Anterior Endo: 2

PFM crown: 1

EXT: 75

Surgical EXT: 5

Ok so that is most of it. This is over approximately 14 weeks of rotation (with a few short weeks in there due to holidays or school business). Now as a DENTAL STUDENT, this is a pretty meaty chunk of experience. I don’t know many dental students at other schools that have pulled 80 teeth by the time they graduate (I am around 150 by now including all my in school rotations). And I’m not saying this to brag or pat myself on the back. I’m saying this to put it in perspective. I am a practitioner that will want to do most of my own extractions without spending 6 years in an OMFS program. Getting as much experience before I graduate will only enhance this plan. More importantly, it allows me to see which types of EXTs I should refer. Same applies to working on kids. I plan to do a lot of my own pedo work, but I know the signs/symptoms of the cases that NEED to be referred. This knowledge is just as valuable as any of the technical skill I have amassed offsite.

Another extremely valuable asset to rotation is working with different people (assistants, hygienists, dentists). You begin to figure out what makes an assistant good, and conversely, what makes them absolutely worthless. You will find dentists that were not trained at UIC who will teach you techniques you never knew, or how to use some instrument that makes your amalgam carving look like a DaVinci. Again, you will also disagree with some of them, and while you can’t be some cocky-ass student, you make a mental note of what and why. While frustrating at times, it is intellectually stimulating as hell and ultimately makes you better because you can further define what you are as a dentist. When is staining no longer staining? When is all the caries truly gone? Does this need a crown? Would I want to even attempt this RCT? Again, the cognitive developments I have gained throughout these rotations have been equally important to any technical accomplishment.

Now rotation isn’t all sunshine and roses. Some days are truly unhelpful. Like the day you get stuck doing 6-9 prophys and zero restorative. But these are not as often as people claim (at least in my experience). The other issue again is managing what little time you have at the school. You find yourself giving your patient’s shorter leashes in terms of leniency. If they fail an appointment during one of my precious days left at the college, I pretty much instantly dismiss them at this point. You also get frustrated during boards time. I really need to be at the college to look for patients either via screening new or my own, all while squeezing my own patient pool in for their own appointments.

So like most everything in life, there are pros and cons. Overall, I feel these rotations have helped shape me quite a bit into what I hope will be a great general dentist.

MOCK?

As you may recall, or may find out by simply scrolling down a bit, you will see that I recently completed the MOCK CRDTS patient-based exam last tuesday. Well, in stark contrast to the mannikin exam, our grades were provided today.

Good news to all, I passed all three procedures. While perio was a bit of close call, I still survived. Most of my mistakes were actually clerical and not clinical which is ok with me, that is why we did this exam, to learn the process. I am going to make a checklist for the real exam to make sure I don't miss any signatures or leave any information blank.

For all my loyal readers, you may note that this the first MOCK exam that I didn't fail. NICE! It would be a real pain in the ass to remediate portions of this test because we essentially would have to do another performance exam in our home clinic prior to graduation. Rumor has it that about 1/3 of the class failed something which is a better percentage than our mannikin exam (about 1/2 I believe), but it still is a high number. Usually a number of people do indeed fail CRDTS, but I don't think it ever comes close to 1/3.

I definitely don't agree with a few remarks on my gradesheet..most notably the gingival contact not being broken on my class II (when it indeed was broken and passable with an explorer), but hell, even with a substandard grade on one section, I still got a reasonable score on the procedure. I even pulled out a hundo on my posterior composite restoration, not to pat myself on the back or anything, just sayin'.

The bottom-line is that despite being extremely stressed and having several things go wrong, the day ended up panning out positively. It was a great experience to have and knowing I can survive a MOCK exam that is graded tough no doubt, all while using less-than-ideal cavities. I'm feeling pretty good assuming I get patients for the real deal.

Speaking of which, I actually won a patient in the lottery this last saturday. So now I only need perio for the real thing. Of course, this is assuming the guy calls me back. Otherwise all bets are off.

So today was allright, despite having an implant crown delivery require re-fab due to the occlusion being MONDO off....bleh.

Allright, that was a quickie but I gotta run.

The light at the end of tunnel is beginning to shimmer!

MOCK!

A major post for a major day. As I D-2, I assisted a D-4 during her CRDTS exam. I remember the intensity, I remember punching holes in the rubber dam faster than I have ever punched before or will ever punch again, and I remember praying not to screw up the simple task of suctioning or mixing amalgam. More specifically, I remember seeing the absolute terror and anxiety amongst the collective soul of all the poor bastards taking the exam.

As a D-3 I was not allowed to assist for the real exam. Instead, we were forced to assist the current D-4s with the mock exam. Basically this exam is identical to the real deal and is sort of a dress rehearsal. That didn’t make it any less stressful. I remember the student I was assisting pacing about anxiously when her second patient was late and then didn’t even show. I remember watching instructors harshly critique preps and restorations. Again, I remember the collective tension of the entire day.

So here we go. I finally am not the assistant, but the unfortunate guy taking the damn thing. The Mock exam was held yesterday for me and I can say without hesitation that it was probably the most stressful day of my life in the category of ‘school.’ I was extremely calm and serene in the days leading up to the exam, consistently reminding myself that this was the Mock exam and not the real thing. However, the day before the exam I just felt crippled by anxiety and paralyzed with trepidation. I couldn’t function. I just sat around like a convict waiting for his last meal. I’m sure many people can relate with this feeling. A BIG event in your life has been approaching and the waiting just becomes unbearable towards the end. The night before you wedding, the night before a big presentation, and the night before whatever - it all ends up the same. You just want the waiting to end.

So let me preface with a quick summary of this exam for those not in the know. I have already done an overview of the CRDTS exam in a THIS post. However, I will outline this final portion now. As you may recall, I took and passed the National written exam (part II) back in august. I also took and passed the manikin portion of the CRDTS exam. What is left? The patient exam: this is what I took a ‘practice’ version of yesterday.

For the patient exam we are required to do three procedures:

Periodontal: Extra-oral, intra-oral exam, calculus detection/removal, probing depth/gingival recession accuracy. All-in-all, we must select a patient with at least 14 surfaces of calculus located within mostly one quadrant of the mouth (with the possibility of using 4 additional teeth from another quad). Three of those 14 surfaces MUST be interproximals of MOLAR teeth while only 5 can be on incisors. So simply finding a patient is a pain in the ass for this exam because you don’t want them to have rampant perio, but they need to have ‘just enough.’ Believe me; the patient pool at the college is mainly of the rampant variety.

Restorative: We must complete two procedures for the restorative portion. A class II amalgam or composite, and a class III composite. Less complicated than perio in terms of selection, but still a pain to find that perfect cavity. Again, you want it to be small, but large enough to warrant treatment.

The hardest part of this entire exam is the fact that we are responsible for finding all of our own patients for both the mock and real exam. As a class, we have held free public screenings on 4 Saturdays over the last few months. Afterwards, all procedures are raffled off. Guess who hasn’t won any raffles despite attending every one of these things? We still have two more, so keeping my fingers crossed.

So up until last Thursday which was the final day of class before the school pretty much shuts down to prepare for the mock exam, I still didn’t have a patient for the perio portion of the mock exam. No patient equates to immediate failure..joy. As fate would have it, I happened to be discussing my quandary with a classmate when another of my peers overheard and graciously allowed me to use one of his patients that he was no longer planning to use. Not an ideal case, but better something then nothing. So it may have been last minute, but I got all three procedures lined up for the mock exam JUST in time. As for the real one which is happening in mid-March, I still need to find two of the three procedures. Five weeks feels like it should be a lot of time, but it isn’t…

OKOK, enough unorganized blather, let’s get to the actual experience I had with this mock exam yesterday. As previously mentioned, I was nervous as I think most people are at this point. The culmination of your LIFE of education hinges on passing this exam. Yea this was just the mock, but it does a decent job emulating the real thing, so it serves as a decent gauge.

So I woke up at 5am, unable to fall back asleep I just got up, showered, and trudged to school at around 6am. 10 degrees, windy, still dark….great start. I arrive at the school around 6:30 and start setting up my assigned unit. At 7am, the sterilization window opens so I get all my instruments for my first procedure – perio. We are allowed to seat the first patient at 7:45am, I told mine to arrive at 7:30, and she arrived at 8:00. I’m not complaining, considering I got this patient a few days ago and had never seen her before, I should be thankful, and I was. So I sit her down and proceed to go through this enormous medical history which I had already reviewed but needed some clarification. What makes this exam even tougher is the volume of paperwork that must be processed and filled out correctly with signatures from varying parties at varying points during the exam. As you might imagine, it is VERY easy to forget to do some of these things in the heat of battle.

All patients require a consent form signed, a medical history form signed, and then there is a procedure progress form that you must get initialed at various points during each procedure. I’m not going to try to outline everything; this is just to give you a basic idea. In short, there is a lot of shit to keep track of all while maintaining your own nerves and not freaking out and projectile vomiting all over the place. So I quickly complete my extra/intra oral exam, and check her teeth for calculus. Remember, I haven’t seen this patient yet, and I need to fill out a big old treatment submission form with all the teeth I plan on cleaning. If there is no calc on the tooth, I had best not put it on the treatment submission form. So once this is all done, I get a start check from a central floor examiner or (CFE). He pretty much reviews the medical history and makes sure it is good to go. I forgot to put one of the meds down from her laundry list of conditions, oops, the first of many tiny mistakes. Next, my assistant takes her off to the evaluation room to see if my tx selection is approved. Here comes the first of many long waits. I can’t emphasize enough how stressful this portion of the exam is. And the funny part is that it is not when you are actually doing anything, it is when you are just sitting on your ass praying the powers that be don’t reject you patient or fail your prep/restoration.

Well she comes back in 15 or so minutes and everything is good to go. I complete the procedure fairly quickly (by dental student standards) with no real noticeable complications. I send her back to be evaluated at around 10:00. At this point my second patient had arrived. My assistant and first patient come back with the “feedback” form which is unique to the mock exam for perio only. Basically I missed a ton of calculus. Now I am not one to bitch (well, maybe just a little), but feeling around the sites they said I missed, I really wasn’t convinced on SEVERAL of their observations. I am now positive that periodontists think the CEJ qualifies as calculus. Basically if the surface isn’t as smooth as glass, it isn’t done. Now the only reason I am not upset really is that EVERYONE for the most part was getting similar feedback. So either the perio faculty is trying to scare the crap out of us, or we all just suck at SRP (probably a little of both). Either way, general dentists will be grading the perio on the real exam, so I’m hoping for more realistic SRP expectations for someone who will most likely never do an SRP again after this exam. So I missed 5 sites (I think) total. I assume this is failing but have heard from several classmates that you can miss 6 and still pass. I also understand the case I was doing was pretty difficult overall and not exactly ideal (really tough to clean 7mm pockets on #16). Whatever, it wasn’t how I wanted to start, but you need to really be able to move on during this exam…as it is a LONG day.

After re-wrapping the chair, I get my second patient seated (#4 DO). Again I will mention that I had a D-3 assisting me throughout the day which was extremely helpful.

So here is where things get interesting. This patient needs to make a phone call at a certain time and also needs to pee every hour. Why? I don’t know, but it annoyed the crap out of me. I get the class II lesion approved, numb him up and attempt to place the rubber dam. Problem! The dam won’t fit in the interproximal surface that I need to clean. Upon further examination, I realized that this was a TERRIBLE tx selection because the adjacent tooth had a huge composite on it with a flat long contact. CRAP! So I start prepping without the dam (only needs to be on during evaluations officially). I soon realize that I am gouging the shit out of the adjacent composite because its bulky ass is getting in the way of my gingival box prepping. Now in real life, I would recontour the composite without question simply to create a better contact when I place the restoration. But I’m not allowed to do this without requesting a modification on the exam. What is a modification? Another piece of paper that requires signatures! So at this point, I realize that I also will need to extend my preparation beyond ideal to get rid of the caries as well as recontour the tooth. Three walls need to be extended/deepened. So I have a total of FOUR mods filled out. I send him over. He comes back 20 mintues later with a piece paper that titles: Instructions to candidate. NOT a form you ever want to see on this exam. This form is the one that comes when you fail. It also comes for other reasons, and this was thankfully one of those. The rubber dam MUST be placed whenever the patient goes to the examiner station. I didn’t have it on and hence wasted 20 minutes. So after a 15 minute phone call and another pee break, I get the dam on and send him back.

At this point it is nearly 1:00 and my third patient has arrived. I am feeling extremely stressed and assume I will probably fail this procedure. Basically, if they don’t allow me to recontour the adjacent tooth I cannot complete the procedure acceptably. He comes back in about 10 minutes and like night a day, things get better instantly. ALL four of my modifications were approved! I instantly recontour the crap out of the adjacent tooth and remove all remaining caries. The prep looked very nice in the end and if rotations have taught me anything, it’s how to detect caries and do directs. So I send him back for the prep evaluation. Yet more anxious waiting ensues. Back he comes…with another instructions to candidate sheet. Crap? Apparently I didn’t break the gingival contact. But wait, when I hold the mirror and look, the contact is passable with an explorer…I’d say that means broken..but hell, I’m just some plebian dental student. So this is not a fail, but a big point deduction - very deflating after feeling very nice about the prep. So I must show the floor examiner the instructions, he looks and the confusingly asks, “It’s not broken?” HAH, at least somebody agrees with me. Bah, I don’t need to prep anymore, the CFE signs without additional prep that I ‘broke’ the already broken contact. So now I fill using composite. Nothing to report, easy fill, good contact, nice margins, no occlusal interference. Send him for the final eval. Comes back, no problems – nice. I forgot to complete my anesthetic record and forgot to have a CFE initial my modification completion…two more whoopsies. I am normally a pretty organized person..but in the chaos of this exam and this particularly difficult case, I just forgot to do some pretty simple things. And yea I’m bitching about the patient a bit when I should be thankful that he took the time to show up. And I AM! Despite the phone calls and hourly urination, I’m glad he was there.

Note to everyone – DO NOT do a restoration that will be touching a poorly contoured adjacent restoration…it sucks.

So this patient took me 3.5 hours. I get my third patient seated (#7 ML) and all paperwork filled out around 2:45 (deadline to start final patient is 3:30). I get him numb and run to the locker room to pound a power bar and bottle of water (5 minute breaks!). The patient was one my cousins and pretty chill and thankfully isn’t peeing every hour. Again, the rubber dam is giving us trouble and requires replacement after I finish the prep. The problem this time was that we made the holes too small and it was stretching and getting small tears. I start the prep, the patient is having difficulty getting numb and I am getting stressed because I don’t exactly have time to wait around for more anesthetic to settle (+ get the signed approval to use it). Luckily, the patient declines additional anesthetic and we press on! This prep ends up being large due to caries and I must send him over for mods. All of my requests were granted 6/6 on the day, not bad. Unfortunately time is becoming an issue, but I manage to remove the remaining decay and get him over to the evaluation station by 3:50 (deadline is 4:00 for preps). He comes back and all we have left to do is fill, easy right? I slide in the mylar matrix, wedge it and fill. Once I remove the wedge and mylar, I notice the contact is NOT closed. After using every profanity in the book as well as a few new improvised phrases (mentally of course), I start wedging the other teeth to push it back. I end up adding more composite and FINALLY get the contact back. After polishing, and smoothing the contours, I BARELY get him over to the evaluation station in time (4:50 with a 5:00 deadline). Christ. Now I don’t feel great about this filling simply because I didn’t have time to really look it over as I normally would. One of my favorite instructors was a floor examiner for the exam and sat down with me while I waited. He could tell I was pretty frustrated and really calmed me a down a bit with some jokes and practical advice. And wouldn’t you know it; my assistant comes back and gives me the big thumbs up, no problems. FINISHED! Forgot to complete my anesthetic record again…whoopsies x4.

So I get home around 6pm…about a 12 hour day no real breaks. I was so exhausted mentally and physically it is indescribable. Hell, I’m actually pretty sore today from doing dentistry..muscles I didn’t even know I had are screaming in agony. I’m just glad it’s over. Besides perio, I’m pretty sure I passed everything which is awesome considering how crappy my treatment selection was. But hey, you don’t want to waste the really perfect lesions on the mock exam anyways.

Grades will be provided next week I believe. Either way, it was a well-organized and beneficial, albeit stressful exam. I applaud the faculty on their organization in running everything so smoothly.

The bottom line is that I got through it. One more Big hurdle (real CRDTS exam) and few small ones (endo performance exam, papers) are all that stand between me and that big fat DDS. The road has been long and arduous, but as my dad told me way back amongst my first year griping - at least there’s an ending. There sure is dad, there sure is.