Wednesday, September 12, 2012

The GPR – Good Idea or No?

Three months out of my completed GPR gives me plenty of time to retrospectively evaluate its worth.  However, I probably won’t be able to truly evaluate the future perks until I get a solid job.  I will discuss the job search in a later post but to sum it up – I have nothing long-term locked in at the moment.  Getting married and going on a honeymoon slowed things up considerably, but my recent contract negotiation which has essentially exploded into nothingness is what really set me back.  I was also na├»ve enough to think that the office I was in negotiation with was not interviewing anyone else whilst negotiating with me.  Seems a bit tatty of them, but hey, won’t make that mistake again. 

But that is a story for next time.  I know I already covered the basic GPR itinerary, so I won’t repeat myself (too much anyways).  The program was exactly 12 months long with an optional second year for those interested.  At my particularly program, they probably get one second year every couple of years.  My group had one such second-year or “chief” resident.  This was both a blessing and a curse.  On the one hand, the second-year provides a great deal of guidance for a lot the first-time experiences (particularly being on call, handling hospital consultation/emergencies.).  On the other hand, the second-year gets a TON of complicated cases and pretty much cherry picks all the good stuff from the previous group.  To put this in perspective, the year before mine placed about 20 implants as a group.  I did not get to restore a single one.  That’s right; I restored more dental implants in dental school.  That is a major con right there.  Our second-year guy was pretty cool though, and I did work with him on multiple occasions for both implant placement and extraction of thirds.  These experiences were extremely positive and I took a lot out of them.

So what is the main purpose of a GPR?  In my mind, it is for someone who wants to be a general dentist, but isn’t sure exactly where to focus.  As a GP, it is really not possible to be great at everything.  That is why specialists exist, to take care of the tough cases that you just don’t have the experience to mess with.  When I graduated dental school, I had no idea where my true strengths/interests were.  I needed more time to figure out where I wanted to focus my continuing education, what strengths I would have in my practice.  One year later, I can tell you I have a strong interest in implant placement/restoration, conscious sedation, and minor perio surgery.  I can tell you that while I don’t particularly love endo, I no longer throw up in my mouth a little when one walks in the door.  Will I be doing a lot of molar endo?  Doubtful.  Can I get it done given the time?  Sure. 

The same can be said for third molars.  I can get most teeth out quite easily now, even the hard ones come out too given the time.  The big thing you learn is time though.  If it takes me one hour to take out 4 impacted thirds when an OS can do it in 20 minutes, then it should be referred.  Simply because it isn’t particularly fair to the patient or in their best interest to be getting cranked on for three times the necessary amount of time.  But again, the GPR has given me such a broad scope of experience with removing thirds that I have a much greater idea of my limitations then I had coming out of school.  The month I spent at cook county was invaluable in developing speed and just seeing a shitload of cases.  The more you see/do the greater your experience, the better you are.

Now all GPR programs are different, they all have a variety of rotations and patient population, so it is hard to quantify numbers.  For example, I was pretty disappointed in my prosthodontic experience overall.  I probably only did about 10-15 units of fixed in an entire year whereas most of my colleagues in private practice are doing that many per month.  But I did more endo than many of them combined.  I took out far more teeth, placed a number of bone grafts, placed an implant, the list goes on.  So while I gained extreme experience in certain areas, I was underdeveloped in others.  In only 12 months, you can’t expect to get it all.

One of the more unique experiences of my program was that every single Thursday of the year is dedicated to treating special needs patients.  This is also where we get the bulk of our conscious sedation experience.  2-3 residents per week would have 2 or 3 sedation cases (1.5 hr time blocks).  Whilst everyone else would treat other patients in 45 min blocks.  Now most ‘other’ patients would probably be good candidates for sedation as well but we just don’t have the numbers or time to treat all as such.  So we get by with restraint or oral seds.  It is tough work, truly.  It is similar to uncooperative pediatric dentistry except the patients can weigh 300 pounds and be far more violent.

The IV sedations themselves are an adventure.  Imagine trying to place your first IV on a patient that is thrashing their arms wildly and trying to bite you.  Pretty unnerving, but you get used to it.  The month we each spent in the anesthesia department in the hospital also really boosts the IV placing skills.  Another plus, albeit somewhat morbid is that since these patients are so uncooperative, we must take them deeper than would be ideal in a standard office setting.  You see, an ideal conscious sedation is just that, the patient is still conscious, although in a bit of a twilight.  The drugs we use also tend to produce amnesia so that is why you don’t remember that wisdom tooth appointment much at all.  A cooperative patient can respond to commands, and more importantly, breath on their own/protect their own airway.  In the special needs patient, we aren’t so lucky.  We must take them deeper, not enough to shut down their breathing, but enough to remove the response to verbal commands.  But as anyone who has worked in anesthesia before knows, this is a very vague and fine line at best.

This results in a lot of situations requiring airway management, either through nasal airway placement, positive pressure ventilation, or a simple head tilt chin-lift.  Seeing the O2 sat drop for the first time or your patient turn blue is absolutely terrifying.  However, seeing how to manage these situations was so absolutely vital.  Our anesthesia attending is always nearby and was one of the best instructors I have had from kindergarten through the end of my formal education.  He encouraged thinking over memorization, and never got flustered regardless of how much proverbial (or literal) shit was hitting the fan.  And that’s just it.  You need to stay calm in emergent situations.  Most dentists will experience one or fewer office emergencies throughout their career.  The rarity of it makes us lazy, unprepared, and that is when you read about some poor soul dying in a dental chair.  You need to keep up to-date, maintain your BLS/ACLS, and keep your staff ready.  Simple as that.  Most dental emergencies are so unbelievably easy to manage if you just stay calm and know your role.
So I have actually received my license in conscious sedation just this last month.  I feel quite comfortable with light sedation on healthy patients at this point and have done well above the minimum requirements for the license.  However, I do realize this greatly increases my liability and overall responsibility and is not something I take lightly.  If I can’t find the right office to perform sedations, I simply won’t perform them.

That leads me to my final major assessment of why the GPR was great.  Dealing with dental emergencies.  Not the kind where the patient is having a stroke in your chair, but the kind where you get paged at 3am because some drunk asshat fell on his face.
The ER is an absolutely unique place – particularly in the middle of the night.  Now I can say that fortunately, through six weeks of primary call and 7 weeks of secondary, I only had to physically drive to the hospital in the middle of the night once, which all things considered, ain’t that bad.  However, we would constantly get stuff during the day or random calls from patients over the weekends.  A valuable tidbit of info I learned – Pain is NOT an emergency.  Does pain suck?  Yes.  Can it lead to an emergency?  Yes.  Will dental pain likely lead to an emergency overnight?  Unlikely.  Most calls are from people who put off seeing the dentist, maintaining a state of delusion that if they don’t do anything, it will go away.  We are all guilty of doing this at some point or another in all walks of life.  The problem is, outside of generalized sensitivity, specific tooth pain is indicative a problem that will NOT go away.  And unfortunately, the longer you wait, the worse it will get.  A true dental emergency is for someone with a rampant infection that is threatening their airway, or someone involved in some form of trauma.  At the beginning of the residency, I had trouble differentiating the different types of emergencies or how to delegate/handle the situation.  Let’s face it, if every dentist went in to the office for every emergency phone call, we would be working 8 days a week.  Most ‘emergencies’ can be handled with simple reassurance, or pain control (assuming this is a patient of record).
Well I’ve kinda rambled all over the place here.  I could go on and on but the core value is what’s important.  The GPR is only one year – the amount of experience/learning you garner is absolutely through the roof.  The program itself counts towards 150hrs of continuing ed, which honestly isn’t even enough all things considered.  At only one year, you are not really sacrificing much income.  Most of my colleagues didn’t really get rolling until a good 4-5 months following graduation.  So yea, you don’t make a dentists salary given the hours you put in, but at least you get tons of experience for your troubles, and can defer your loans.

So now, if I can find the right fit for me as an associate, all this training will hopefully pay off.  Up next, the job hunt.

Saturday, September 8, 2012

A Phoenix Perhaps?

Oh my, well.  Where to begin?  If you actually pay attention to this little corner of internet heaven, then you may be asking where the hell did this guy go?

By all accounts, if you are going off my last post, it would appear that I was slain at Cook County.  My burning ruin, left smoldering on the cold, unwashed floors.  You would be wrong though!  I simply got lazy, uninspired, busy, distracted, insert adjective.  Not an excuse, just a reality.  Life moves along at a steady clip, and while I still have plenty of time to myself, I use that time differently than a few years back.

Speaking of moving fast, how about that GPR?  Over before it began.  An entire year, one of the fastest of my life leaves me finally understanding what my dad means when he says it just goes faster each and every year.  Hell, I’ll be dead before too long at this rate.

I WILL make a detailed post about the GPR at some point.  I simply cannot do it justice right now.  I will say it was 100% worth the time/effort/lack of $$$.  At least it feels that way now.   The unfortunate reality is that unless I find a PERFECT fit to utilize my skill-set, I will probably end up doing fairly standard dentistry until I can finally open my own office.  That feels like centuries away right now…what with the massive pile of debt sitting at my doorstep.

But I digress!

A quick year-long summary which is fitting considering how fast this year has gone:
1) Completed the GPR successfully on June 30th, 2012
2) Attained my license in conscious sedation with intent to utilize
3) Improved in pretty much every aspect of dentistry (did more root canals in first month than all of dental school).
4) July 2012, got married….to a dentist….gross.  Remember when I was saying how class-cest was a bad idea.  Damn that crow tastes good.
5) Slow start to job hunt due to wedding/honeymoon
6) 2-month part-time gig as a mercenary dentist in a public health clinic begins in October
7) What felt like a sure-thing part-time job in a decent west-suburban office has crumbled over the last few weeks due contract negotiation, details forthcoming.
8) I still live!

I can’t promise anything, but seeing as the job hunt is taking about 5x longer than I expected, I may as well use my time to relate the experience.  Hell, this stuff is just as important to the dental nerds reading the blog as passing classes was.  Getting a job in a major metropolitan area is not difficult.  Getting a GOOD job is.

And the great thing about being married to a dentist is that her income keeps us afloat so that I don’t need to rush into a bad situation.  I WILL find the right fit.  You could also argue that the bad thing about being married to a dentist is that we owe the government about 750,000k in loans and that we really need the dual income sooner rather than later.


Ok enough, I need to finish reading a contract that I’m about to sign for the 2-month mercenary job.  Oh and mercenary could also be replaced with the word temp, I just think it sounds way better.

Sorry for not responding to emails, at this point it seems silly to reply to something 9 months old.  So I can just cop out and give a blanket apology.  I WILL TRY TO IMPROVE!


Sorry for the dramatics, being a fan hurts sometimes.