The D-4 Experience II

Let’s face it; I’m due for another one of these. It is difficult to come up with a proper description of the fourth year at this point. It actually feels similar to the fourth year of high school, or the fourth year of college. Similar in that you just are ready to get the hell out. Your third year is full of so many learning experiences and adjustments and failures that you barely have time to take it all in. Now I feel like I have pretty much come as far as I can in the dental school setting.

Sure, there is still a lifetime of learning ahead of me, but it seems best suited that I do that learning in the real world at this point. Seeing two patients a day truly limits what you can do. Not ever having an assistant truly limits what you can do. Having to do your own lab work, wrap your own chair, become a collection agency, or get cases sent to PG because they are “too tough” truly limits what you can do.

Don’t get me wrong, I still do learn at school – but I feel like I’m trying to squeeze juice from a turnip rather than an orange at this point. For example, I started my first bridge maybe a month or so ago. The preps were great, the temp was ok, and the impression turned out awesome. So I tried to send the impression, bite reg, and opposing cast out to get a framework made. Wait, no that is not allowed. For some reason I am required to trim my own dies and mount the case myself first…to get the framework. I am no longer naïve enough to think that general dentists mount every single bridge case themselves. In fact, I KNOW they do not. ESPECIALLY in cases where you can get MI without bite reg. So why am I forced to waste another week sending out the impression to get poured up so I can trim the die and mount it myself while attempting to work around all my rotations…sigh. That is one example of why school just annoys me nowadays.

The framework try-in is tomorrow. Assuming it goes smoothly, this poor bastard may have his bridge by the second week of January. So this will take at least 3 months. Ouch.

But bitching aside, what do I like? Pretty much feeling like the big fish again. All the people that used to be scary or intimidating are truly pleasant to me at this point. I feel like the faculty is giving me more and more lee-way with cases. Discussing cases with classmates has become a regular occurrence with genuinely good debates and questions regarding what the appropriate treatment should be. You just are feeling close to becoming a dentist which I guess is how it should be given how close graduation is.

School feels like a home away from home now. I enjoy just sitting around the conference room, BSing with faculty, classmates or the one dental assistant in our clinic. I also like having NO class. I only have to be at school by 8am one day a week for urgent care/screening sessions.

Now the other huge difference between the third and fourth year is rotations. Third year you are on a bunch of in-house rotations. The only truly beneficial block was oral surgery (8-weeks of extractions is pretty sweet for any third year). The fourth year has REAL rotations though. And while my experience is a bit different from the majority (mainly in that I am gone 19 weeks as opposed to 10), it is still unique to the fourth year. In fact, accepting my invitation to the 2x2 rotation program was a great decision. Sure the overall complexities of the cases I get outside are not all that great, but the sheer volume of work is what makes up for it. I still do get the occasional crown or endo, but it is mostly directs, exams, and extractions. However, you generally see 6-10 patients per day (as opposed to 0-2) and you also get a glorious assistant. Yea there is a lot of pedo, but that has been GREAT for me. It has made me comfortable with a very large portion of dentistry.

My first stainless steel crown at the college took me 2.5 hours to complete and it still was opening the kid’s bite. The last SS crown I completed was last Thursday and it took me 15 minutes from start to finish (note the pulpotomy was already done at a prior visit). This would not have ever happened without the massive pediatric exposure that these rotations provide. I am planning a future post comparing rotations to the school so I will save my comments.

The final difference I am going to touch upon today is the licensure exams. Third year is stressful because you have a bunch of performance exams to get finished each semester. Fourth year is stressful because everything you have done so far won’t matter if you don’t get licensed. I can graduate, but if I don’t have my license, it sure will be hard to practice dentistry. That thought alone is terrifying. Now granted, I feel that once you hack up the 2k that this licensure exam costs, that pretty much gets you the license. Sure you may have to retake something, but I honestly have NEVER heard of anyone failing the retakes. I hope I’m not the first!

The exams are simply stressful, but each one you knock off just brings you that much closer to the light.

One more HUGE hurdle and about three smaller ones is all that stands in my way.

Closer and closer every day.

GPR Bound

Officially got offered a contract today. Next year I will be busting out dentistry over at Illinois Masonic. Nothing officially signed yet, so I will get into more details about the program in future posts. Needless to say, I am in very high spirits tonight.

Much like passing manikin boards or part II of the written exam, there is just this rush of pure euphoria. The soaking-in period should last a good week or so. I am on rotation so I am busting my ass off seeing 10ish patients per day but this was a nice bit of news.

While the stress wasn't as intense as the week leading up to finding out that I passed the manikin exam, it got pretty bad the last few days. As mentioned, I only applied to two programs, and while I got interviews at both, you really can't account for the luck factor involved in any application process. I feel like I interviewd well at both, so luckily my top choice panned out. Everytime my phone would start vibrating, my heart would crank up the pace for a few minutes. And so many times it was a friend or patient or even wrong number. BUT NOT TODAY!

All I know for sure is that I gotta buy a christmas present for one of my letter or rec writers because several of the interviewers mentioned how impressed they were with it. I wish I didn't sign away my right to read it because I'm damn curious now.

Pass NBDE part II - check
Pass Manikin CRDTS - check
Get into GPR - check
Pass patient CRDTS - taking in march
Don't die before graduation - pending

So there you have it, really not much left. I still have an endo performance exam to complete on a posterior tooth and a few implant cases to finish (surgeries already done); but otherwise I'm pretty much graduated. Holy crap.

Posts on the way:
D-4 Experience
Rotation v School

2/3

Done. I have one more major test to take before I can legally practice dentistry (assuming I also graduate).

Let me see if I can portray just exactly how stressful this crap is. So as explained, the mannikin exam is just as it sounds, we perform several dental procedures on a fake patient with plastic teeth. There are two sections: prosth and endo. Prosth involves prepping #9 all-ceramic, #5 PFM and #3 FGC. 3 and 5 are to be made as a bridge prep meaning the must draw together. Endo equates to a #14 access and #8 full RCT. If you fail ANY tooth from any section you must remediate the entire section. So if I have 100% on my bridge prep but leave an undercut on #9, I have to redo all the prosth section. This also costs 950 dollars...ghee.

OKOK, so now realize we have been practicing for this thing since the summer pretty much. I failed the summer mock mock exam. I also failed the mock exam we had this fall. The trend was not looking good. So imagine my utter jubilation when I finally found out my score this morning. PASS. And REALLLY passed too. No score was below 90 which washed away any and all dental self-confidence issues I had been experiencing over this exam.

But let me emphasize that this was a terrible process indeed. First off, the exam itself was extremely stressful. But that's not even the bad part. The bad part is waiting 26 days for them to actually grade it. TWENTY SIX DAYS. It wasn't so bad for the first two weeks because you know it will take awhile. But oh boy, this last week I was border line going insane with anticipation. To the point where I was having trouble sleeping, concentrating on school, doing ANYTHING. I'm sure I've lost a month off of my life simply do the accelerated aging all this stress has placed on my organs.

I though the joy of passing the written exam was going to be tough to beat. I was wrong, this definitely takes the cake. And I'm sure the only thing that will surpass this feeling shall be finishing that last portion come spring time. Knowing that it is finally over. Good lord I can't wait.

Now I can move on with my life and get out of the mire of simply not knowing. I have two GPR interviews coming up. Seeing as I only applied to two programs, I couldn't have asked for anything better. They both are in the next week so my focus must now shift off the academics and towards the future.

Just thought I'd throw this celebratory post up before I head off for the evening to continue taking in all the good vibes. The blue label is coming out tonight.

Off I go!

Out There

This is my first lap top post. I am writing this as I lay on a tiny bed in Rockford IL in a dumpy little duplex out behind the Rockford Memorial Hospital. I hate typing on these things. It feels so unnatural and the keys don't have the same feel.

I wonder what most people think of when they hear the word dental student. Hard work? Stressed? Insane? An amalgamation of the aforementioned descriptors (get it?). Or do they picture some dude sitting in his boxers on a bed after pounding down some taco bell typing about dentistry and dental related experiences. Sexy.

These rotations have been great though. The sheer volume of learning is expanded beyond what the traditional school setting is capable of. I mean just this last week at school, I spent about 5 hours of in-school time busting my ass catching up on paperwork and doing lab work that practicing dentists never perform. Why can't I send my impression out with an opposing cast/bite reg and get the bridge framework back? Why do I have to trim my own die and mount the case. Do they realize that this adds approximately 10 business days to the patient's already long-ass wait. I was so excited that I hammered this bridge prep out (my first one actually) in two appointments. But I probably won't deliver it until mid-January because of all the red tape.

I've said it many times, there is a window of maybe 60 minutes each day at school where I am truly learning and perfecting my craft. The other 5+ hours is completely worthless. This is coming from a fourth year student mind you, I would be pretty brash to say the same one year ago.

Did I mention the tuition is insane. My girlfriend and I will be combined over 500K at graduation. That's HALF A MILLION...geeeeh. Granted our combined income will be nice, but not .5 million nice...

Speaking of future. I got my second GPR interview last week. That makes me 2 for 2, not too shabby. I am really looking forward to the interviews which are both in the same week of november. Both programs have their pros and cons, I shall elaborate in future posts.

Back to the rotation. Today I got a great refresher course on emergency dentistry. A patient I was working on started out normal, but just sort of drifted off mid-procedure. At first I attributed this to sleep. The pulse-ox was good and I could get her carotid pulse fine. Still something clearly seemed off. Once the doc came in to check on me, he had me sit her up and verbally snapped her out of it. Now this clinic caters exclusively to mentally disabled patients, so you get some really tough cases. As such, sedation is used as necessary. However, some parents decide to self-medicate and not tell the dentist. As per today, this patient was loaded up on valium without us knowing. Needless to say, the doc was pissed and the mom lied about it. Ugh. Thankfully nothing bad happened, but it got me thinking.

WHAT THE HELL DO I DO IN THESE SITUATIONS!? This is PERFECT example of why I want to do a GPR. I have no confidence in handling emergent situations. Why is it tough? Becuase they are so freaking rare in dentistry that being experienced is near impossible. Thankfully my preceptor is extremely good at walking me through the more medical aspects of dentistry and he really boiled it down to the essentials. Airway, breathing, circulation, drugs, BAM. It is all stuff I've learned, but in a real emergency, the dentist needs to keep it together and know what the hell to do. None of it is complicated, it is a matter of staying calm and acting correctly.

Today was a "slow" day at this clinic, yet I saw 9 patients (4 which required ops/exts). Again, rotations = mondo experience (by dental student standards). It also serves as a blunt reminder that you are indeed "not the shit." I mean, this clinic has handed me my head on a platter more than once. Trying to place 2 back to back MO/DOs on a screaming punching 250-pound autistic adult in 15 minutes is extremely difficult and quite frankly, scary as hell. It truly is great though, because you walk out of there with a new confidence everyday. Even if your work wasn't anything to brag about, the amount of experience and simle comfort level with tough patients earned is unbelievably useful.

Speaking of which, it is time for me to hit the head followed by the hay. Getting up at 6am and working until 6pm is hard.

Keeping my fingers crossed that I passed CRDTS. I know I overtapered the distal of my molar to get the bridge to draw...but was it enough to fail? Gulp? My endo felt meh overall, who knows. I'm mentally preparing myself to retake the whole exam because that way I won't be crushed if it actually happens. And on the flip side, if I passed 1/2 of it or the entire thing, I will be pretty damn sassified.

Here's to good luck!

One Small Step...

Just finished up the official mannikin portion of the CRDTS test today. I am too exhausted for a full debriefing. Let's just say I didn't have any glaring mistakes, but my endo was definitely not my best work. You don't realize how exhausting this exam is.

I practiced a good six times including our mock exam. Each practice takes about 7 hours. Then you finally get to the real thing. By the time I was on my last procedure (full RCT #8) I was just out of gas. I think it's OK, but who knows. The good news is that I felt pretty similar walking out of this thing as I did walking out of the written exam that I took in August. Not super confident, but not down either. So hopefully the result will be the same. We won't know for about three weeks. I will brood over it for a day or so, then it will slowly leave the forefront of my mind until the grades show up...gulp.

I really hope I passed simply because I'd hate to spend another 900 bucks to retake it. Not to mention the arduous process of preparing and actually taking the exam.

We go from 7:30am until 4:00pm with really no true lunch break. That just tires you out. Especially when you are trying to make everything perfect.

Needless to say, I went out with some classmates for a few beers afterwards. So here I sit now, ready to just pop a movie in and relax with the lady.

I think I outlined this exam already so I won't even try to do it right now. I figured I'd post while in that hazy after-aura of just completing part of the most important exam in my life.

Whew. Now I have to recover tomorrow and get back in the trenches starting monday. I have to give a case presentation on thursday. Why the hell did I sign up for the first time slot? CURSE YOU PAST SELF!

Sorry for the lack of posts, just been all over the place with board prep and rotations and life experiences.

In other news, I got my first GPR interview coming up in november. 1 for 2 in interview offers so far. Haven't heard anything from the other yet. We will see.

I'll shoot for another D-4 experience post by the end of the month. No guarantees, just a goal!!

Sorry for slowness in response to emails, same excuse as above. I will get to them ASAP though.

And I'm done.

Celebration Amongst Impending Doom

While I am begining to feel the full weight of the CRDTS licensure exam as I mailed out my 1,900 doller chasier's check, there was a nice ray of sunshine to brighten up the begining of this semester - I passed the written boards part 2.

I didn't knock it out of the park, but I didn't sneak by either, a satisfying "in-yo-face' moment to open the letter and see that magical word PASS.

What makes it more gratifying is that aparently my class is being subjugated to a mandatory 'mock' NBDE part II exam in three weeks. If we do not attain an acceptable percentage - we will not be certified to take the exam. This is bad form in general because three weeks notice is not enough time to prepare for anything, not to mention we have mock boards in 2 weeks as well as more rotations to deal with.

But I can't complain because I already passed and am excused from the test. What actually appears most interesting is that I think I am the only person that has taken it in my class. This roughly makes me a hollywood action star in the school as droves of my classmates congratulate me and ask for advice. Fun times.

It is the same as with part I. The summer semester is the best time to prepare for any big exam - get it done.

Studying for this test amongst licensure preparation would simply be too much for me.

For those wondering - I used the MOSBY text, the dental decks only for prosth, pharm, path, and radiology, and finally, all of the old released ADA exams. Studied lightly from May until August. Some days of heavy cramming but not much, usually averaged 1-2 hours a day.

Passing the test requires a much higher raw score compared with part I, so study accordingly.

Enough of the test though, on to more pressing matters.

Let me explain how the Central Region Testing Services (CRDTS) is handled during this final stretch of dental school.

The test is broken into 5 parts.

Part 1 = NBDE exams (both 1 and 2) - DONE
Part 2 = endodontic exam
Part 3 = prosthodontic exam
Part 4 = periodontal exam
Part 5 = operative exam

So Part 1 gets done on your own time. Everyone should be done with the first NBDE exam by now, it is simply a matter of knocking out part II.

Part 2 and Part 3 will be taken in october, with a mock exam in two weeks. This is known as the manikin portion of the test because we work with plastic teeth. This makes the endodontic portion seem a bit absurd to me..but hey whatever.

For the endo section we must access, cleanse/shape, and obturate #8. We must also access #14. We need to follow all sterile protocols and place a rubber dam. We actually get to measure #8 by hand prior to placing it in the dentech to determine working length (see why this is sorta dumb?)

Afterwards we have the prosthodontic exam which we already practiced once over the summer. This entails preparing #3 FGC and #5 PFM for a bridge and #9 ACC. We must make PVS occlusal indexes prior to preparing the teeth as these will be used to evaluate reduction.

Still with me?

The big daddy is Part 4 and Part 5 which we will be taking in March. There is also a mock test for these portions as well in February. The periodontal portion involves probing, detecting calculus as well as removing said calculus. The operative portion involves completing one class III and one class II prep/restoration. This will be the most stressful portion simply because the patients are real and not always predictable - both in terms of what the tooth will look like when you start working and if they actually show up on time.

I will go into this more later because the thought of it is stressing me out right now.

We got a big packet of info regarding the test that I have just begun to read through. Needless to say, this will be the most stressful/important exam of my entire existance. Fitting as it will be the last major exam I ever take.

Two semesters left.

I am also apparently one of the "top 30 dental blogs of 2010.'

Back pats for all!

Profiling the Pediatric Patient

After spending four weeks (with one more to go) at a clinic devoted solely to pediatric dentistry, I have begun to notice that every patient falls into a specific pre-determined (by me of course) category. Allow me to elaborate:

KEY:

Tell-Show-Do = this is when you show the kid everything you are using (aside from the needle) and explain what it does. For example, I will let them see the mouth mirror before I use it. I will show them my “tooth fixing wand” (the highspeed) and show them the noise it makes and even spray their arm with the water a little so they see what it feels like. This goes on as necessary.

N2O = Nitrous Oxide, a commonly used anxiolytic in the medical setting. Easy to use, easy to remove the effects, and pretty much no chance of killing someone.

Manhandling = when all else fails, you just go medieval on the kid to get the job done. This includes papoose boards, head holding, mouth props, and half-assed dentistry. Really, there is no way to do a great job on a patient with zero compliance. You just need it to last long enough for the permanent teeth to get in. Manhandling is more commonly used for the 6 and under crowd but there are always exceptions.

Difficulty = a generic scale of how tough the kid is to work on. Scaled out of five. One being easier than an adult, and five being extremely tough (general anesthesia candidate).

And now for the profiling!

The Vomiter

This patient, like most kids, wants nothing to do with the dentist. Once you papoose their ass and headlock them with two assistants, they still find ways to defend themselves. Frankly, they try to puke all over you. And it isn’t friendly gurgling puke, it is projectile – get in your eyes puke. What’s worse is that they inadvertently could kill themselves by choking on said puke. So you need to brave it out to suction all that shit up (god bless the assistants). The only way to tackle this patient is to wait out the vomiting because they will eventually run out of ammo.

Tell-Show-Do - ineffective

N20 - ineffective

Manhandling - marginally effective

Difficulty = 4/5

The Old Man

This patient is actually pretty relaxed. Nitrous can work wonders sometimes. They may still get crotchety during the injection, but afterwards they will just sleep – THE ENTIRE APPOINTMENT. A real treat to work with. Only annoying when mom comes back and thinks I OD’d her kid on nitrous…bah.

TSD - unnecessary

N20 - extremely effective

Manhandling -unnecessary

Difficulty - 2/5

The Stoner

A close relative of “The Old Man,” this patient wants nitrous and wants it bad. It may be hard to associate a 9 year old with a 25 year old pot-head. But when one sees these kids craving the “magic nose,” one can’t help but make the comparison. These patients generally are pleasant to work on because they are riding the good waves of N2O. I’ve even had kids laughing while getting a block…crazy.

TSD - Pointless, they aren’t listening

N20 - EXTREMELY effective

Manhandling - unnecessary

Difficulty - 2/5

The Question Asker

This patient simply doesn’t shut-up. They constantly need to know what you are up to. N2O is only marginally effective because they never stop talking. TSD is only helpful to a certain extent because I still haven’t found a pleasant way to show them the 25gauge needle. I am good at hiding it like a magician though. These patients can be really easy or really tough – they are unpredictable.

TSD – Marginally effective

N2O – Marginally effective

Manhandling – Effective when necessary

Difficulty – ranges from 2-4

The Victim of Circumstance

Perhaps the most depressing patient to work on. This is the kid who shows up with cheetoes all over his teeth and a bag of skittles in his pocket. This is the patient with parent’s that are ignorant, negligent, or just suck at parenting. “I can’t get him to shut up at night without giving him a bag of Doritos and a pepsi” is the most ridiculous thing I have ever heard. Suck-it up and lay down the law. These kids are generally too young to know any better, so it is really the parent’s responsibility to take care of them. Unfortunately, I see a lot of neglect going on.

TSD – variable

N2O – variable

Manhandling – variable

Difficulty – variable

The Momma's Boy

This patient generally arrives clinging to mom and is too old to be exhibiting such behavior. They generally freak out once detached and go one of two ways: total meltdown or total calm. Again, a bipolar patient type. If they freak out, being extremely stern often solves the problem immediately. Parents are not allowed in the operatory if the kid is 5 or older so this type is always a wildcard. After the procedure they always run straight back to their leech like hold on mom’s leg.

TSD – Effective to Useless

N2O – Effective to Useless

Manhandling – always effective

Difficulty – 2 to 4

The Screamer

Name says it all. This patient screams the entire appointment with variable pitches. Surprisingly easy to deal with if you aren’t fazed by the noise. The papoose is usually all that is necessary, they rarely thrash their heads around.

TSD – ineffective

N20 – ineffective

Manhandling – very effective

Difficulty – 3/5

The Negotiator

This patient will do anything to get out of the chair. They will bargain with you. For example, "please don't put that in my mouth (bite block), I promise I'll keep my mouth open." You may fall for the negotiator at first, that is until they bite down on the running bur and change that small occlusal composite into a pulp/crown. I usually just re-negotiate. "Be good and you get a shiny toy." If this doesn't work - proceed to manhandling.

TSD - slightly effective
N20 - slightly effective
Manhandling - effective if necessary
Difficulty - 2-3/5


The Mongolian Warlord

Containing attributes of both “The Vomiter” and “The Screamer,” this breed is the absolute worst. They are combative, spit at you, vomit on you, scream at you, and essentially struggle the entire time. Unlike other difficult patients, they don’t get tired. These patients unfortunately seem to have the most neglect as well in terms of oral hygiene. If they require multiple pulps/crowns – they are best referred to a hospital for general anesthesia, there is no way you can get it done acceptably otherwise.

TSD – ineffective

N2O – ineffective

Manhandling – ineffective

Difficulty – 5/5

The Angel

This is the type of patient that makes you happy to be a dentist. They are cooperative, exhibit very little apprehension, and are just cute as the dickens. TSD and N2O are always effective but are often not necessary as the patient will be compliant regardless.

TSD – often unnecessary

N2O – often unnecessary

Manhandling – unnecessary

Difficulty – 1/5

I may add or edit this post as the year goes on. I haven’t covered all the types – just the most common run-ins for me so far.

PS. sorry for the lack of spacing after periods. I swear I didn't type it up like that... but the mystery makes it even more exciting right?