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What I wish I knew – top tips for younger practitioners

24 December 2020

Dr Kiran Keshwara, Dentolegal Consultant at Dental Protection, looks back at his own early career experiences and emphasises the importance of building good habits right at the start. 

At Dental Protection, we talk to many young practitioners about the key areas of dentistry that they need to be mindful of, especially in the first few years out of university, as building good habits at the early stage of their career stands them in good stead later on as well.

What aspects of dentistry are important for recent graduates to consider?

The first area to talk about, and the most obvious, is the provision of clinical treatment.

It’s important to work within scope. This means providing treatment that you are comfortable with and have sufficient training and experience in. It is not wise to decide to provide treatment such as implants after watching a video on YouTube, Instagram or TikTok. Similarly, it's not a good idea to decide to provide adult orthodontics after you’ve been on a weekend course in beginner ortho.  If any complaints do come about after providing such treatment, one of the first things the Dental Board (or Dental Council) will ask you is how much experience you have and what further training you’ve had in this area of dentistry.

In recognition of the areas of dentistry where you can’t, or don’t want to, provide treatment, you should be comfortable referring patients to other clinicians – which could be a more experienced practitioner within the practice or a clinician or specialist outside. Build up a network and talk to colleagues about who they usually refer to and, hopefully, over time you’ll build a decent list of clinicians, who you can work with as a team.  

Which areas of clinical dentistry are recent graduates reporting struggles with?

The ones they report are often related to experience and exposure to more complex treatments. For recent graduates, about 50% of the cases that we open are for endodontics and oral surgery, which includes simple extractions.

Endodontics accounts for about twice as many cases than we see with dentists who are more experienced. We’re also seeing an increase in cases with implants and adult orthodontics across the board.

What’s the most common endodontic complication? How should a practitioner deal with it?

The most common complications we see are those involving file separation, and this has been increasing with rotary endo systems being used more frequently.

If a file separation occurs, you should temporise the tooth and tell the patient what’s happened. It’s usually a good idea not to charge the patient for the incomplete endodontic treatment and, ideally, you would then give us a call to discuss what’s happened.

We would usually advise to refer to an endodontist, who will hopefully be able to bypass or remove the file and complete the endo. Naturally, the patient may be quite annoyed that this has happened. Usually, a good way of resolving this without it going any further will be to offer to pay any additional treatment costs over and above those that you had already discussed with the patient.

It’s very important that before you make any offers to the patient, you discuss them with us first.

As with all aspects of clinical dentistry, as you gain more experience and complete further training and CPD, you will hopefully encounter fewer problems with endo treatment and be able to identify and refer out those treatments that you are not comfortable with.

What non-clinical aspects of dentistry should dental practitioners consider?

Along with the clinical aspects of dentistry, I think the most important thing to consider is communication. You can be the best clinician in the world but if you do not clearly communicate and build a rapport with a patient, many studies have shown that you are more likely to get a complaint. 

Remember that communication isn't only about the words you use, it is also about how you talk to a patient and your body language. Rolling your eyes, sighing and trying to rush through your conversation with your patient is likely to lead to a patient complaint.  

I find that a lot of my patients appreciate it when I talk to them honestly about their options, risks, benefits and costs – a) it doesn’t feel like a sales pitch and b) you are showing the patient the respect that they deserve; if they feel this, they will have an honest and open discussion with you, which means that the patient will feel more involved with the treatment.

Part of being honest is being able to say “no” to a patient. A patient can, for example, ask you to give them eight upper veneers or take out all of their teeth. I’ve had patients at both extremes saying, “I’m sure you can do this, it’ll probably be so easy for you” and another patient who has said to me “they’re my teeth so you have to provide the treatment I want you to”. If at any point you feel that you can’t or don’t want to provide certain treatment, it’s usually wise to go with your gut instinct and say no. Many times we have had members call up after a complaint and the first thing they will say is that “it didn’t feel right for me but the patient insisted,” and “I didn’t know how to say no, so I provided the treatment.”

Other tips on communication

It is very important to avoid baffling your patient with jargon and remember that just because you understand what you're saying, it doesn't mean that the patient will. Give them the opportunity to ask questions and clarify the information provided – a good way of checking understanding is to ask them to repeat back to you in their own words what they’ve understood. By doing this, you can more appropriately document that you had provided information and given the patient the opportunity to discuss this with you.

Another aspect of communication is understanding and managing the patient’s expectations, especially when you are providing elective or aesthetic treatment. By having a detailed discussion with the patient and recording it in detail, you will be able to understand the patient’s expectations and then manage them – sometimes this may be by telling the patient that you can’t meet their expectations and offering to refer them to another clinician.

How important is record keeping?

Record keeping is very important and the requirements are set out in the Dental Board’s overarching document on how we should behave, the Code of Conduct. It is important to record sufficient information and you need to include any discussions, special tests, diagnoses and any discussion with the patient about the risks and benefits of treatment, and then you should note what the patient agreed to.

Auto-templating, or quick notes, has greatly improved efficiency when it comes to writing patient records but we are seeing that a lot of the information in the records is not relevant. An example being for the extraction of a 37: you may say that you discussed risks and warnings, which is great, but if auto-templated notes indicate that one of the risks that you had discussed is the risk of an OAC, which we know wouldn’t happen, the validity and accuracy of your records are called into doubt.

There is extensive guidance on record keeping on the Dental Protection website. We highly recommend taking a look as, without adequate records, you run the risk of either not remembering the treatments and discussions had with patients, or another practitioner not being able to understand it. The Dental Board look at records in detail, so it’s important to make sure that you don’t fall into bad record keeping habits.

Finally, I think one of the traps that many recent graduates fall into is working in isolation. This means working without any other clinicians around you. It can get very lonely and we have seen our colleagues affected by this isolation and burnout, leading to complications, mistakes and complaints, which can then lead to a deep cycle of stress and dissatisfaction with your career.

We also offer a confidential counselling service for members and encourage everyone to use it.

For a more in-depth discussion with Dr Keshwara and Dr Annalene Weston on this topic, listen to our podcast episode “Tip tips for young practitioners - what I wish I knew” available now.

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