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For my first ramble of this year I actually don't want to do that much of the talking. Instead I want to bring your attention to some previous posts by Lincoln Harris. You have probably already heard of him. He is the original creator of the R.I.P.E (Restorative Implant Practice Excellence) forum: https://www.facebook.com/groups/381541188712740/
If you haven't already found that forum I would strongly suggest you check it out. He also has his own site where he documents his work and often posts very thought provoking writing on various aspects of dentistry. I am not ashamed to say that I was inspired by these posts when I started thinking about creating my first Rambles. The ones I want to highlight today relate to treatment planning which Dr Harris compares to the 3 legs of a tripod. The first leg is "What does the patient want?". He discusses that here: https://www.facebook.com/RestoringExcellenceAcademy/posts/961267583933326 The second leg is "What does the patient have?": https://www.facebook.com/RestoringExcellenceAcademy/posts/962892833770801 The third leg is "What can the patient afford?": https://www.facebook.com/RestoringExcellenceAcademy/posts/990588244334593 Last year I had the opportunity to attend one of Dr Harris' courses about rapid efficient treatment planning but chose not to and instead invested the money on more photographic equipment. I am happy that I have a better camera but in hindsight I wish I had gone on his course. I will admit that I often struggle with the concept of treatment planning. Particularly regarding the points of what the pt wants and what they can afford. I make assumptions which may not ring true. Over time I feel I have got better at letting the pt talk and not putting words in their mouth but I still sometimes find this tricky. So one thing I will be trialling this year is a simple document that I call "The Objectives Compass". I am hoping that when I feel I am struggling to nail down what a pt really wants I might be able to use that to help guide the conversation. As you can see from the photo, it is just a very simple compass with common dental objectives for the different directions. The pt can then indicate which path they feel is right for them and that can then be the basis for further discussions about treatment options and costs. It wont work in every case, but for example it broadly works that if a pt states their main objective is to have the best looking smile, that is going to be pulling them away from minimally invasive work and will also cost more than other options and they should be made aware that some alternatives may last longer. And it works the same for each direction on the compass. It can be handled in the same way as the consent forms via the adobe fill and sign app which allows you to add extra text as shown in the example. It also allows you to document the pts selection via underlining, or circling certain words, or just putting a point anywhere on the compass if the pt is equally drawn by 2 objectives. So the main point of this post is to draw your attention to the posts by Dr Harris but also add my little addition. I am happy to take any feedback on this idea. So below is the original objectives compass I posted and an alternative version that may be useful based on discussions with other dentists. What's your excuse for not taking a lot of photos?
I used to have 3 main excuses: 1) It takes too long. Previously that was a very valid excuse. When my old camera lived in a camera bag in a cupboard and taking dental photos was a rare occasion then understandably it took quite a while to set it all up and get half decent photos. I also then had to spend a fair chunk of my lunch break or at the end of the day using a card reader to transfer them onto the computer. 2) It is such a faff getting good photos. If your camera is not setup right and you are not used to taking photos then this is the case. 3) It doesn't make much difference whether I take photos or not. Hopefully I will show that these excuses were pretty lame and it is now possible to make dental photography quick, simple and very effective. Over the past few weeks I have been trying an experiment. Instead of picking up my basic chair mounted intra-oral camera I have been seeing if I can instead get half decent proper SLR photos and show them to the pt in that appt. I will make it clear that I have not been aiming for perfect photos, but instead, quick, simple and effective (useful) photos. I will explain how it works: 1) I say out-loud "I want to get a photo of some of your teeth so I can show you what I can see." My nurse knows this is the cue to get me some cheek retractors and start putting the pts details into the photo consent form. 2) I take one or two quick photos. 3) I sit the pt up and let the nurse do a little small talk while I connect my wifi SD card to the iPad. 4) I transfer those photos onto the iPad. 5) I explain photo consent and get the pt to sign the form. 6) Now I can start showing the pt their photos. This whole process once you are used to it takes about 3 minutes. Thats really not a long time. It is possible to do it this quickly because I have practiced at it and I have simplified the process as much as I can with a few shortcuts: 1) I have fine tuned my camera settings so that I can turn the camera on and I am ready to go for the vast majority of situations. I do not change any settings about 80% of the time. You can only do this by practicing and seeing what works for you. I will admit that if I took longer it would be possible to get better photos. I have come to certain compromises so my occlusal photos may be very slightly underexposed etc. 2) I package up my retractors in standard sets. Each set has a pair of large, small, and cut off retractors so that any pt can be accommodated. 3) I use a heated blanket so that my occlusal mirrors are ready to go all day long. 4) My camera has a shortcut button which I have programmed to take me straight to the part of the menu relating to creating a wifi link with an iPad. See photo below. 5) My iPad knows to automatically connect to that network when it sees it. 6) The relevant apps for the photo transfer, photo storage and consent forms are all my favourites at the bottom of the iPad screen. Now finally the effectiveness part. I honestly used to think that it didn't make much difference whether I took photos or not. I felt like I was good enough at explaining things so that the pts would understand me whether then can see their tooth or not. I also felt like my work was probably good enough without taking photos too. A recent examination proved this was not the case. I recently had a 5 year review of a veneer case I did just after qualifying. A lady in her mid 70s with a midline diastema she wanted to close and centrals with multiple composites on the buccal surfaces. I removed the fillings and prepared for feldspathic veneers and they are still in place. At the time I was happy with the result and the pt is still really very happy with how things look. However I was shocked at how many faults I can see with my previous work. A lot has changed in those 5 years. I am the first to admit that back then my passion for dentistry was almost non-existent. I did the job and went home. I have since then upgraded to 5x loupes. I now work exclusively with a very highly skilled technician. However the big factor for me is that if I had taken photos before I picked up a handpiece then I would have treated this case differently. And now that I am so much more used to studying photos of teeth in detail I know that my attention to detail is a lot higher and I would have been able to get a better result. So below are a selection of photos I have taken in the last few weeks. Every single one of them was taken, transferred onto the iPad and discussed with the pt at the same appt in my normal allotted times. I did not extend any of the appts to allow me to do this experiment. When my diary gets fully booked to everything apart from emergencies up till Christmas this for me is the trigger that I use to start reflecting upon how the year has gone. I like to write down a list of changes that I have implemented in the past 12 months and consider what I want to do over the next year. I call this my Annual Review.
I like to try to keep this process positive rather than dwelling on the things that have not gone well. It is easy for time to march on and you so easily forget how many improvements you make but can instead so easily recall the problems you encountered. I try to separate this into a few different categories such as new materials I am using, new techniques I am employing, administration/non-clinical changes, and personal life situation. I won’t list everything but here are a few examples of things in my 2016 review: New Materials Bioclear matrices. Still in the early learning stages but quite liking these. Unodent heavy non-latex Rubber dam. 12 months ago rubber dam use was a very rare thing for me. Now I will not do RCT without it and I am starting to use it for other work too. Ivoclar stump shade guide. My demo model. I had it made as an early Christmas present to myself 12 months ago. I use it every single day. New techniques Heated composite. An absolute revelation. Steam cleaner. So useful for cleaning grubby dentures and ensuring indirect restorations are clean after try-in. Heated blanket for photography mirrors so they are always ready to go. Just makes it so much quicker to take some good photos. Administration/non clinical changes I think the big changes for me over the past 12 months have been in this area. I changed my diary to 20 min slots rather than 15 back in January. This has really allowed for more thorough exams and more time for higher quality treatments. Slowly getting away from the 35 pt days. OHI postcards. These have had a huge influence on how I give my OHI and is really showing results. Written New pt packs. Complex treatment consultation packs. Written consent forms. I now much more regularly refer work out e.g. complex endo. I feel much more comfortable stating to the pt when something looks beyond my capabilities and then offering solutions and as a result it means that I am doing more of the treatment I want rather than failing at work beyond my capabilities. I have done my first bit of paid teaching of some FDs. I really enjoyed this and have begun looking at other opportunities to do more. I have been involved in a local dental study club and have found this has helped to create better bonds with other local dentists in similar situations. And another big change is starting these rambles. Something that I find is a great way to focus my mind and make better use of my wasted time at work when pts DNA etc. Personal life We moved house just over 12 months ago so a lot of work this year has gone into getting settled in our new home and kids in a new school etc. I am taking much better care of myself now than I have in previous years. I used to be dehydrated almost every work day and not eat well while at work. I now do basic Tai Chi exercises at least 2 times a week to help relax my body and stretch out the back and shoulders. I now do short jogs a few times a week whereas for the past few years I have done no exercise at all. As I said this list is not exhaustive and it isn’t meant to be bragging in any way rather just an example of how many aspects of my life have changed in the past year. I would be interested to hear how other people reflect on how this year has gone for them. The year ahead Now having reflected on this year it is a good opportunity to consider what you want to do next year. This can be with small changes like those mentioned previously or can be relating to hitting certainly financial targets etc. In January 2017 my diary is being zoned so that most of my treatments will be booked in the morning and most of my exams are done in the afternoon. I will also have more time dedicated to emergencies and time specifically set aside for new patient exams. I have been meaning to try this for years and am quite looking forward to see how it works when we get there. I am going to spend a fair bit of time researching different air-abrasion systems that I know a lot of people on these forums use as I feel they may benefit my work. And I am going to be a lot more pro-active in looking for new job opportunities. Either closer to home (getting bored of my 45 minute commute) or with different prospects such as buying in to a practice or learning a lot from a very experienced clinician as I have decided I want to be doing a restorative diploma/masters at some point soon. |
AuthorDr Chris Harper Archives
August 2020
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