The good, the bad and the ugly – dentistry and COVID-19: an uncomfortable alliance
It is incredibly difficult to write an article about my return to work experiences without adding to the mountain of depressive news and articles that litter our physical and electronic existence. I, for one, find myself exasperated by the sheer volume of negativity surrounding dentistry in 2020, and here I am, on the precipice of adding to it! I’ll start with what my reality has been, then turn my attention to more positive matters.
As we emerge from being buried alive by an avalanche of Standard Operating Procedures (SOPs), what has occurred to me most strikingly is that there is nothing standard about our operating environment at all. The human factors involved in how patient-centred dentistry is delivered means standardisation of anything in a dental clinic is incredibly challenging – and attempting to implement standardised procedures can be incredibly stress inducing. We spend our days being flexible, thinking on our feet, problem solving and communicating – and all with a fluid blend of carefully mastered skills and experience. Suddenly, we have found all we hold true to be under threat from COVID-19 and its fallout, with an overbearing requirement to adapt rapidly to the consequences.
It has been fascinating to watch how different character traits have responded to this crisis within dentistry – both within my own local environment and also on a broader level within the profession. There have certainly been many negatives within dentistry as a result of the pandemic, but also an opportunity for many positives. I thought I would share my own experiences of returning to dentistry through the provision of one single defining treatment and how my own perceptions of the profession have changed as a result.
My first day back…
My first post-COVID-19 clinical session was right in amongst the confusion and disarray over the eligibility of private practices to return to face-to-face dental care provision. It felt very much like we were operating without jurisdiction and, in doing so, we were risking our professional status. A mind-boggling scenario now in retrospect, but a feeling very much forced upon us by our regulators.
To provide some background to this, I had been receiving regular calls from a very unwell patient (late stage liver failure) who was evidently in the final stages of his life. This particular patient was shielding, acutely aware that if he contracted COVID-19 he would most likely not survive, and had no desire to seek any form of healthcare in a secondary care setting. Unfortunately, he was suffering from a persistent pulpitis, which did not subside throughout the whole of lockdown. This pulpitis was the worst sort – never reaching a crescendo and abating, but instead sat there in the background, which meant this poor gentleman could not sleep. I had, of course, offered antibiotics (as we had been advised to do despite them being wholly ineffective for this man’s needs) and also offered referral to a UDC. This gentleman didn’t want antibiotics as they made him more unwell, and certainly didn’t want to be referred away for treatment in an unfamiliar environment. This went on for many, many weeks. My patient simply wanted to enjoy his final weeks of life without pain.
And so, when we began to be operational again on a very basic level, I just knew I had to help this patient as best as I could. The reality was, however, that we were restricting our services to non-AGP only. How do you manage a pulpitis with a non-AGP approach? Quite simply, as we all know, you cannot. How many more patients like this, nationwide were being denied the most basic care? I couldn’t help but wonder.
I was duty bound to treat this gentleman as I saw fit, and would happily justify my reasons for doing so to any regulatory body. His needs, and my willingness to help, superseded any directives from the OCDO or anyone else for that matter. And so, with a visor, gown, rubber dam and the best fitting respirator mask I could find, I set to work to open and dress his carious lower left 8. I felt nervous because of the opaque jurisdiction under which I was working, I felt nervous because of the patient’s fragile medical health and, not forgetting, this was a clinically challenging procedure – so not one to be taken lightly.
It was a stressful and tiring procedure, taking probably well over an hour. The pulp was hyperaemic, insufficiently anaesthetised and difficult to restore, but an intra-pulpal sedative dressing was placed, and the patient left happy and content that we had done our best to help in such difficult circumstances. I was left feeling like I had behaved irresponsibly somehow and wanted to get home and forget all about it. It was the weekend after all…
6.45pm that evening
I was on call on this particular weekend – quite fortuitously as it turned out because later that evening I received a phone call from the patient’s wife, evidently very distressed. It transpired that the patient had returned home and gone straight to bed, reportedly feeling unwell. This was now some seven hours after his appointment. The patient’s wife had rung his hepatologist who felt his symptoms resembled sepsis. Cue panicked phone calls to his GP (who was a locum), local pharmacists and finally tracking down his hepatologist by telephone who was on annual leave. I was pushing for the patient to be admitted to hospital, but the patient simply did not want to go for fear of contracting COVID-19. I felt at this stage, I had done all I possibly could.
The outcome was that the patient did not go to hospital and recovered after several days thankfully, out of pain and able to sleep well. The whole episode did affect me profoundly however, and I want to explore the reasons for this.
All in all, it was a harrowing 48 hours, instantly making me remember what I loathed and loved about dentistry. It came at a time when the patient was at his most vulnerable, but in a very different way, so was I. The relief that my intervention had had a positive outcome for this patient was extraordinary and made me remember why I do this job in the first place- to help those in need. It did leave me wondering why I felt the way I did. Why was this one situation so frightening?
I think, on reflection, we all returned to work in a heightened state of anxiety and fear (like we needed any more of that). And, as much as SOPs and guidelines were there to help us, they also acted as an added burden under which we had to now operate. The pandemic was beyond our control quite evidently, but our response to it as a profession was something that was controllable. The cessation of face-to-face care, coupled with the unclear and fragmented communications on resumption of treatment provision, created uncertainty. Thinly veiled warnings about how our regulators may react to any breach in protocol were coming thick and fast with fear, nervousness and anxiety forming a formidable backdrop to chairside care provision.
Give us a break!
We, as a profession, should stop being so hard on ourselves. This decade of self-flagellation has to stop before it becomes any more destructive. We are emerging out of this crisis under incredible emotional and fiscal pressure, into an environment that is tense, to say the least. Although it is a relief to be back, I find myself at my wits end, before I have even got into the swing of things. With the majority of nursing staff still on furlough, dentists working side by side (which is challenging), enhanced cross infection protocols which are physically draining, additional triaging duties during the day which are laborious and this is even before we have set to work on our actual job, in full length gowns and searing summer heat.
It is important that we do not forget that we are only human. We have limits of physical and mental endurance, pushed to the limits by factors outside of our control. I have tried to take a step back and appreciate that this may only be for a short time, and this time will surely pass.
Perhaps it will only last for a short while, but I have found patient appreciation of our mere existence to have dramatically improved. Several time I have been thanked ‘for being there’, ‘being open’, ‘making the effort to see me under such difficult circumstances’. These are simple words which I have not heard at all often in thirteen years of clinical practice. It offers much needed relief to my barraged ears.
People talk about taking stock, and I didn’t feel I did much of this during lockdown if I’m honest. I did take stock though over my first few days, when I began to realise that dentistry is just a job, and quite honestly, for much of the time, the immense stress it puts us under makes me question if it is worth it. I had not experienced that heart sink feeling for almost three months, like I did on that first Friday night back, and I hadn’t missed it. It made me question if I wanted to continue putting myself in the firing line for these situations again.
Realising what creates stress is no bad thing, and I intend to use this as an opportunity to make changes to how I work, where I see myself in ten years-time, and how I intend to get there. I no longer want to have my vision blurred or my career direction obscured by the hum drum, day to day, hamster wheel of clinical dentistry. I want to use this as a springboard for more positive changes to my working life.
I am sure many people will have taken the time to upskill ‘virtually’, but not beat themselves up when their rubber dam is not inverted beautifully like the dentist they watched on social media. Failure to make it look like it did in the webinar should be welcomed, because nothing is ever right first time. A more positive outlook would be to welcome the opportunity and time to practice these new skills.
In my opinion, dentistry as it is right now, in June 2020, isn’t a new normal. It is a temporary response to a crisis on a scale we may never witness (hopefully) again in our lifetime. It is merely a symptom of a fragmented profession and a hyper-responsive society, who have over indulged on sensationalist journalism. In my opinion, lessons need to be learnt about how dentistry responds in the future to a viral pandemic threat and be much better informed, prepared and led. Dentists are dentists, whether working in the public or private sector, with each of us meeting the needs of our patients to the best of our abilities. I intend to free myself from the shackles of regulatory burden and start to enjoy my job again. I intend to enjoy the mistakes, for they are an essential tool by which we learn and begin to practice with a smile again. I believe this will shape my future and make me a far better clinician. The only problem is nobody will see my smile behind my six-foot Perspex face shield.
Damien McNee BDS, MSc, PGCert is a general dental practitioner working in private practice in Banbury, Oxfordshire. He is a communication sub-committee member of the British Association of Private Dentistry (BAPD). For more about the BAPD, visit https://bapd.org.uk