The Grass Was Always Greener

Another posting from an angry / disillusioned middle aged dentist on a bulletin board.

The usual content – I can’t wait to get out, I’m only holding on for my pension/next new contract/someone to buy me out. As ever there was the associated blame game GDC, BDA, CQC, Government, politicians of all hues, patients, banks, Dental School overproduction and so on. Along with this comes the hankering after the Golden Age when things were good, when you could make a good living without intervention and so on.

So when was this Golden Age was when the grass was greener, the days were sunnier and the sea warmer?

Tobias Smollett’s Humphrey Clinker felt the same in 18th century, “was the world always as contemptible as it appears to me at present?” he exhibits the common vice of old men “tiresome, complaining, a praiser of past times”.

According to Horace the middle-age have always been moaning about things. My mother, like many mothers, used the litany “I don’t know what the world is coming to” from the first day I can remember, until her mind finally went.

It made me wonder about “Dentistry’s Golden Age”. It strikes me that the Golden Age of Dentistry (or of anything) took place in the years just before you joined it. So depending upon your age that will be just before the last new contract (2006), the contract before that (1992), the last hike in patient charges or the last change of government.

The principals in my first practice (who were 5 – 10 years my senior) told me that, everything had changed for the worse but the dentists before them had had it pretty good. They in their turn no doubt could point to the generation that flourished when the high speed turbine was introduced circa 1960. Of course in the years just after the introduction of the NHS it is fair to say that dentists were faced with an ocean of disease and had little choice but to fill their boots. That particular Golden Age ended in 1951 when, to raise funds for a war, the government introduced charges for prescriptions and dentistry.

I think you can get my point here.

To those who came after me let me tell you about the Golden Age that I lived through:

  • General Anaesthetic sessions in practice where 20 or more children had anything from 1 to a dozen teeth removed in a “sniff and snatch” session at the end of which would be 3 or 4 Dental Clearances and the delivery of approximate, “fit where they touch” full dentures.
  • An acceptance that the route was a filling, a larger filling, a crown, then root treatment, extraction and denture.
  • Periodontal disease was something that could be neither cured nor treated.
  • Where composite fillings were mixed from two pastes and set before you got them to the mouth in summer and seemingly never in winter.
  • Where occlusion was only about straight up and down movement.
  • Where orthodontic treatment for the majority was, upper fours out and a removable appliance to retract everything else – hence the ‘British straight down the throat’ appearance.
  • Where one serious option for a cosmetic solution was extraction and a plastic denture.
  • Etc

Not so much Golden as Silver (Amalgam).

Then that all changed for me. In the space of 12 months I had a turn around, a paradigm shift or whatever you want to call it and refused to accept the lessons that I had been given. So I wouldn’t take teeth out that didn’t need to be removed, I did believe that people were given teeth for life and it was my role to help them keep them for as long as they wished and that gum disease could be controlled.

I learnt to take a long view of my patients dental health and that the relationship was between the patient and me and not a third party.

A few short months later I realised that I would have to remove myself and my patients from the shackles of the NHS which was being increasingly driven by political fad and dogma. It took courage but it wasn’t impossible. My friends who hadn’t, didn’t or wouldn’t convert said the usual, “they wouldn’t have it round me”, “they don’t value what I do” or “I’m committed to the NHS”.  I was never convinced by their reasons but I made my own Golden Age and I see others enjoying their own Golden Age now.

So where is this going?

It’s up to you to create your own future, to build your own Golden Age. Companies like Shell build their businesses by looking 25 years or more ahead, politicians rarely look further than the next election. Which model will deliver you greater success and happiness? Yes you have to be agile as a business, you must know which way the wind is blowing and learn to respond to trends both social and economic. But you must also decide on how you will live your life and run your business.

Ask yourself, “If I wasn’t starting from here what would I do? What would I want to achieve? How would I go about it?”.

Take out the politics. Look at your patients, their diseases, their elective needs and wants and what would you do that is different from the way that you live your professional life now? Is that the right thing to do? Or not?

What’s stopping you from creating your own Golden Age?


Doctors Make Worse Decisions as the Day Wears On

Doctors Make Worse Decisions as the Day Wears On

From The New York Times

Primary-care doctors’ likelihood of prescribing antibiotics for acute respiratory infections increased by 1% in their second hour of work, 14% in the third hour, and 26% in the fourth, suggesting that physicians experience “decision fatigue” over the course of a day, according to a New York Times report of an 18-month U.S. medical study.

Overprescription of antibiotics is a widespread phenomenon: In two-thirds of the cases studied by the researchers, antibiotics were prescribed even though they were not indicated, the Times says.

Need help with your scheduling? Give Alun a call.


The Monday Morning Quote #293

“We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.”

Atul Gawande,

Atul Gawande is delivering The Reith Lectures 2014 – BBC Radio 4 starting on November 25th

The Monday Morning Quote #292

“The art of writing is the art of applying the seat of the pants to the seat of the chair.”


Can you guess what I struggled with last week?

Here are a few more things that he wrote.


Guest post from Mark Topley – “what if your child had toothache, and no hope of help?”

I want to share this blog post from Mark Topley the CEO of Bridge2Aid – the message is simple, please read then take action and join the whatif campaign

3 years ago this month we shot a video with our friends JSP Media about Bridge2Aid and our pioneering work training local Health Professionals to provide a simple, safe but vital emergency dental service. I spent the best part of a week with Jem and the team, and we travelled to one of our training sites to view the volunteer training team in action.

The reason I tell you this today is because what I am going to ask you to do below was inspired in part by one of the children we saw on that trip. He was around 5 years old, and has probably been one of the most deeply impacting patients I have ever come across on DVP.










He was in a bad way. His face was swollen badly on both sides, and he was having difficulty breathing.

Ian, one of the training team, examined him and talked to his trainee as he did so…

As Ian says – tragic.

Not just tragic because he has such a bad swelling on both sides of his face, but tragic that he ever got into that position in the first place.

The truth is, that if, by accident of birth, you hadn’t been born in the UK, or a developed country, this could be you as a parent,  sat with a very sick child in pain on your lap – this could be your child.

Toothache is really common. So common that we don’t think about it much, such is the level of access to safe and free treatment we are fortunate to have.

But what if that wasn’t the case?

What if your child had toothache and no hope of help?

With not even the most basic dental service available for the majority of people living in the rural areas of places like Tanzania, there are countless cases like this out there. And more than half of people with toothache will develop complications like this without access to basic treatment.

This is the treatment we provide. It’s what we train and equip government Health Professionals who are already embedded in rural villages to do, day in, day out. And we need to do more – we need your help to do that.

I want you to click here and join with us and our ‘What if?’ campaign.

Simply enter your email and over the coming days we will tell you just how you can help and be part of making tragic cases like this little boy, a thing of the past.

Thank you.

Just because you can doesn’t mean you should.

I am no longer a clinician but that doesn’t mean that I have forgotten all the lessons that I learned from 30+ years of full time practice. My instinct meant that I was cautious when dealing with what nature had provided for people. In spite of that during the years 1981-86 I did large numbers of clearances for patients in the practices where I worked and had the services of an anaesthetist (a long time ago I know). 90% of those cases were for the other dentists in the practice, I was the one with the surgical skills and enjoyed the challenges that these “cases” presented. I choose the word case rather than person deliberately.

From the day I started my own practice in 1988 until I (finally) stopped clinical work in early 2013 I did only one procedure that could be considered a dental clearance. It was the right thing to do for the lady at that time, but I remember how it upset me and how I felt I had somehow failed her.

I went on an all day course on restorative dentistry at the Royal College of Surgeons in about 1990 where I fell into conversation with someone who told me he was getting through 4 or 5 “full mouth re-habs” a week. When I asked him how he managed to find the time and the patients, he told me that he only needed to allow 2 hours for a “full mouth” and there were no end of people who were grateful for his saving them from dentures. This last phrase confused me because I had never come across anyone who had lost teeth because they lacked porcelain fused to metal crowns.

My thoughts then spread to how poor my undergraduate education must have been when compared with this chap’s superior skill base (from a well known London teaching hospital) and he had qualified only 5 years before. When I said that I had recently completed my year long training in occlusion he replied that I was wasting my time and money as all that occlusion stuff was nonsense because the technician would just put things where they fitted anyway.

HippocratesI drifted away because he started talking at someone else about new models of Porsche – a subject about which I knew little and cared less.

I resolved that I would have to ‘up my game’ if I was going to be a proper dentist. So my studies with Mike Wise and more meant that I did know more and if anything did less in the line of “full-mouth” work – at least in one stage.

Implants have been a game changer in restorative dentistry, I always referred my patients to someone I knew and trusted, as it was not an area that appealed to me. I am aware that it is seen as a ‘big earner’ and a practice builder by some – and I know many highly skilled and experienced implantologists.

My concern is about those who, because they have the new hammer, tend to see everything as a nail. This was brought home to me last night in a conversation with one of my longest standing clients, a experienced and highly skilled all round restorative dentist who has been undertaking implant work for more than 10 years, when they said to me,“an implant is a great replacement for no tooth but it is a poor replacement for a tooth. The more implants I do the more I like teeth.”

We agreed that just because you can doesn’t mean that you should.

Now that is a dentist I would recommend.

The Monday Morning Quote #291

“The worst walls are never the ones you find in your way.

The worst walls are the ones you put there—you build yourself.”

Ursula K. Le Guin, writer


Thanks to Michael Bungay Stanier

The Monday Morning Quote #290

“Muscles without strength,

friendship without trust,

opinion without risk,

change without aesthetics,

age without values,

food without nourishment,

power without fairness,

facts without rigor,

degrees without erudition,

militarism without fortitude,

progress without civilization,

complication without depth,

fluency without content;

these are the sins to remember.”

Nassim Nicholas Taleb


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