Student Section by Kishan Sheth

Dear fellow colleagues, friends, ladies and gentlemen, I was deeply and truly honoured when I was appointed as the student honorary associate editor for the Dental Town UK publication. The entire concept of Dental Town in the USA has empowered dentists all around the world and has been an extremely beneficial learning tool for students, including myself, and I was very excited to hear that the movement was being brought to the UK. It is indeed a chance and an opportunity to discuss important matters and trends in dentistry and share ideas, which lead to the spreading of knowledge and generation of discussion and debate.

I very much hope that I will be able to fulfill the expectations of my fellow students and ensure the publication includes a wealth of material for them to read and learn from.

The primary goal of the student section is to empower undergraduate dental students to write about topics they are passionate about, and share their experiences with all their fellow dental students in the UK.

We would, over the upcoming year, love to receive articles about your electives, relevant articles on topics such as seeing your first patient, or articles about how you balance your extra-curricular endeavours with university work and what these extra-curricular endeavours are.

This is a magnificent platform to showcase yourself, your thoughts and your ideas to the entire profession and I would encourage each and every one of you to write in with your articles and reports. Is there an area within dentistry that you have been reading about? Would you like to put together a brief article summarizing your findings? Have you read a book recently that you think has changed the way you view something? Would like to write up a book review? Whatever empowers the profession and begins discussion should be shared for all to benefit from, and we all encourage the discussion of ideas which will help us to raise our standards and become more effective providers of patient-centred, evidence-based, minimally invasive and holistic dentistry.

In starting my role, I very much hope that the publication, which I hope to continue to serve, will be able to look forward to nation-wide support from every sector of dentistry, including the future of the profession, the student body.

I am confident that Dental Town UK will deliver an unrivalled service to the profession, and will play a pivotal role in the way in which students and professionals come together.

I would like to take this opportunity to express my sincere thanks to the very many people who have individually and collectively supported me so far with all my ventures, from the lectures that I’ve put on and the publications I have managed to publish, to the dance shows I have been humbled to take part in. I am truly indebted to my colleagues, friends and family for the generous hospitality and kind wishes extended towards me whatever I do, or wherever I go. I truly am extremely excited to take up my role on the honorary editorial board for Dental Town UK, and I would like to thank Mike Gow for believing that I was the right person to deliver on this role.

Finally, I must congratulate the other members of the honorary editorial board for being appointed. It is incredibly impressive to see so many of my mentors and role models on the board, and I am very much looking forward to collaborating and working with each one of them to take the publication from strength to strength.

This edition, the first to be published, is full of exceptional hand-picked, evidence-based and interesting information which will help to challenge ideas in dentistry. The student section has some incredible insights into the lives of talented dental students studying in the UK, and we are also excited to promote the informative reports written by Ajay Mehta and Vedaant Patel about dental electives and DFT/DCT respectively. I am also very humbled to have been given the opportunity to talk about breaking bad news about periodontal disease to your patients, and I’d be very interested to hear back with all your thoughts and comments.

I hope you enjoy this Dental Town UK edition, and am confident that it will spark the start of an amazing and exciting line up of magazine publications which will inspire and engage dental professionals and students all throughout the country, and indeed the world!

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I would like to begin this article by explaining carefully that I am a student in my fourth year, and not a professional dentist or an expert in the field, and therefore this is a synopsis of my experiences when being on the consultation clinic or when assessing patients for the very first time in my periodontology treatment sessions.

 

 

Many of the patients I have seen have gone for long periods without seeing a dentist, and they have noticed ‘wobbly’ teeth, or receding gum margins, and have come for an assessment to find out exactly what is going on. The biofilm will always be resident on the tooth surface, but if left to grow in size, it will allow for anaerobic species to colonise the environment, and these anaerobes can produce the toxins and enzymes needed to destroy the host tissues themselves.

 

 

Patients must understand that essentially the disease dynamic is a face off between the host’s immune system cells and processes, and the bacterial challengers, with factors such as smoking, systemic disease, genetics and certain drugs affecting the speed of onset and severity of the disease process.

 

 

Even as fourth year dental students at King’s College London, it has become apparent by the clinical work we undertake and the patient interaction we experience, that communication skills are paramount to good dental practice. It must be learnt through experience, and in particular, so must the art of delivering bad news (Sheth, 2015).

 

 

The Collins Dictionary would define bad news as being the following: ‘someone or something regarded as undesirable’, however I would personally define bad news as any information which, when delivered, will adversely alter a person’s expectations and trigger an emotional response, as their vision of their future will be, in some way, negatively impacted. I fundamentally believe what makes bad news negative in nature is the disruption to someone’s beliefs and views of the future, and this will in turn generate an emotional response.

 

 

As dentists and dentists to be, we are not formally taught how to communicate with patients during our undergraduate training. The exact nature of the bad news will of course depend on what clinical work the clinician carries out.

 

 

I have had the task of explaining to several patients why they should have their teeth extracted due to low levels of bone and problems with cleaning the adjacent teeth, and ultimately why their condition cannot be reversed, as periodontitis is an irreversible and destructive disease process. A very important fact to note is that, if this process of delivering the bad news is not carefully planned or conducted, the patient may not fully acknowledge and understand the impact or severity of the information being delivered, and thus a misunderstanding arises between patient and operator.

 

 

The demonstration of empathy is an essential element of generating patient trust and confidence. Some key aspects of delivering bad news that I have learnt to adopt are as follows: prepare myself for the task ahead – you must ensure you have all the relevant information on hand, what is likely to have caused the disease and how can it be stopped? Full assessment of radiographs and special test results must be on hand.

 

 

Furthermore, explore the patient’s view of the situation and how much of their condition or situation do they actually know about – this makes it more efficient when trying to talk to them regarding their oral health problems as you are more aware of how much information you actually need to deliver for them to accurately acknowledge what is going on inside their mouths and understand the way forward.

 

 

Finally, always reflect and review your performance – what aspects could you do differently next time, what worked and what didn’t work as much as you expected it to? At the same time, don’t forget to evaluate what you did well so you know to integrate it into your delivery next time too – although it’s important to remember that no two patients are the same, and the method, manner and content of deliver should be thought through and tailored where possible for that particular patient! A valuable tool for me has been my clinical tutors who have been able to pin point what aspects of information delivery I was doing well, and the aspects, which needed improving.

 

 

The work of Bail et al. (2000) was critical in allowing clinicians to understand, analyse, evaluate and conduct a six step protocol in which they could accurately and effectively break bad news, in a way in which the patient still felt cared for and safe, a critical breakthrough in the way in which patient centred care is conducted as previously there was no evidence based regime or system for information delivery to patients, and each operator had a different style. The concept then progressed and is today, referred to as the SPIKES strategy (Buckman, 2005).

 

SETTING

The location in which the information is delivered can have a major impact on the way in which the patient reacts to the news. Remove distractions such as the TV or radio, try to have a discussion in a private area, such as an interview room, as the patient will want to feel safe and in a private environment when sensitive information is discussed.

 

PERCEPTION

Instead of blasting all the information at the patient, take a step back and try to understand and acknowledge their actual level of understanding with regards to their situation. Ask the patient questions like ‘What is your understanding of what’s going on inside your mouth?’ ‘Are you aware of why you have high levels of bone loss/ ‘wobbly’ teeth?’ or ‘What have you been told so far about your situation?’ This will allow you to accurately assess the difference between what the patient understands of the situation, and what the medical reality of the situation actually is.

 

INVITE

Although most patients may want to know about all the relevant information in its entirety regarding their dental situation, you should never automatically assume that this is the case. Some patients may prefer to know a little bit at one appointment and then the rest at a follow up to give themselves time and space to process the discussed information in stages.

 

KNOWLEDGE

Never drop a bombshell when you can gently ease the patient into the news. Warn the patient that some bad news is about to come. I often start by saying ‘I’m so sorry to inform you that you have gum disease….’ ‘Unfortunately, I’m very sorry to inform you that you have very little bone left around some of these teeth’ ‘I’m sorry to inform you that I have found large pockets around several of your teeth’ or ‘I’m sorry to tell you that this tooth is no longer alive, the nerves and blood vessels on the inside have died and the tooth is dead and must be extracted’.

 

EMPATHY

Listen to what the patient has to say and don’t interrupt them when they’re in the middle of offloading their thoughts and expressing their feelings. I find that it is better to empathise with patients than attempting to sympathise with them. It is wise to validate the patients’ feelings to ensure that you tell them exactly how you think they feel.

 

SUMMARISE

It is likely that during your delivery of bad news, you have given lots of relevant information that the patient may not have had time to process. Briefly summarise your discussion into bite-size chunks the patient can understand and retain and provide them with a clear action plan going forward, ensuring that they know what is expected of them, and what they should expect from you. Make it clear that they can contact your office or student officer should they have any additional questions, and that you’re on hand to help. Dentistry is always a team effort between patient and professional! The patient must be kept in the loop at all times with how the treatment is going and how their tissues are responding to the treatment, regardless of the treatment outcome.

 

The SPIKES protocol has really helped me to analyse, evaluate and deliver bad news in a simple and structured manner. Delivering bad news is a challenging and demanding task, but I hope that this article will benefit you and your team members in the challenges that lie ahead for both yourselves and your patients.

References
Collins English Dictionary Online, collinsdictionary.com. Sheth K. How can dentists minimise their stress levels? Dental Town 2005; 2:32-34. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES- a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302-311. Buckman RA. Breaking bad news: the S-P-I-K-E-S strategy. Community Oncology 2005;2:138-142