NHS vs Private Dentistry – Can you be Comprehensive? – IC012

Jaz’s Introduction: This episode is brought to you by Make Me Clear. Now makemeclear.com is a website I use to make really beautifully presented treatment plans for my patients so anytime I’m doing a bigger plan I will use make me clear you can slot in your photos your text all the diagnoses it’s got these visual charts which are nothing like the nasty ones you have on your uh software that you use at work. These are really easy to understand for the patients with a great way to communicate costs and different phases of treatment and if you haven’t already listened to episode 49 with the founder of Make Me Clear, Dr. Jorge Cardoso you should definitely check it out and listen to the value it can have for you as a dentist even if it increases your case acceptance by one patient for the whole year it’s totally worth it.

So do check out Make Me Clear in fact one of the Protruserati, Robert Young had this to say Rob said “I’ve started using mmc the other day it’s a game changer for me and my practice patients love the report and communicating costs is made so much easier. ” So guys check out episode 49 and if you like make me clear do the 21 day free trial to get 25% off use the coupon code “protrusive”. So once again makemeclear.com coupon code protrusive for 25% off but see for yourself do the 21 day free trial, give the treatment plans to your patients and just see for yourself the impact it has to your practice hope you enjoy this next episode.

Hello, Protruserati. I’m Jaz Gulati and welcome to this interference cast on NHS versus Private Dentistry. Now it’s not what you think it’s not the cats versus dog sort of fights that you see on social media where NHS dentists and private dentists are going at each other’s throats. None of that. It’s not happening. Think of this episode as NHS versus private in terms of is it possible to be a comprehensive dentist on the NHS? Is it possible to practice a high level of dentistry whilst also having an NHS contract?

That’s the kind of burning question I want to answer today and to answer I’ve got Dr Devang Patel, who is such a brilliant dentist and you’ll hear his journey I mean he is very much a mix practice practitioner if that makes sense. He has an NHS contract but the kind of dentistry he does is definitely comprehensive, it’s brilliant. So I know that the number one issue or the number one burning problem that NHS dentists have is I want to be able to do more, I want to be able to do better for my patients but you have that blurred line that blurred boundary in terms of how can you deliver that care to the patient within the realms of the NHS contract.

Now I know you know what I mean but for those of you listening from around the world you probably just listened to this and thought what the hell is Jaz talking about right? So guys this is a really an interference cast predominantly I think for UK dentists because we talk about this the way that dentists are remunerated in the UK for those who work in the public health sector which is the majority and the way that they experience challenges in terms of giving a high level of care while still being profitable or not losing money I mean it sounds really bad saying it this way but this is the truth I’m probably going to be for this reason making sure that this video is not available on YouTube publicly this will be an unlisted link. So that patients don’t come onto this because I’m not bad mouthing the NHS, we’re just going to be discussing about how we can do better while still having an NHS contract.

So if you’re from listening from around the world I still think you will gain a lot from this episode and you definitely want to hang around for the Protrusive Dental pearl which is a free communication course but I’ll come to that in a moment but I think you should hang around because I think this episode does give you so much value maybe you are working in an insurance-based system or a public health system and you are frustrated then I think you will learn a lot from how Dr Devang Kumar Patel was able to speak to his patients in a way and get them on board with the fact that there’s only so much he can do within a public setting and give him options that are a bit more premium if you like. So do hang around if you think that will be valuable to you.

Protruserati, boy. Do I have a Protrusive dental pearl for you okay? So this episode which is by Dr Devang Patel, he has a website and he’s got lots of courses for you to do. One of his courses which is communication in dentistry. You can get it completely free by doing the following okay? You need to go to www.protrusive.co.uk/communicationdp. The DP stands for Devang Patel. So it’s /communicationdp. When you sign in there you will get an email with the link to the course and the secret code to get 100 off the course price so this is an absolute gift so thank you so much Devang Patel for this amazing protrusive pearl you’re sharing with us today. I’ve been through a course myself. I’m actually working through it now and it’s really well set up, easy to access, bite-sized chunks, everything you want from an online course. So thank you Devang Patel to making this available for the Protruserati and now let’s dive into the main part of the episode.

Devang Patel welcome to the Protrusive Dental Podcast, it’s so, so, good to have you, my friend. How are you?

[Devang]
I’m very well and nice to be here, Jaz I mean I listen to your podcast really all the time, I drive a lot and really good work really good product really good job.

[Jaz]
Thank you so much and it’s an absolute honor to have clinicians like you listening honestly it really, really, bumps up my ego a million times I guess when I think oh my god these awesome clinicians. Because one thing I was thinking about and we had a little chat beforehand, we’re emailing a little bit about your journey. And I was convinced I know I recognize this guy I think he’s taught me before and I remember that in Eastman they were doing these like what we call the section 63 or e wisdom sort of courses and it was all about taking beautiful impressions and soft tissue management around taking impressions and stuff and I really think it was you who’s doing it and it makes sense because your history between 2012 and 2014 you were teaching at the Eastman as well and I know so you really rang a bell and then to learn what you’ve been up to since then and it’s been brilliant but today’s episode we’re going to be covering a few different things.

We’ll be talking a little about your journey because I think it’s very interesting journey. We’re going to be talking a little bit about the four pyramids that you sort of allude to in your email which I think is brilliant. Starting from diagnosis and the very last thing being actual that the treatment and the importance of communication which I think will be so powerful and useful. At the end we’ll talk a little bit about a very controversial subject which is how can you possibly be comprehensive in a mixed practice or a public funded system aka NHS for those of you in the UK? But before we get there just should we just start with your journey, Devang, should we just go into that because I think it’s quite special.

[Devang]
Yeah, well thank you I think well I graduated in 2004 in India and I wanted to do masters so I did at that time IQE to enter the UK and to be able to practice. It was a really tough exam and actually at that time I really first time experienced a nervous patient because I never seen a nervous patient in India and because they all come in when they’re in pain many times so they’re not nervous but yeah so I saw a nurse patient I mean we’ve gone through that then when I came here I realized that I had to pay sort of twice the fees if I want to get into a specialism. So I worked for six years in NHS practice doing 99.9% NHS work until I got my residency residence sort of status and then I joined, in that six years I was doing I did a one year sort of a restorative dental practice from Eastman which I really loved. I did another few couple of restorative certificates sort of a one year long courses MJDF.

So I was quite active doing CPDs but the Eastman sort of rang really resonated with me their philosophy and the way they looked into detail things. So I applied for MSC in Cons which was or which is still I hope a quite popular course to go to this one.

[Jaz]
It’s also known as, were you married at the time?

[Devang]
I was. It was a marriage breaker, yes.

[Jaz]
It’s cool I was very tempted to actually do the conservative dentistry about four years ago but then it was also known as a divorce course so then I kind of shied away from that. So it’s a tough course for those who don’t know it is a very intense year you can tell us more about that.

[Devang]
Yeah I was there seven days a week but my wife was very supportive. I didn’t have my son at that time that was a good thing. Really struggled and because I was there seven days a week you know working from seven o’clock till ten o’clock. So if I basically placed an implant or did any crown prep. I made the crowns for those implants I made the sort of crowns, those simple crowns, I did the mounting, I did 100% of the work including their casting and everything.

So it was a hard work but and then if you don’t do too much laboratory work you can’t do too much clinical work because it’s sort of combined so yeah it was a long hours but I mean I saw someone posted yesterday on Facebook and it was the best one year of my life really so enjoyed it and but when I applied actually Andrew Kroy still he actually picked up the phone and it was like all sides. So he talked to the course director it’s like oh you need to take this guy in so it’s like I applied it and you know he just told her can we take him in so I knew that I was in other ways it was very difficult competitive to get into there.

[Jaz]
Is this because of your prior study at the Eastman?

[Devang]
Yes because I did a certificate at Eastman and he stole my work and he was impressed with it and he actually suggested for me to do this MSC. So yeah it was good. So I did for one year and then my ego was really high you know I was like I know everything and apply for like literally 150 jobs. I didn’t get any of them because I don’t know probably because I’m not a specialist when you come out you’re kind of in the middle, you’re not a specialist and you’re kind of a bit too much for a general dentist but then yeah so I worked in a couple of prior practices a couple of days a week. I was at the same time then teaching at least last 2012 to 2014. I was a program director for restorative dental practice which I did but I was a sort of a program coordinator for certificate part and I was also deputy head of ORE for UK. So whatever I did I sort of flipped aside and I was on the other side of the spectrum and it was nice to see you know how it feels to be at the sun. I would rather be on the other side though.

[Jaz]
I mean oh I just want to say ORE for those listening who may not know what ore is overseas registration exam, so if you’re coming from a different country to the UK and you want to convert your dental license to a UK one so you can practice in the UK you have to do an ORE and actually Devang, a few weeks ago I did record with them with a really great dentist who actually is from Syria and he’s done his ORE and he really shared his experience about giving tips to people who are looking to do that or actually. So that episode will probably come just a few episodes before you so it’s good that you mentioned it.

[Devang]
Yeah it’s a tough exam not just because of the quality of the dentistry expect which is I mean I was told that we need to expect you know what general dentist would can do not the specialist can do but they’re tough is because there’s a lot of financial burden because I remember when I did my IQE which was ORE 15 years ago and it’s a lot of outlay for someone for coming from abroad, to pay from rupees to pound which is a lot of money and if you fail you have to pay a game and that’s a lot of nervousness comes from fear of failure which everyone has. But that’s a unique exam but to be honest that exam and preparation made me a better dentist because I was not very good when I finished my graduation it’s because you’re quite in a cocoon aren’t you?

So you’re not really experience the outside world and all of a sudden you’re there and you need to really have a communication with patient and discuss a few things and it’s not at least in my time wasn’t taught very well. I’m not sure how it is now but when I came out all I had was a degree certificate but and some basic knowledge but nowhere near to start practicing properly. So yeah IQE prepared me up very well. So come here so I was a deputy head for ORE until my son was born so 2014 august and then I really thought okay I’m not going too much far I mean I’m just hanging about in you know doing couple two three days in practice doing teaching and I didn’t have a clear future. So at that time because I was still had two days free yet and I couldn’t get into prior practices, I sold my ego and I applied for mixed practices now because the whole point of doing MSC was I wanted to get out of NHS practice I want to do MSC, do a pro go prior practice but I’ll be really good and I can treat patients really well. So okay I sold my pride in this okay.

[Jaz]
But can I just stop you there because I think it’s a really great point to just interject there and just ask you for your opinion right? Because back then when I was considering doing the MSC in conservative dentistry it was also for a reason of to not only enhance my knowledge and skills but a ticket out of the NHS and into private practice but you’re speaking from experience and I know you’re not the only one I know you’re not the only one who’s done the MSC or done a significant program any MSC in the country whichever especially the Eastman one conservative and then you’re struggling to find the right job. What is that about? So what advice would you give to someone maybe you’re going to come on to it now with your experience in mixed practice but who’s but let’s do that.

[Devang]
Because I think when we chat about NHS and private I really want to highlight a few points but so basically I then applied for NHS sort of a mixed practice job because I was tied for cash because the thing is with the MSC I had a house, I was paying mortgage, I had no income and always there’s a lot of outlay for a year. I had really drained all my cash and I had nothing left after I finished my MSC. So I was quite cash tight and that was one of the reason I didn’t went for specialism because it was three years.

You have to do three years full time and then obviously the MRD which is not a problem but three years funding mortgages without income is a difficult and job and I truly believe that if you really want to learn for me at least like I’m not a multi-tasker so I have to really concentrate on one thing. So anyway so that was the reason I applied for mixed practice and fortunately one of my friend spotted my application and he said he got me a job and he owned at that time I think. For now he owns 16 practices and that’s why I work in eight practices of his. I started working for him in 2013 late. 2013 and when I saw my son was born I went to him and I said look I don’t know I mean I’ve got these skills and I can’t really I’m doing one full month reconstruction a year. I placed like two implants last year and it’s I’m not going anywhere and it’s quite originally.

He’s an ancient pangotra from alliance dental and he told me that “look you’re putting your foot into too many ships you need to really concentrate on one thing.” So then I quit Eastman teaching, quit the ORE and started visiting three practices and still working in the mixed setting. So I was contracted for 6000 UDAs a year and it was distributed into three practices and started going around and he taught me a lot of communication skills, a really fundamental communication skills and he was quite hard on me because he was my friend and he’s like a brother to me so he would literally shout at me he’s like how can you do this and so I would take it in because at that time I would like a sponge you know I’ll take everything in and I feel that I’m still am but then it improved and I’m at the stage where I’m doing two three full mouth construction every month its ongoing. I’m placing around 300 implants a year.

So it gradually builds up but the skills obviously yes I’ve invested quite heavily into doing courses and I think youth was saying that you go abroad I mean I went to San Francisco so I learned endo from John West, the person who invented protaper. I learned Autogenous Bone Grafting from Kuri. So I’ve done a couple of times master class. I’ve done sausage technique from eastward urban. I went to Germany to learn soft tissue augmentation for otto and hersley were amazing so I mean the courses, they’re like ten thousand dollars a week but they’re all worth it.

So invested a lot of investment and obviously here I am I mean still I’m general dentist, I’m not a specialist register, I do a lot of stuff as I was telling you I mean there was one day I remember and I took a snapshot of the day list in the morning I saw a patient for NHS patio and exam then I did autogenous bone grafting then I did a re-root canal for one of the patient then I did a composite incisal bonding then I did ortho we I had a fixed ortho so I just changed the wires and I did basically I did almost everything what dentistry involves in one day and that’s what I liked about 360 degree dentistry.

Obviously I’m now more concentrated which I like as well but I felt that was really good for me to learn everything and then pick what I can do not because I can’t do the other stuff because I want to really concentrate on one thing and start improving on that because I also believe and it’s quite contralateral one point I’m saying we should learn everything. The other thing you need to concentrate on one thing and the reason is it becomes much more, more, efficient if you are doing just one thing. If you’re doing everything it does the efficiency is a tiny bit lost you know you can’t streamline things but yeah so-

[Jaz]
I think what you’ve achieved is the very reason why I, in the end decided not to specialize I mean for a long time if you ask me a year out of dental school I was very much looking at and making my cv and application geared towards restorative registrar training so I can become a restorative specialist because at the time I was like whoa I want to be a specialist in endo, perio right? That was like the dream but then the more I came across people like yourselves what I call super GPs, Lincoln Harris, people like you guys you’re not specialists but you guys do such high level dentistry and you guys have invested probably just as much money as someone who’s going to specialize but just in the private sector like you’ve said all these amazing people you just named in all courses you’ve done. But I also like the fact that you realize that you had to niche down so you actually found your niche so if I was to ask you what other, what is your niche now compared to a few years ago because that day list that you said highlights the variety that you could see and treat but what is your main niche now would you say?

[Devang]
So I’m mainly doing implant reconstruction. So implants complex bone grafting like as I said autogenous bone grafting, vertical grafting and a full mouth reconstruction restorative full mouth reconstructions.

[Jaz]
Do you do your own Endo?

[Devang]
If I’m doing a full mouth reconstruction I do my own endo, if it’s a re-root canal which is tricky I can do it if I spend like three four hours so but I record them because I think it’s fair for patients they get a better treatment quicker treatment mainly so I refer sort of a complex re-root canal treatments but all the normal and first endos I do and simple v-root canals I do myself.

If I’m doing so I used to accept referrals like four years ago that was the whole point of doing John West course for endo and I used to just do simply that but again I think at some point you need to try and streamline. So I do full mouth constructions so if the patient needs braces like three of my patient currently needs ortho and I’m seeing more and more patient needing also when the full mouth reconstruction because the teeth are not in the position where you want to be and you like the heck the hell after them or just move them and just do a minor minimum dentistry so those cases I will do also myself. I still prefer fix but now I’m going into a bit more Invisalign because I’m working in eight practice it is a bit easier to manage if there’s a bracket.

[Jaz]
No more lost brackets.

[Devang]
It’s just no one knows actually in general practice how to stick a bracket in to be honest. So you know so Invisalign helps that way but again if it’s a very complex also I would rather refer patient to also don’t test the only reason I’m doing things is because it’s easy for patients you know patient coming to one dentist there’s less lack of community probably issue with communication and I know that I can give patients good results as soon as I think that there’s someone else who can get better result than me I’ll refer because it’s best for patient.

[Jaz]
Brilliant that’s a great little background and we’ve covered a lot of themes and just your background alone. You touched on your four pyramids before because it sounds a lot like you had a lot of hand skills and you invested in your hand skills but the point at which in your story and your origin story that it really took off is when your friend, your brother, your mentor if you like he really changed something about your communication skills. And then that’s when it sounds like you went from doing one form of full mouth rehab and two implants to doing more of what you wanted to do so tell us about what you were saying were the four parts of the pyramid because I think it’s a great analogy and where, what we can learn from that to do the kind of dentistry now you’re doing some dentists out there who say you know what I’m stuck like you were a few years ago and so I want to maybe focus more on one area of dentistry and do more of it to a high standard how can you help them?

[Devang]
I mean so the four I mean I would like to sort of say one thing like we’ve always seen a dentist who do lots of whitening, so another dentist will do lots of Invisalign, another dentist will do lots of onlays otherwise you’ll do lots of sort of full mouth reconstruction. How come like they are the pace they only get those kind of patients you know it’s tricky because like some people will in one practice someone will do a lot of whitening and another one will do a lot of Invisalign and it doesn’t crisscross and I think that’s because the way we want to look at the mouth and not the way we should look at the mouth because if you’re not doing ortho I can guarantee you that you will miss a lot of patient who needs ortho, adult patient obviously.

If you’re not into whitening you will not feel comfortable or you will not even think about whitening as an option. These are the two most common things people miss in my experience at least.

[Jaz]
That’s a really great viewpoint, Devang, because it’s the same thing you see on social media as well how come this dentist is constantly posting the same treatment over again, why is everyone in Leicester in one practice in Leicester having so many of these veneers done when the other practice down the road in Leicester is just doing the simple whitening and not doing the veneers is because of you the dentist and how you see the world I completely 100% agree with you.

[Devang]
It is like that and I it took me long time to realize this actually you’re quite ahead of me but I think well that’s the reason and I thought that’s why I thought what’s the issue so quickly the four pyramids or four sort of pillars of dentistry I think is important is for and it is this works like this so the first is diagnosis, the second is treatment planning, third is communication and fourth is execution of your treatment.

Now communication you need to think like a roof so it goes over all those four or three remaining pillar because that’s needed for every single step you can’t really just do communication on the communication bit and just forget about the rest of the time so it’s like an overarching thing and that’s why I feel the communication is the most important thing we should learn before even we could acquire the skill. Because we can always refer to person who who can do the treatment but the patient will get the best if you don’t communicate very well, patient will not get the treatment they should deserve and they will just they will not make no decision basically so and also communication is the least invested I mean how many thousands of pounds you invested in learning communication worse is how many thousands of pounds you learn that you spend learning the skills. And I think communication comes before the execution so I think that’s these four pillars are really important.

[Jaz]
You’re right and you can’t get your patients to because dentistry I always think dentistry is for a lot of patients a stress purchase it’s the same as when your tires in your car they need to be when you hate paying for a new tire, you hate paying for a repair in your car you just want to buy the car, you want any problems, you want to run smooth right?

But when something goes wrong you have to pay a thousand pounds for your tire to get fixed. It’s a stress purchase on a similar scale dentistry for a lot of people. They crack their tooth oh a thousand pounds of crown they’re like well I’d say a thousand times a crown oh it’s a stress purchase but then when you can actually flip that around and diagnose and communicate so well that they you can make a patient realize that there’s so much more they could be having to improve their quality of life, their appearance, their chewing function, all these things and then when they realize actually yeah I want that Maserati, the Ferrari for my mouth because I want it and I want to look after it and I know what’s involved that’s when you can do the more fun dentistry. So that’s where communication comes in you know?

[Devang]
Yeah I mean that’s the reason I wasn’t doing many full mouth reconstruction because I couldn’t communicate to patients even though I think it’s not for aesthetic reasons it’s quite functional however we have this sort of in UK dentistry we have this we don’t want to promote too much cause because if you’re talking about cosmetic dentistry you kind of people you feel that people look at you, your colleagues that oh this guy is you know doing.

[Jaz]
But so do the British public. I find the British public the average patient Mrs. Smith 61 years old, who’s got a class two div two she’s always had it you know really yellow teeth, worn chipped edges, missing several teeth and you almost don’t want to raise that topic right? As a dentist you don’t want to make them feel bad about their smile because they’ve lived it with 60 years or whatever. How do you tackle that?

[Devang]
I mean I’ve got simple advice, take photographs and put it up in a big screen and just do say nothing just let them see it and most of the time like literally 90% of the time when patient looks at their teeth enough on the screen they are like ‘oh they are in a bad state and then now you go open gate and you can start communicating with patients. So photography is one thing which really changed my communication I really I mean tell all the practice, so I actually teach train the associates working in the practices I go as well so once I finish the day, six o’clock whatever we discuss cases because I’m there only once a week or something like that so we’ve got cases to discuss. So we discuss cases but all I tell newcomers is that start taking photographs.

You can nowadays have a sim card or separate memory on your phone so you don’t need to even invest in sort of slr cameras you should but that’s a big outlay for some of the dentists just buy cheap retractors just take some photos connect it to laptop and then you know within a one month, within 15 days I think you will be able to purchase slr the top of the range because you will be communicating, you’ll be your case acceptance were will be high so I think photo, I’m not very good at I don’t think I’m very good at words in that way in that sense so photos helps me a lot and so I tend to take photos for every single patient I see.

[Jaz]
Amazing and I echo that as well I think photography we’ve said it before as well it’s just a huge thing and yet you still have dentists who just don’t do it. I just don’t get it I just don’t get it because I think even if you’re in an NHS practice.

[Devang]
Yeah I mean I had, I took a bit because you’re quite right because I think most of the objections I get from dentists like it’s time consuming. So I took a video for me to take full set of photographs, an extraoral, intraoral in three minutes and 40 seconds everything. Now I don’t take when I did general dentistry I took photographs but not every single shot for every single patient. I took six basic shots the smile photo, the retracted view, side views, occlusal and then take it from there you don’t need to really go too much until patient says yes when patient says yes with the treatment then you can take more photos later on.

But so I think diagnosis when you if you go through the pillars, the diagnosis again photography is important when you’re diagnosing as well because many times I take photos and I tell patients like I’ll see you one more time because I need to really see this in detail I want to I want to sit down and really think about you know what’s going on here because sometimes when you’re really pressured with time, you really don’t want to think on the spot because you probably not doing justice to the patient because you can’t really think everything on the spot so but it’s a one thing which I think is underutilized as you said for taking photographs.

[Jaz]
Amazing and I think what you refer to there’s the treatment planning on the spot as Zak Kara called it a few episodes ago shotgun treatment planning and it’s not nice to be in that position and I yeah I loved it, I loved when you said that and I hate it like whenever I find someone who’s got more than one issue, new patient to practice and say yes it’s a young lady and she’s if she’s got one tooth problem or two teeth problem and generally everything’s working it’s so much easier to say okay you need this that the other communicate done but when they got multiple issues you’re really, you’re thinking and the patient’s looking at you and you’re looking confused and you’re like you’re not very sure, you don’t sound very confident. It’s so much easier and better say you know what there’s a lot of things going on here. I need more time. Let’s do this properly for you I’ve talked about already I don’t know if you heard the episode about makemeclear to make those treatment reports I’ve really enjoyed doing that as well so that’s when the fun and the beauty of it comes in so you touched on the diagnosis, we know about the treatment execution that’s all the courses that we go on, communication being the roof but really with that communication one I think you shared a really great tip there if you’re not already taking photos that’s the place to start right?

[Devang]
Yeah hundred percent, taking photos are the first thing even if you don’t it’s not a talkative person you don’t talk to patients much or something at least you take photographs and show it to them you they will do the most of the work patient will do the most of the work you just point and don’t speak and that will help really well and if you speak few words you know at least definitely increase the cases so but I think I cannot really stress enough and I’ve been banging about photography I mean I do teach photography as well at Eastman I used to teach but I still see it’s not really very well incorporated people are using intraoral cameras a lot now to be honest I am never a great fan of intraoral cameras in that sense. I always use slr because it’s just high quality resolution, it doesn’t take me that long to take photos. The only downside is that you need to then manually put it on the system and that takes time obviously but I think it’s a small price to pay for the quality of the photos.

[Jaz]
Yeah I agree I mean on that debate about intro vs dslr I mean I have both and when I’ve got Mrs. Smith in for her you know fifth time seeing her for a checkup every six months and things are good but there’s a crack tooth and I want to just quickly grab a photo and show her there and there to have a chat that’s invaluable you have to get all kit out dslr, load it, crop it to zoom in but for most for all your comprehensive cases really depends on me is your patient a general patient or are they a what we call I would call a complete patient basically and that also has a role in whether I’m just using intraoral photography but most of the time you’re right there’s nothing will beat your dslr photography.

[Devang]
I mean right now the intraoral is slightly better because of the AGPs how do you manage to cover the camera so I’ve got the plastic bag and all the stuff but if you have intraoral camera that’s nice to take a mid-treatment photos when you’re doing agp because you don’t want to really contaminate stuff so that’s why I think yeah it has more role now than ever before into mid-treatment.

[Jaz]
Brilliant before we now jump on to private versus NHS. Anything else you want to mention on the four pillars I think you really described it quite nicely you’ve given your biggest communication gem but is there anything else that you want to touch on that you think a dentist should know?

[Devang]
No, I think coming back to diagnosis I think diagnosis I feel is really important and I think generally dentists under treat patients because they’re not diagnosing things very well, not their fault, it’s just that it’s not very well taught as far as I can see because I can only give my reflection from the new graduate who come and join us and their skills of the teaching level because I don’t know how the teaching level of the country is but yeah diagnosis is difficult and main reason so some of them are they discuss where is one of the main thing people don’t diagnose very well if they do, they don’t do anything about it they just write down generalize where and that’s it. Full stop or maybe give mouth cut.

Crowding is another thing diagnosing issues then crackling you are mentioning you know amalgam crackling but there are controversies you know and I don’t want to get into I know you really love talking about the crack teeth but but I think when to treat, when not to treat for me it’s pretty simple. I would treat it because you and I obviously tell patients give both options but if you don’t, I don’t want to be in the ship where the hole can appear any time and it will sink you know I would rather put an extra layer of a resin or something to protect myself you know so I think that’s another thing.

The other thing people well diagnosed which is blatantly obvious which is Edentulism you know people have eventual spaces but I’ve seen a lot of patients who haven’t talked, they haven’t talked about implant the potential risk of teeth movement when they take the teeth out and I think this all needs to be discussed before even you take the tooth out to the patient because I think it’s just that some of the sort of a legal firms need to find out the loophole and it’s a disaster waiting to happen where patient will come to you and say why didn’t you tell me about the teeth movement when you took the teeth out, my teeth have moved now I need implants and you pay for it I had a patient actually sued the dentist for 15 year old tooth removal.

So the tooth was taken out 15 years ago and everything were collapsed, so two molars were taken out on both the side the teeth were collapsed the supra eruption happened and I said well you know what I mean she had otherwise good teeth and I said well if you want to treat this space because there is a collapsed bite and everything we’re probably looking at orthodontic treat movement on the uppers move them and then potentially realign trim them and reshape them and it was a lot of treatment and the lower needed bone grafting orthogenous bone relaxation so the bill was coming into 20s 30 000 or something and she wasn’t very happy that she wasn’t told by subsequent dentists for 15 years the effect of teeth movement. She didn’t get anything for it but for her it was more like a moral issue rather than she wasn’t in for a money I told her from the beginning that look you’re not going to get anything out of it and she knows she said I know but I think dentists should be aware of this.

[Jaz]
Very fair point to tell.

[Devang]
So yes that’s I think regarding the diagnosis with the treatment planning again if you haven’t diagnosed you can’t go to the next step. If you haven’t even diagnosed the wear how you’re going to plan the treatment and when it comes to planning treatment I think most of the dentists are many times they feel that it’s their fault that the patient’s dentition is messed up and they take it personally and feel fearful again I’m talking about fuel in my experience from the dentist I teach so I’m not talking about the general dentist everyone but they fearful of telling patients that it’s going to cost tens of thousands of pounds to fix it and also the main fear they have is that if they tell patients that you’re going to need 10 fillings what if patients say yeah do all them on the NHS so because with all of the practice I visit they’re all mixed practices right so you could point out 10 things which have gone wrong and say you need 10 crowns and the patient might say okay do something.

[Jaz]
Let’s do it yeah absolutely it’s a bargain why not exactly that’s why one thing we’re going to talk about is how can you be comprehensive as an NHS dentist because there’s an and I don’t want to get into it too much now because there’s a few points on arrays based on some really key facts you said there I think some people some really good dentists listen right now I think they’ll need to look back at their notes template right for the examination or their custom screen whatever they use do they have a section there for diagnosis I bet a huge percentage a significant percentage of dentists will not have an area to write your diagnosis. So I think the most simple step like think of the micro step that you could do after listening to what you said there to be able to diagnose more is just simply having a box that says diagnosis because once you have a box called diagnosis then you can write your gingivitis then you can write your recession then you can write your missing lower right six upper left two upper left seven then you can write hairline cracks then you can write attrition and erosion if you don’t have that box where are you going to write it and then it gets missed it doesn’t get done and so it’s a vicious circle right but the other thing I want to ask you Devang is you’re very comprehensive dentist we can tell that because you’re diagnosing very thoroughly and you’re not afraid to tell the patient how it is like okay this is what you need and it might cost a lot of money but I’m sure you’ll you have two reactions from patients to you because if they’ve seen dentists before you who are not as comprehensive. A) they’re going to be like wow you’re so thorough I bet you get that a lot and thankfully it’s something that I get as well and I’m proud when people say that I don’t think that oh it’s because other than said that it’s because I’m trying to be as comprehensive as possible yeah but B) this is the thing I get challenged with right is that the next question they’re going to ask you is a why had no one else ever told me about this and then the other thing with that is that now when you present this suddenly big treatment plan there are some patients who think hang on a minute this page this dentist is trying to fleece me here right no other dentist ever told me this. This dentist tell me all these things, this dentist is going after my money. How can you go over that?

[Devang]
Yeah I’ll just quick one on the you know the you’re saying about the diagnosis thing what I because not everyone has exact I don’t know what system do you use because the exact is quite nice to write it down but what I advised every dentist is have like a sticky note and write down all the treatment like wear, whitening, ortho on the side of the computer and make sure that you checklist all of that a patient’s mouth so make sure patients have the patient go away has got this this patient need writing this so if you have all the checklist that is less likely that you will miss anything so I think checklist works really well and the dentist who used it not everyone says what I do/do what I say basically but someone people who have used it and they all are quite impressed. So coming back to your question regarding again I get that a lot that you know patients are like you know you’re very thorough and even though some most many times even if they don’t go ahead with the treatment they appreciate the fact that you’ve taken time you explain them everything and I think if you show patient photographs again I know I’m banging on the photographs but if you show patient photographs like if there’s a cracked tooth and if you show a patient a crack they can’t argue can they? They can’t say oh there is no crack. Now once you’ve done that you I’m giving them option from nothing or do nothing to do everything so I’m discussing option with patients all the options so there is no way the patient can feel that you know I had been given you know this big plan because dentist wants to make money out of me I actually had a patient I had an it’s an interesting story, so I said yesterday I saw a couple two weeks ago I saw a couple both were referred to me for consultation, implant consultation. So I saw husband first and he had the four lower and serious mobile which was patched up for a long time but the other teeth weren’t in great condition so I had a chat with him I’ve come gathered what he wanted and I said look for what you want implant is not the best thing for you, go to your general dentist have this 4 teeth extracted have a nice chrome made up and you can add the teeth in the chrome and because I cannot place implant where the other teeth are not doing really great but you can have a denture because they’re not terribly bad and they might, you might be able to hang on to them and then the next patient was his wife and I just presented to her yesterday around 42 000 pounds treatment plan and they both were sitting with me and you know they were like oh that’s a lot of money but then I told them that look husband that you came to me for implant and I think it wasn’t appropriate for you. Now what I’m telling her is appropriate for her and I mean that resonates they understood I mean before you when I spoke to them so I think if you’re genuine then you don’t get that you always get from people that oh it’s a lot of money because it is many times the treatment I do but I don’t generally get that I’m after that money because the communication because I’ve shown them the photographs do you know when I used to get that? Is earlier in my career when I never took photographs and I literally presented full mouth reconstruction cases, I only start taking photographs after patients said yes okay for my record-keeping and all the so before patients said yes I didn’t take photographs i just explained it to them and I used to get patient like I came for NHS checkup and now I’m going out with ten thousand pounds bill and this is a rubbish and all that so I should get that a lot but since I’ve started taking photographs and explaining them even though I’m taking the same amount of time probably less I don’t get that.

[Jaz]
Amazing. Brilliant but both points are comprehensive answer there which leads us to for the very saucy part of this episode where we’re going to try and extract from you a few gems in terms of if you’re working in a what we call in the UK a mixed practice, so there is a public funded element and a private funded element and I don’t want to get too much into the UK politics because there is an international audience here but I think the lessons we can learn you know it can apply anywhere in the world because in the US you have the insurance based systems which there are issues with that as well anywhere in the world, any system is always going to have its downside. So in the UK we have a system whereby you cannot be comprehensive because you do not get fairly remunerated for being comprehensive. So what advice can you give Devang to a dentist who wants to do more complex dentistry but they are in a run-of-the-mill busy predominantly NHS practice?

[Devang]
As I said before I think we were chatting and I don’t like to get into controversies so I really stay away from it and you love you say you don’t mind it so there’s a disclaimer that I’m not an expert into doing that or whatever advising I’m advising right now but what I can tell you is I can share my experience okay? So I did a mixed. I worked in a mixed practice until 2018 okay so pretty recently early 2018 so still sort of three years maybe ago and I as I said I had a 6 000 UDA target that used to pay for my left fees because I used to do a lot of implants and a lot of other work, so my regimen I’ll share what I did for my normal diary because I don’t think I’m still quite distance from that past because what happens I think that’s what one of the issues is that everywhere you go like all the courses John West or whatever they all are aimed towards private dentistry, they all are either private dentists I mean I have yet to see a mixed dentist, a dentist who’s doing in a mixed NHS practice running a really big courses and promoting that I’m sure there are out there but most of the big names are all private dentists and that leaves dentists with the illusion that okay we can’t really do this in national health because we don’t have the patience cohort and they can do it because the energy they’re private they can do whatever they like.

And I had that as well but I’ve proven that wrong in eight different areas. So I’ve proven that wrong, I worked in half a share I worked in Devon. I worked in Bournemouth. So I’ve proven that because I had this limited mindset that mixed practice you can only do good private in certain areas where you have really that’s more affluent areas but perhaps exactly however it’s other way around. The more affluent areas, patients teeth are very well maintained so there’s not much work to do whereas if there’s less staff learned patient and desperate need to do have the treatment done so they will have the best treatment and if you explain properly so you’ll have more work, so I have more work in the practices which is in the less affluent areas because patients ignored their teeth and they didn’t have funding, now they have funding and they want to sort it out.

So coming back to my schedule so I used to have 6000 UDAs, I did work long days. So I worked many time 8 till 8 or 8 till 6 because I worked in three practices at that time doing NHS or mixed and my checklist used to be 25 minutes so no less, sometimes 30 minutes if he’s a new patient and 30 minutes otherwise regular patient 25 minutes. In that time I used to take photographs radiographs, explain the treatment if patient wants NHS, MOD or occlusal I’ll do it there and then amalgam so it doesn’t really take that long to do amalgam. And to be honest yes you can carve the amalgam really beautifully but it’s still going to be black okay so it’s not going to just turn white if you carve them, I still carve because it’s my ego you know you really like it’s just for me patient looks at it and the thing is it’s sort of a metal feeling right so it doesn’t take that long.

So I used to do 25 minutes that now if I’ve taken photographs and if I think as you say that patient needs comprehensive treatment I would tell the patient that look this is you need more than just a general dentistry. So come back and I used to see them in lunch time I’m quite renowned for not taking lunch breaks. So I used to see patient for a chat so the nurse can have a lunch and I’ll just have a chat with them and I’ll show them everything and I’ll go through all the NHS and private options so and I never told patient that the NHS is substandard because I think if you have committed to do NHS dentistry you have obligation to give patient a fair good treatment. So all my root canals NHS all private were to the apex if it’s not to the apex it’s not to the apex. It’s not because it’s NHS or private so you don’t have a card just because you’re doing an NHS treatment to do a rubbish job and I strongly feel about that and my nurses used to tell me that you know your patients are getting private treatment at NHS which because I like to sleep at night I like to make sure, good for patients.

[Jaz]
With root canal, Devang, I’ve just found with endodontics I found that the more you learn the more courses you do, the more you invest. You can’t unsee it. You can’t unlearn it. You can’t then ignore the fact that mb2 is right there no matter how you get remember you can’t not use your 17 edta, you can’t not do it.

[Devang]
Yeah so the only difference I used to tell patient is I used to do backfills I used to do you know backfill obturation for private patients and use protaper gold files versus the standard rotary files and electro condensation for NHS patients but that’s about it the rest the material was the only difference this the skill stays the same. I need to negotiate I need to negotiate the canal.

So when patient comes to me initially I had that issue where okay patient’s coming now patients got number of cracked teeth and if I tell patients you’re going to need onlays for all those teeth patients might come back to me and say look do it under natural health you know why are you doing what I don’t want to spend privately and that limited me even discussing with patients unfortunately you know all that thing because I was scared if patient tells me do 10 crowns I will be ripped off basically.

[Jaz]
You might as well work in Tesco’s.

[Devang]
I have actually done in couple of patient four crowns and I’ve done four root canals and I’ve done lots of fillings in some of the patients but they are a handful you know I would say those three to five percent of the patient which sits in your head and you know just keep talking to you not the 95% which are you know you’re successful but that prevented me once I got that out of it I had one patient where I had to do the work and I thought you know what it’s not that bad you know okay yes I lost money on them but I’m making it in doing cervical you know fillings you know sometimes you do cervical abrasion filling and you get three UDAs and it doesn’t take you that long so you swings it.

[Jaz]
Swings around about?

[Devang]
Yeah you even it out um but um if you if you explain patient properly that look this is if it’s a full month reconstruction it’s pretty easy you tell patients that this is out of general dental practitioners limit I strongly feel that the fact that you invested thousands of pounds into learning something which NHS doesn’t fund you shouldn’t provide that kind of treatment under national health because it’s not your obligation to provide advanced care and I was quite strong to the patient as well I tell patients that look I can do everything I can do implants I can do autogenous bone grafting and it just doesn’t include that what NHS will include is a basic dentistry to keep your mouth going to keep it stable and this is very common known fact in medicine if you go to hospital, if you go to GP they’re quite open and upfront about NHS funding that this is not funded by NHS but for somehow NHS dentists are under illusion or given the illusion by whoever sets the rules that everything is available and it’s just minus the implant and that’s why it’s easy for me when I’m doing implant there’s no discussion but I think dentists forget that we are in a business we at the end of the day is a dentistry it’s a health business but it’s a there’s an ethical and moral dilemma you don’t want to over treat or do something to the patient just to make money but you have to struck a balance and you need to communicate that with patients so I used to tell patients like look I can do really nice crown for you.

My technician charges I mean I used to use a technician from Italy so if my technician charges 280 euros and if I’m paying you’re paying me 260 pounds I cannot make money in this thing so I’ll have to use the normal technician who I can afford to use to do your treatment he doesn’t do a bad job but obviously that’s the difference and with the posterior teeth amalgams and metal sort of a non-precious or precious crowns the white crowns you can justify that is for cosmetic reasons for posteriorly and if patient asks why you just ask them why do you want white teeth for the crown at the back if patient says cosmetic reasons then it’s not available for cosmetic reasons. Protection is the same. So I think so that’s what I used to do so when I explained patient full mouth reconstruction I used to tell them that we don’t have a contract from NHS to do advanced mandatory treatment, you don’t get funded if you want I can refer you to hospital by all means and then see what they can do or I can provide you that treatment privately here.

So there’s a clear distinct line there are some areas like root canal which is one of the big thing private NHS I never could convince that many patients to do private root canal because I couldn’t tell them that I’m going to do a rubbish job at NHS root canal and I never did the only I used to tell them the material I use more expensive and obviously I can’t afford to use it in the national health if I’m using I’m getting paid whatever 50, 60 quid and the other issues is obviously the correct when to intervene what to do and communicating that with patient but it’s really communication a frank communication with patient telling them that we have limited funding in that sense that what NHS can fund, NHS won’t be able to fund your full month reconstruction a really nice smile. It will give you good treatment so that it keeps ticking it’s good to keep you alive basically. So that’s but you need to have that conversation with patients.

[Jaz]
That’s amazing. I mean that’s probably the I’m being very honest here that’s probably the best explanation because I always found it very difficult to have that conversation even with dentists like different dentists do it differently different dentists have their own theories of and let’s be honest the way you do it is yours is the way, you saw the world and it’s the way that you made it work not in terms of just your interest but in the patient’s interest as well so they were able to choose the superior option that will you know might be more complex as well. So I think every dentist does it differently and this is because every dentist learnt to do it differently because there’s no unified guidance I mean the only guidance there is from the people high up who say there’s no difference, NHS is awesome everything’s included and that’s a pipe dream so I really like the fact that you shared that with us all I think hundreds of if not thousands of dentists in the public system will listen to this and say you know what I could do things a bit better I could spend a bit more time to explain things with better take photos and hopefully they will get better results because yes we’re working in a sub optimal system and I hope no one takes offense and saying that I think we can all take raise our hand and say okay it’s not perfect let’s agree to that okay but if we can take a few leaves from your book and read be able to apply things in a better way then that’s amazing. So, Devang, thank you so much for sharing a very diverse your journey and education to these the four pillars if you like and at the end they’re just giving us a very from the heart, from your hands, from your experience how you’ve communicated with different patients. How you can help your patients to understand that there is a difference between complex dentistry and what is maybe possible under the NHS. Any closing comments, Devang?

[Devang]
No. I mean I’m glad to be I mean as I said thanks for inviting me to be honest to share my experience the only thing I would say is that you know the four pillars which I said invest equally in all of them make sure you have a diagnosed treatment plan even if you can’t execute that treatment I think you should treatment plan as if you can and then refer patients to the dentist who can’t execute but don’t stop there I think you need to then learn from that dentist how to do it. So you can start doing and I’m 100% sure that whoever you’re referring cases to they will be more than happy to teach you or that you know shadow you the case you’re doing so you know go there and have a look at them communication as I said is a big thing which changed my perspective and that’s why I can really have that frank NHS private discussion because I build that rapport with patient you can’t just go and discuss that kind of thing with patient out the front you’re building rapport, patient knows you very well you know the patient and you can set the tone up as to how you are going to communicate you know you choose your word carefully because everyone thinks if you say the same word they will think different things about that word you know so you have to be very specific as to what word you’re choosing and then of course execution of your treatment so learn all the skills which I think dentists are generally good at doing or good at improving, it’s the fourth pillar but the other three it comes first that’s the whole point.

Jaz’s Outro: 
Thanks so much. Shout out to Rishi Joshi, thanks so much for helping this happen. I really appreciate you buddy thanks so much. Well there we have it I hope you enjoyed with Dr Devang Patel as always, I really appreciate you listening all the way to the end. Now listen if you have a colleague who you think will benefit from this episode because maybe it meant a lot to you, maybe it’s got you thinking a little bit differently in terms of how you can do things differently on Monday morning with your patients and you think that this has helped you surely, this could help another one of your colleagues so please send them, WhatsApp them, email them, print them this episode. Show them how they can listen and learn from Dr Devang Patel as well and I’m sure they’ll really benefit and thank you for that. So thanks again for listening and back to straightpril now on the orthodontic episodes the website is protrusive.co.uk/communicationdp for the free communication course by Dr Devang Patel. Check it out and thanks again for listening as always.