I was delighted to be invited by Dr Miguel Stanley and his sister Nina Blaettler-Rosa da Silva, founder and president of Slow Dentistry respectively, to the 29th floor of the Millbank Towers on 23 November 2019 to help bring the concept of Slow Dentistry to UK.
I immediately saw the importance of putting a name, a recognisable slogan, to what the best dental clinics across the world already do – spending time to do things properly. As one of Slow Dentistry’s honorary global ambassadors I was asked to convey to a substantial audience for a Saturday evening what Slow Dentistry meant to me.
The four cornerstones of Slow Dentistry are:
- Proper patient consent to treatment that has been proposed
- Proper room and equipment disinfection and sterilisation and avoidance of cross contamination in the dental office
- The use of dental rubber dam to ensure high quality of modern adhesive dentistry
- Proper anaesthesia and analgesia to ensure that modern dentistry is comfortable as it has ever been
All good practices already do this. The key issue is that to be able to carry these out to modern standards requires more time and background activity than ever before and patients may simply not be aware of what goes into providing them with the highest quality dental treatment.
My particular topic was mainly the first one. Modern consent in medicine and dentistry is a rigourous, ongoing process throughout treatment. For a patient to consent to treatment, it is important that they are truly given all of the information and advice that they require to make sure that it is fully informed and that they completely understand what is being proposed.
I have found over time that most issues that arise that create problems are where dental surgeons and patients are not on the same page. This may be due to a variety of factors. However the one that I find is the most common is that the dental surgeon never really allocated the time to fully collect and analyse all of the necessary information pertinent to a patient’s case and consequently was not able to give all of the diagnoses and options the patient may wish to have. They simply did not think the entire case through with all of its nuances.
This is directly linked not only to the time spent in the surgery collecting information but the lack of time that is normally spent after collecting this information to really look at it, really think about the case and systematically analyse, diagnose, plan, cost out and properly communicate what is being proposed to the patient.
As a result, most dental treatment plans are carried out in a piecemeal or itemised fashion – one hygiene visit, one root canal treatment, two implants, three crowns. This is not how we work. It is artificial. It is what Daniel Kahneman refers to as System One or fast thinking. It is often a spur of the moment decision, admittedly based on experience and knowledge but perhaps not always taking into account other factors that may influence the success of a particular treatment.
Information collection is not only clinical but also pertains to the patient themselves – their personality, their philosophy, their availability, their finances, their autonomy in decision-making which may be at odds with what the dental surgeon feels should be done. It is only by combining this knowledge with the complete and documented clinical information that is systematically collected at the patient consultation that a proper diagnosis, treatment plan and communication can be carried out.
This requires slow thinking. This requires Kahneman’s SystemTwo. This requires the dentist to be able to think in a quiet environment with all of the information to hand. It requires them to create proper documentation and correspondence for the patient. And very sadly, this is often rushed since it is carried out during a dental surgeons private time.
Dental surgeons do not get paid or have time allocated for thinking. Yet this is arguably the most important step in the entire consent and treatment process. It is the architect’s plans before the building. It is a step-by-step analysis of the information to hand and the decision-making sequence that ensures that treatment goes smoothly and to plan. That the patient is aware of the costs and the time involved that must be invested to get the desired result. Yet it is the part of treatment that is most often overlooked.
The more one looks at a case, the photographs, the clinical notes, the videos, the radiographs, the scans, the laboratory models, the digital scans the more one sees. The more aspects must be communicated to the patient. The more thought needs to go into conveying the relative importance of these findings for the patient and for the outcomes of treatment.
This simply cannot be carried out with System One thinking when no time has been allocated in a dentist’s working week. A list of treatment items with a fee attached is not a plan. It is not proper communication. It is not adequate for valid consent. A treatment plan cannot be done “on the hoof”. It takes me between 2 to 4 hours to work through a patient’s case and create a document that conveys all of the information I feel needs to be conveyed. Yet the patient never sees this process. A patient complains our consultation fee and report fee is high. Yet this is exactly where a proper investment will save substantial amounts of time, money and mishap later. How much time would you like a cardiac surgeon to spend thinking about your case before opening up your chest? 10 minutes? An hour? Two days? A week? Come back to it and think again after discussions?
Whilst we are not in the business of saving lives, some of the procedures we carry out may irreversibly alter somebody’s quality of life. Do we not owe our patients thinking time and do they not owe us for thinking time?
Some dental surgeons carry out free consultations to attract patients to their practices. Not only do they not get paid for the clinical time they spend with the patient in the hope that they may get paid for it later if the patient takes up treatment, but they also do not get paid for an even more precious commodity. Time away from their family and friends and private time thinking, planning, documenting, writing and answering questions from patients.
Which other profession gives over a thousand hours a year of its time completely free outside working hours when their entire careers rest on the results of the time that is spent on diagnosis, planning and communication.
Things must change.
The dental profession can use the concept of Slow Dentistry to convey to patients that the time they spend thinking and diagnosing and planning and corresponding is as valuable as that of any solicitor or barrister. Thinking time and Slow Dentistry must carry a reasonable fee so that dental surgeons are paid for this aspect of their skill set the same way as they are paid for a crown or an implant or a filling. This is the only way that we can defend ourselves against the increasing incidence of litigation and investigations by the General Dental Council into our day-to-day care of patients. Not only must be carry out Slow Dentistry but we must also be seen to carry out Slow Dentistry and make it the norm.
Good modern dentistry cannot be carried out without proper planning time and time to correspond and discuss and obtain consent from the patient. All of clinical dentistry is based on this step which is the least well funded, least well planned and it is this stage of treatment that is most often omitted.
Together with my esteemed colleagues Dr Miguel Stanley, Dr Simon Chard, Dr Rhona Eskander, Dr Marcus Engleschalk and Dr Jameel Gardee and fellow ambassador Dr Zaki Kanaan, I was absolutely thrilled at the incredible turnout and positive response to the message that was conveyed throughout the evening, especially amongst our young colleagues and dental students who had been invited to participate in this meeting.
Slow Dentistry is of course about not rushing clinical dentistry and making sure we do things properly. But all dentists know this. The Slow Thinking is the part I feel the profession must adopt, and soon, as a routine aspect of dental care and it must allocate adequate time and be adequately remuerated for it.
This is the next revolution in dentistry.