homam.alba 
“Dentists have high suicide rates. Did you know?” I heard this sentiment so many times along my dental journey. Back when I would express interest in the profession; or when I shared that I was in training; or even currently as a practicing dentist. I used to dismiss it as a myth or a misconception and laugh at it. Other times, I would react defensively and say something like “I am pretty sure Lawyers’ are higher”. Of course neither statement is true. I certainly do not mean to be facetious; Suicide is a very serious matter and it has even hit close to home at UofT Dentistry. And I am not trying to be an alarmist, rather I want to emphasize that many of us are indeed under a lot of stress and are often too proud to admit it. Seeking help and therapy is one facet to think about. But this entry is not another mindfulness or burnout conversation. Albeit those are important conversations to be had. This one is more about those community of practice conversations. I find it odd that we often have no qualms repeating that “only a dentist understands where a dentist is coming from”. Yet, we shy away from engaging in candid conversations aiming to resolve contextual problems conducive to those stressors. And such conversations are increasingly foreign in this age of hyper-individualism, where more often than not, we are sharing glimpses of our best selves and completely forgetting the importance of talking about the difficulties and barriers one faces. If those barriers are not examined in our collective discourses, it will leave us only treading around them with resignation.
No man is an island, entire of itself; every man is a piece of the continent, a part of the main … any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee.
John Donne
I must say most challenges I previously envisioned to operate within dentistry, now seem like rudimentary nuisances. Lately, I have been thinking about bigger “systems” problems. Just last week, I had a patient with Cerebral palsy who had come to see me back in February – at Mount Sinai Hospital – with her old grandmother. She is lucky to have a grandmother to care and advocate for her, many do not. She seemed like a happy patient. She suffered from dysarthria, but she was readily engaged and aware. She needed one tooth extracted, a couple of fillings and a cleaning. It is amazing that she didn’t need more. She was cooperative enough to take radiographs and was rather pleasant. But when it came to operative treatment, she was very anxious, tense and was not cooperative at all. Even prophylactic scaling was traumatic to her. I mean she had always had that done under general anaesthesia at Sick Kids Hospital (until she was graduated), which sometimes makes me question traditional approaches that overlook behavioral management. Nonetheless, that is not my area of expertise. She has had at least 4 courses of antibiotics to help with infections (from said tooth) from various practitioners (including yours truly). Until this amazing oral maxillofacial surgeon (OMFS) I work with offered to sedate her while I did the work (our only dental anaesthesiologist was not going to be back until October because of COVID and reduced clinic capacity). The day arrived, we were all set up. Her personal support worker (PSW) and father were there to help transfer her to the dental chair. We were ready and hopeful. Unfortunately, our veteran nurse tried feverishly to get the iv in and it was not possible, she was too tense even with some nitrous gas. If you have seen persons with cerebral palsy before, they often exhibit hypertonicity of their limb muscles. She was actually calm and not frantic. But the veins kept blowing. In cases like this, things have to be predictable for safe treatment. Sedation involves variable degrees of risk and should you need to inject rescue medication, you need to know your set-up is reliable. Unfortunately, they now have to wait months on the wait-list for outpatient operating room time. May be we are lucky and we can get them in on a cancellation. Another logistical nightmare.
Imagine the amount of hassle this poor grandmother went through to bring her granddaughter in to get her out of pain. And the amount of resources our system expended, without accomplishing the preferred outcome. Those challenges operate differently in dentistry compared to medicine. More often than not, special care resources are scant to begin with, and doubly so for dental interventions compared to medical ones. Medical doctors, at least in Canada, will get remunerated irrespective of outcome. I do not say this to emphasize a compensation issue, which is a valid issue in itself, rather to highlight how tertiary dental care is so difficult to finance. And competing for operating room time adds a whole other level of complexity and challenge. And sadly, it is a recurrent problem. As for us, we are always motivated to try and deliver care faster and advocate for the patient, but often we face barriers bigger than our resources can overcome. That same OMFS is seeing one of my patients next week, a brilliant professor now with advanced dementia, that I am hoping will progress better than this one had, for the sake of the patient.
Every day I work there I think to myself “there has to be a better way”. But that way requires funding. Being realistic about the system you operate within is necessary. Public dental units, and especially specialized ones like ours really struggle with minimal resources. But those moments of struggle and challenge need to be the center of a lot of conversations that aim at creating innovative solutions. I told a mentor once that having immersed myself in the “system”, you start seeing gaps and when you learn “frameworks”, you start wanting to fix things. Or to be politically neutral, wanting to “understand” them. So I hope for this to be a contribution to those collective conversations. And who knows, may be, in some serendipitous way, it will lead to those much needed innovations.
