Jack on placement in Peru
I knew I wanted to be a dentist when I was about 13
It was between medicine and dentistry, but dentistry tipped it for me because it seemed like it was going to be more hands-on and utilises hand motor skills. Another factor that appealed to me was that it was a career that encouraged lifelong learning and allowed me to help patients on a daily basis.
Plymouth's Peninsula Dental School is a fantastic modern dental school which equipped me well for the working world.
I was introduced to one student who was a few years ahead of me and had done an elective with Work the World – the organisation that ultimately ended up organising my placement. I knew I wanted to do something like that, so I reached out to her and asked her if it was worth doing. She said yes, do it.
I chose to travel to Peru because I’d never been to South America and thought it would be fun to learn some Spanish. And before I knew it, I was on a plane to Arequipa. I was doing weekly Spanish lessons in the run up to the trip, but I wasn’t sure how proficient I was going to be by the time I travelled. I’d also learned that a number of people in Arequipa spoke Quechua, the language of the Inca.
So, I developed a visual communication aid to help me with diagnoses, but also to help provide preventative advice. For example, I had a pain scale that had images to denote the kind of pain a patient might be in. I had a picture of pins they could point to if the pain was sharp. Or there was a picture of an ice cube if the pain was triggered by anything cold. The preventative advice section had pictures of things like sweets, biscuits and chocolate so I could effectively ask, “Are you eating any of these?”
There’s been a big shift in dentistry in the last 50 years, especially in Europe. Dentistry is no longer reactionary – it’s a lot more about preventative treatment. I found that when I was in Arequipa, there wasn’t much in the way of education around what causes tooth decay and gum disease. Few people were being told to cut out the sugars, brush twice a day, make sure your fluoride exposure is high and so on. So, the communication tool I made was incredibly helpful.
Plymouth helped me by producing the finished product, so it was quite a professional-looking booklet.
It was a bit like a flow chart, functionally. From a preventative education perspective, it was invaluable. I got the sense that talking to patients about what causes tooth decay was eye-opening for them.
Was it just a general lack of awareness you feel was contributing to the severity of the cases you saw? Or do you think it could also be resource related. For example, people eating cheaper, more sugary foods in absence of anything else.
There was definitely a high availability of refined sugars. I remember there being a popular soft drink called Inca Cola that was a sort of fluorescent green colour and undoubtedly full of things that aren’t good for you.
Having said that, even in the UK people don’t necessarily understand that a lot of pre-made sauces, like ketchup, have a lot of sugar in them. There’s always room for a bit of education in these things, and that has been a really important shift in medicine and dentistry.
Were there any demographics that you noticed were more affected by this than others?
Well I did spend some time in a juvenile detention centre. That was the one place I couldn’t use my communication tool as we were patted down and had to hand in all our belongings before heading further into the building.
It was a fascinating experience and very different from the UK. The dental chair was powered by a petrol generator, which made conversation quite difficult.
We saw kids from the ages of probably around 12 to 16. The coordinator for the detention centre would bring in five patients at a time, and we had two chairs operating simultaneously. These kids had a lot of decay. They needed four or five fillings each. Myself and my supervising dentist spent the whole day removing tooth decay and placing fillings. On the first day, I think I had completed about 80 fillings!
Though I don’t know whether or not this was more to do with diet in the detention centre or access to things that would help with oral hygiene. To see that much decay was really quite shocking, and again this highlighted to me the importance of education and preventative advice.
When I was in the outpatient clinic, where my main placement was based, I didn’t see many young people.
Gaining experience in a low-resource healthcare system
They were fantastic. They talked me through a lot of the rationale behind why they did things a certain way. Despite any language barrier there might have been, wherever you go in the world it’s the same profession, so we had plenty of common ground.
They really took me under their wing. As I say, my Spanish was only conversational, but the local dentists were really patient with me, which I appreciated. Dentistry can get quite advanced when it comes to terminology, but because most terminology is Latin based…
So, there was some universality there?
There was. There were plenty of times where the local dentists would use a Spanish term for something, and I’d understand what they meant thanks to the common Latin root of the medical term.
Were there any stark differences compared to the UK?
At University, the educational focus is on holistic dentistry, and prevention is the priority. It’s about the whole patient, not just about the mouth. So, we learn a preventative approach – sort out your brushing, sort out your diet and you’re less likely to have fillings. That means you’re less likely to need treatment in the future.
Treatments in my placement were far more reactive. And patients had to pay the full sum for any treatment they received. If they wanted local anaesthetic, they had to pay for it. If they wanted the dentist to use gloves, they had to pay for it.
I brought all my own PPE. And at the end I was able to donate a lot of what I brought over to them. Their resources were extremely low in that regard, at least in the government clinic I worked at.
That said, the dentists did the very best they could with what they had.
And on that point, it was eye-opening in the sense that it renewed my appreciation for the NHS.
In the UK, we grow up thinking that yes, the NHS is fantastic, but also that it’s a human right. I think we have a tendency to develop a sense of entitlement towards it.
Practicing dentistry in Arequipa showed me that we absolutely should not take it for granted. Because one day, should the NHS come to an end for whatever reason, things could be very different for us. I came away from the experience much more appreciative.
Getting to know local healthcare staff in Peru
What was the day-to-day of the placement like?
In the mornings I’d get up and jump on the bus to the outskirts of the city. We were packed in like sardines, but the bus journey was an adventure in and of itself. Arequipa is a beautiful city, so it was cool just winding around the roads, watching the morning’s hustle and bustle. Then I’d get to the clinic, say my good mornings to the staff and wait for the patients to start rolling in.
When patients came in, the local dentists would tell me what they wanted me to review and what would likely be the issue. All the charts were done on paper as opposed to the computer systems we’re used to back home. I’d learned paper charts at University, that they teach you right at the start just so you know what they are. But I’ve not thought about it since, so it was interesting to have to rely so heavily on them while I was over in Peru.
If there were any complex procedures, I’d get the opportunity to watch one of the more senior dentists go to work. There was a case of a girl who had an extra tooth. It was showing up on the X-ray as being buried under the top central incisors, which are your front teeth. If that stayed there, there was potential for it to have resorbed the roots of the other teeth. So, she could have lost those teeth altogether.
They decided to operate, so I got to observe the dentist perform the oral surgery, which was very interesting and not something I had seen at University.
The X-rays, by the way, are not digital. They were all developed in the darkroom, which was interesting to see.
And then in between patients, we’d chat about dentistry and the differences between our approaches.
On that point, there were some instances where I was surprised to see certain practices. One particular practice that differed was the mixing of amalgams. I noticed quite early on that the local dentists were hand mixing in the mercury. Mercury is obviously toxic and has detrimental effects on the environment once disposed of. Once in amalgam mercury is safe, as an alloy is formed, but hand mixing is something we don’t do anymore in the UK. These were the processes and materials available to local staff and so that was what they worked with.
The material selection was a big stand out in general. In the UK, we’re so lucky that we have multiple choices when it comes to material options. Each person, each tooth, will have some uniqueness to it where you might think that a certain filling might not work in here, or that crown material might not work in there. And we can pick and choose what materials to use and when. Whereas in Peru, this was not the case. My placement was in a government outpatient clinic and we had the resources we were given, and they were a little limited.
Overall, my placement was fantastic. The Work the World house was brilliant, there were 34 of us in total. I was the only dental student, but the rest were medics and nurses who came from the States, the Netherlands, Australia… We had this camaraderie that can only be borne of being thrown together like that. And then there’s the experience you get clinically.
It just opens your eyes to other ways of approaching treatment. You’ll also see things you would never see in the UK.
Jack as a student studying at Plymouth
You finished your placement and came back home. What was your trajectory from there on?
I got home and had two years left of study at Plymouth. I finished that off and then decided to try to get a placement in my hometown. My friends and family were there, so it made sense for me. The way it works in dentistry is the NHS pay for your final year and you work solely for them for the duration of that year. It’s called a Dental Foundation Year or Dental Foundation Training.
You do one exam and two interviews, which gives you a rank among all the other dentists in their 5th year of dental school. You then choose your number one area, which for me was Cambridgeshire. There is something like 60 areas and in each are 12–16 practices, each with one place in.
There are roughly 1300 students and around 1100 places, so unfortunately some people do not get a place.
Luckily, I ranked pretty highly and was able to get my first-choice area, and then within my area I was able to get my first-choice practice.
I spent the year there and completed that in August 2020. I’m still working there now as well as in another practice just outside the city.
What was the transition from education to the real deal like?
It’s interesting because at university you have a supervisor come and check every stage of the procedure. Then, all of a sudden, you’re by yourself and the onus is solely on you to make the right decision. Having said that, we do have educational supervisors. If I had a difficult case, or something I’ve not encountered particularly frequently, I can get them to come down at which point I’ll ask them for advice. So that first year you have lots of support around. I’m lucky enough at my practice now that if I come across a complicated case, then there are plenty of people around who can offer advice and support.
So, ambitions for the future. Your own practice eventually?
At the moment my focus is being good at my job. I’m doing lots of extra courses, trying to invest in and advance my skills so I can do the best for my patients. Job satisfaction and life satisfaction are intimately linked, and that’s why I want to continually strive for improvement and development.
Another thing I’d like to do at some point is something called Mercy Ships. It’s a massive ship that travels to Africa and the Caribbean. On board there are qualified medics, dentists… lots of healthcare professionals. They dock up for several months and provide free medical and dental treatment for patients who can’t afford it otherwise. Often it can be life changing!
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