tumbledry

True Learning

Afternoon appointments at the University of Minnesota School of Dentistry are scheduled from 1:15 to 4:00 in the afternoon. Here’s something you quickly learn: unless you have a really good reason for taking that long for one patient, you’d better finish up well before four in the afternoon. Expediency makes both the patients and the supervising dentists (under whose licenses we work on patients) much happier. So, in the three o’clock hour, only those dental students experiencing extenuating circumstances (impossible prophy, crown prep marathon, treatment planning issues) remain on the clinic floor, patiently working away. Some days, that’s me; other days, it isn’t. Today, I fixed the problems in my progress note, got it signed by the supervising dentist, and then turned in my dirty instruments and clinic gown to dispensing. Before everyone left at 4, I slipped downstairs to seventh floor to sign up for a radiological interpretation session.

One of the perverse realities of courses which are both strictly didactic in nature and poorly guided by their course directors is the distinct absence of useful knowledge. For example, I am well-educated in the a small slice of terminology of rare radiographic presentations PLUS I was given a grounding in the physics of ionizing radiation. None of this is helpful in clinic, where I now spend half my days. As a result, dental students schedule themselves for “radiographic interpretation” sessions where we attempt to locate carious lesions, defective restorations, and oddities requiring clinical investigation.

Our radiology suite at the school has an interp room which isn’t glamorous like the ones you see on television. Essentially a hallway lined by fluorescent viewboxes, it still has a certain coziness, imparted to it by its necessarily dim lighting. Since I escaped clinic relatively unscathed I was feeling relaxed—and so, I stepped into this radiology den, looking for a sign-up sheet. I found it, but I overheard something very interesting. Having sat through hundreds of hours of lecture from myriad personalities, I can recognize an experienced teacher taking full advantage of the Socratic method. In this setting, full of little nagging questions from another day actually trying to practice dentistry, I think I was primed to learn.

I began to listen in on a little quorum: six of my peers were learning from a nice fellow named Dr. Gavino. I’d never met him before, but his artistic yet purposeful pen strokes on a piece of scratch paper snatched from the corners of the dim room were telltale signs of the enthusiastic communication of ideas. I stepped into the circle as he continued talking about his rules of thumb for reading radiographs: “… so what is this? Right, that’s the margin of the attached gingiva, and it blocks food from descending along the root surface. So you can’t get caries here, unless the gingiva recede.” Real teaching!

Now, it was apparent that Dr. Gavino knew what he was saying inside and out—the difference was that he didn’t insist on dispensing dense, arcane phrases of impossible length from some ivory tower of academia. On the contrary, he was addressing us with terminology that was precise but not unnecessarily complex, asking us questions that reinforced what he was describing. Now this is why I came to the dental school! Without even thinking, drawn like a moth to a flame, I listened and answered his questions (he called us all by name) for the next 45 minutes. He sprinkled in little anecdotes and context, for which I am always a sucker. For example: in Europe, E1 and E2 lesions (penetrating only the enamel) are never operated on; the tooth is not surgically disturbed until a lesion penetrates into dentin. Or: instead of aggressively removing all decay above the nerve, developing countries where radiographs aren’t available simply cut down until the tissue is leathery (not glassy, like we pursue), and then stop, cap the pulp, and let the nerve recede on its own. Part of the operation goes like this: “We’ll cut until you say it hurts… then we’ll stop and cap it off.” They save teeth this way! And here we are, exposing roots in the name of eliminating every last trace of leathery decay. Which is better? He left it for us to decide.

The time was filled with exclamations of “aha!” and “oh, right!” and “but what about this?” It was wonderful. As I was a little bit of a late-comer, I didn’t realize why everyone laughed during one part of the lecture. Having us look closely at a bitewing of some posterior teeth, Dr. Gavino asked us what we saw. “Caries? Yes or no.” I hemmed and hawed: “Well, yes… I think so?” I wasn’t present for his introduction, where he implored my classmates to be decisive. If you’re going to be wrong, at least be wrong with authority!

But the most valuable piece of advice went beyond interpreting radiographs. It went like this: images are composed of pixels (or in film radiographs, like the ones we have: film grains), which you can’t resolve into an image close-up. If your nose is on top of the image, you just see little discrete specks. If you want to see what you need to see, back up! If you’re too close, you’ll miss what you’re looking for.

At the end of his lecture, one of my classmates asked Dr. Gavino why he insisted on calling us by name. “When you spin around on highway 35 and come to a stop inches from the median, you don’t forget how that happened. You don’t drive recklessly again! I have students from years ago who come up to me and say they remembered these little lectures. I called you by name to get your adrenaline going: adrenaline helps you remember—and I want you to remember these things, they’re important.”

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