Building confidence in your work

Building confidence in your work is a tricky topic. As new graduates from university we are thrust into the world of clinical dentistry fresh from the warm embrace of clinical supervisors. The harsh reality of increased legal responsibility and autonomy can be jarring for some. Personally, I feel like we were prepared sufficiently for this eventuality, perhaps a bit too much so causing me to err on the side of under treatment and over-referral. Like many things in life this is a see-saw and we move from one end of the spectrum to another. I think for now I've reached a happy medium where I can plan and tackle cases I am comfortable with and will attempt those that look only just a touch out of my comfort zone.

In countless lectures, the speaker will bring up a diagram explaining the four stages of competence (unconscious incompetence-conscious incompetence-conscious competence- unconscious competence). This recurring theme does highlight that very experienced operators have gone through this exact cycle. I don't think I would be too bold to add 2 stages on the end of this: conscious excellence and unconscious excellence because why would we be satisfied to stop at competence. However, far from being a simple linear equation that shows that increased repetitions of performing the same procedures will improve our competence level, there are actually multiple pitfalls and a ton of effort along the way. In a way, these stages can be represented as a steep mountain and effort is required to reach an adequate level of excellence.

• Unconscious incompetence: As it turns out, they really don't teach us much in university. Much of the theoretical knowledge we have been taught in basic sciences and dental science isn't relevant in clinical practice. Much like the subjects in high school we questioned would ever be relevant, university education has broad content to prepare us for the many specialties that can be opened to us down the line and to allow communication with our medical colleagues. Dentistry itself is mainly a clinical discipline and much of these skills are developed post graduation. Some people take a while to realise that they are incompetent. Those who attend continuing education may start to realise that they are learning things that university didn't teach them and will start to wonder what else they aren't aware of. Others will find friction with their workmates who have different methods of working and depending on their level of stubbornness, they may start to wonder if there is another way to reach a clinical goal. Isolated practitioners who avoid continuing education are in a dangerous position; they will not see their failures until the work starts to break down years down the track and will not adapt their technique to overcome this. In fact they will fall behind the times and continue to use the same obsolete methods to achieve their goals. 
• Conscious incompetence: Once you are at the stage that you realise that you have much to learn you should ideally feel liberated. Taking a narrow minded view to the field you are in can only lead to danger. Staying stagnant in your knowledge will be doing your patients a disservice. 
• Conscious competence: Once you have learnt more and have been in your practice for long enough you will start to notice improvements in your work. Initially when you start to see your work return you realised that although things looked good on the day, patients aren't static creatures and they will break down any work you do eventually. Suddenly the old dentistry that you made fun of the first time you saw them starts to look suspiciously like your own. At this stage, once you have the methods that suit you, practicing the same techniques over and over again does lead to an improvement in your skills.
• Unconscious competence: When you can unconsciously look at a case and begin to break it down into the smaller skills needed to solve the problems presented you are unconsciously competent. Once you can start a case from start to finish and it almost feels routine then you have achieved a good level of skill. Adverse outcomes that come your way will rarely surprise you as you have seen it all before and you are well equipped and trained to deal with these inevitable eventualities.
• Conscious excellence: Once you are unconsciously competent, don't stop there! There is more to learn and more improvements to make. Just like the techniques you have mastered were once just a thought at the back of their inventor's mind, new techniques are emerging all the time as skilled clinicians are reinventing new ways to use old materials and new materials are being invented all the time. Finding new continuing education courses and expending your current knowledge base is never a bad thing. Unfortunately discovering a new tidbit will it will drop you right back into the consciously incompetent stage but this is part of your road to self improvement. Even the consciously excellent in their field can be unconsciously incompetent in another's field.
• Unconscious excellence: This stage is reserved for the gurus of your profession. Those who have mastered current clinical techniques and knowledge and are pioneering new ways to achieve a more efficient, predictable or superior result.

A post on building confidence would be incomplete without first discussing the cycle of confidence loss. When we have an undesirable outcome it tends to overshadow all the positive outcomes that we have achieved in the past. One bad extraction experience or one failed implant integration can often be the reason we avoid this particular procedure for a while. Feeling of inadequacy reign and we tend to avoid difficult situations from then on. This is a natural reaction and should be acknowledged. However, when getting back on our feet we must also acknowledge all the times we have managed to extract the tooth without issues and focus on that during our recovery. We are working on human beings who are individuals with endless variations in anatomy and physiology. Adverse outcomes are normal. As much as we try, we cannot prepare for every eventuality and we would be doing a disservice to our patients by avoiding a more sensible treatment option because we are afraid of performing it. Naturally as we develop as clinicians we will find certain procedures that we gain more satisfaction out of providing and if you reach a stage in your career that you have the opportunity to only provide these services then by all means do so. This is the basis of specialist practice. However, using fear of performing a procedure as the basis of restricting your practice is unwise. It will lead to loss of confidence in your other work as you ask yourself the question "If I failed at that, what else will I fail at?" Instead, have the confidence in yourself as a clinician to recognise that you are on a cycle of confidence and slowly work on building that confidence back up.

Early on in your career, focus on continuing education and finding mentors to guide your work. These do not have to be more senior dentists that you work with. Specialists in your area or clinicians that you have met at CE courses can be valuable mentors. Family and friends can also help guide you in non clinical areas i.e mental health and building resilience. Once you have found people willing to help, lean on them and ask for advice when needed. Seeing others more experienced than you can be disheartening when you realise how far behind the curve you are as a clinician but you do have to realise that they have had many more years of experience than you and they started in a similar position to you. Aim to get to a stage where you yourself are good enough to mentor others. Consult mentors for treatment planning of simple and difficult cases. They will be able to point out facets of the treatment planning that you haven't thought of and you will learn from this. There is no one way to reach a goal and multiple mentors will be able to provide different viewpoints to the same problem. Be sure to consult them before you start the case and not during or after when you have had an adverse effect. If you area really very unsure, ask them if they can be nearby while you are working the case and can step in if need be. This kind of support is important in building your confidence to a stage where you don't need their input.

You can spend as much time learning theory as you want but putting this theory into practice is the way that you will learn. When learning a new skill, it can seem like a huge mountain to climb but consider the overall task like a brick wall made up of many smaller bricks. Sometimes breaking down the larger task into smaller building blocks will help you process the skill easier. For example in the surgical removal of a tooth, working on individual skills is handy. Separate processes such as consent, local anaesthesia, incison, raising a flap, bone removal, sectioning, elevation and suturing are all parts of the big picture. Working on each of these will allow you to produce a much better result. Working up to tackling harder procedures will make simpler cases run smoother and less stressful.

In the end, we will be afraid of procedures we do not know enough about. In difficult cases, it is easy to suggest a compromise if the compromise is what we are comfortable with. However, this is not fair on the patient as they are not being presented with the full range of treatment that is available to them and they may receive a substandard result in the end. If their case requires, orthodontics, do orthodontics, if their case requires crown lengthening then do crown lengthening etc. You don't have to be the one performing the treatment but you will have to know the indications of the treatment and how it fits into your overall plan. Especially for aesthetic cases, you should have a working knowledge of the procedure and be involved in the design process as if you are working on the final prostheses you need to be in control of things like tooth position and gingival margin. Just like you need to direct your technician to reshape teeth and choose shade, you need to direct your auxillary clinicians in the final result they are to aim for. Expanding your knowledge to previously uncharted treatments will allow you to formulate larger and more complex treatment plans with a more ideal end result.

Confidence isn't something you build overnight. Even very insecure people can build confidence but everything you do needs to be taken at your own pace. If you try and compete with your peers and do too much in too little time you will soon find yourself overwhelmed. Don't be afraid of expanding your knowledge, it is the only way you will improve. Don't be afraid of trying new things, you might find a way to achieve your goals that is more comfortable than your current technique. But with anything new comes a steep learning curve and be sure to surround yourself with colleagues that will help you through this process so you are never alone in what you do.