Dentistry was always in the stars for today’s guest, Rob Jacobs.
Rob’s father Tony is a prominent dentist and founder of the GDPUK website and forum, so you could say dentistry was destiny.
In this episode, Rob gets geeky about his passion and specialism – endodontics. He also talks family and lets us in on what happened during hid dad’s recent brush with COVID.
In This Episode
01.02 – COVID life and lockdown
02.17 – On dad and growing up
10.49 – What makes a great endodontologist?
15.21 – Insta-endo
19.01 – Heroics, referrals and day-to-day endo
25.42 – On pricing
32.17 – COVID and family values
46.30 – Future and practice ownership
51.03 – Rob’s black box moment
56.09 – To specialise or not to specialise?
01.02.15 – One thing you need to know about endo
01.07.16 – Rob’s last day on earth
About Rob Jacobs
Mancunian Rob Jacobs gained his bachelor of dental surgery from Newcastle University in 2012 and went on to work in Manchester as a general dentist.
In 2015, Rob embarked on specialist training in endodontics at Liverpool University, where he also completed a doctorate-level research project on patient-reported outcomes.
Rob currently practices in Garstang, Lancashire.
Rob Jacobs: Yeah, and I think we want to make it a smoother journey for the patient. If they can have an endo in an hour and 20 minutes instead of an hour and 50, I think every single person in the world would go for the hour 20.
Prav: And your hourly rate goes up, mate.
Rob Jacobs: Yeah. Well, you sounded like Sanjeev now.
Intro Voice: This is Dental Leaders. The podcast where you get to go one-on-one with emerging leaders in dentistry. Your hosts Payman Langroudi and Prav Solanki.
Payman Langroud…: It gives me great pleasure to welcome Rob Jacobs onto the podcast. Rob’s a specialist endodontist and we thought it would be good to speak a specialist, especially an endodontist to get their position and particularly Rob’s own position on where everything’s going in endo. Rob, welcome to the show.
Rob Jacobs: Thank you. Great to be here.
Payman Langroud…: It’s been a long time coming. We started talking about this pre-COVID and all of that, but how’s COVID been for endodontists? You guys must be busy as hell right now, right?
Rob Jacobs: Well, it’s a bit of an unknown because we’ve come back. Obviously, we had three months of patients to sort out, and then we’ve had a lot of new referrals because obviously there’s been people in pain and I think, if there’s any time a GDP doesn’t want to do endo, it’s right now with all the additional difficulties in terms of PPE and heat and stress. So, we’ve had a really busy July in both practises. August looks busy as well, but we know there’s uncertainty around the corner because we don’t know how much patients are going to value endo in the coming months. Especially as furloughing finishes and we’ll just have to see which direction things go.
Rob Jacobs: I think your patient who can afford endo, who wanted endo before COVID will still come along, but we don’t know about the other people who were managing but maybe now their job situation’s changed, et cetera.
Payman Langroud…: Rob, let’s start with your dad. You’ve a prominent dad in dentistry, Tony Jacobs, who started GDPUK. Did you know what that meant, the magnitude of that before you became a dentist? He’s been going a long time with that, right?
Rob Jacobs: Yeah. He started that in 1997. So, 10 years old I definitely had no idea. I thought he just spent a lot of time in his office. Wasn’t quite sure what he was up to really, and I think I was much more interested in football and not much else, but it grew and grew. It started out pretty small, just an email [inaudible] between four people. And then it outgrew that to the point where they then set up a website, and it grew and grew and grew, but I think by the time I was in my late teenage years, that was probably where it was at its height, and dad was doing a lot of work along normal dentistry.
Rob Jacobs: He then cut down from five days a week to four so that he had time for GDPUK. So, it’s been a big part of his life. Latter years, it’s become more a hobby again because it’s still doing really well, but obviously Facebook has changed everything. Well, he still sits in the office for hours, but I think that’s just to get away from my mom maybe. I don’t know.
Payman Langroud…: And do you remember conversations with your dad when you were deciding on dentistry? What was he saying about it?
Rob Jacobs: Yeah, so my dad never pushed me towards dentistry at all. I mean, I had a really good upbringing in terms of opportunities I got, but dad never said, “You’re going to be a dentist,” and I never said… I wasn’t one of these who at 12 years old was destined to be a dentist. It was more I got towards looking at the UCAS brochure in the careers room at school, and I kind of ticked through and I thought, “Accounting, no. Lawyer, no. Dentistry looks all right.” It was more of that. And obviously, I’d always had a good experience going to my dad’s. I didn’t mind dentistry, but I can’t say I loved before that.
Rob Jacobs: You get some people that turn up at undergrad and say, “When I was 9 I knew I wanted to be a dentist.” Definitely wasn’t me, but when I did want to do dentistry, my dad was really happy about it, and we’ve had endless hours of chats on the phone since then, which has been amazing for me. But he never pushed me in towards it.
Payman Langroud…: And did you grow up in North Manchester where the practise is?
Rob Jacobs: Yeah. So, we grew up in Prestwich, a little suburb in Manchester. My mom and dad still in the same house since where I was born. My dad’s practise is exactly a mile from the house. He’s never walked there, or he claims he’s walked there once, but he had the luxury of going home for lunch every day, and my mom would have lunch on the table every day even if she was at work. So, he’s had a very nice work life there. And I still live just down the road. We’re actually moving. We’re currently about 10 minutes from my parents’ house, and we’re moving to about 5 minutes away. So, we’re not far away from them, and family’s a big part of our life. Yeah.
Payman Langroud…: And did you used to visit the practise as a kid?
Rob Jacobs: Yeah. So, I think I had a very relaxed dental experience because I didn’t really have any dentistry. I just used to kind of mess around and go in the drawers and annoy my dad, but I’ve always been comfortable in the practise and I suppose I didn’t ever work in the practise. I did do work as a teenager, but we never mixed my relationship with my dad and the practise, but yeah, we’ve always gone there for our dentistry.
Payman Langroud…: When you finally decided to go to dentistry, did you study at Manchester?
Rob Jacobs: No, so I got into Newcastle and Liverpool. They were my two options, and honest reasoning was I just hated Liverpool Football Club at that age. I was a United fan. So, I was like, “No. Not going to Liverpool. Going to Newcastle,” but I did end up there for my post-grad, so it got me eventually. But no, I wanted to get away. I know that dentistry was a bit of a late decision because I suddenly thought, “I need to show that I’ve got hand skills.” Because people bring along musical instruments or different bits and pieces.
Rob Jacobs: So, I decided to build a model aeroplane, but I only ever built one. That was the one I took to my interview. So, I know it was all pretty late in the day, and I was like, “Oh yeah. I love model aeroplanes .” And it got me through. And Newcastle was just a brilliant experience. Absolutely loved it up there.
Payman Langroud…: Good town.
Rob Jacobs: Yeah, really good. And just got away from Manchester and my culture. Just threw myself into something new.
Payman Langroud…: And a lot of dentists hate endo, and then a lot of dentists love endo. Was there a mentor? Was there a something? What happened that made you look at endo? Was your dad saying, “Be a specialist?”
Rob Jacobs: So, my relationship with endo… I can vividly remember phoning my dad in my first week of undergrad training, basic endo skills in the lab or wherever we were. And I just phoned him and I was like, “I can’t do endo. I’m either perforating or I can’t find the canals. This is a nightmare.” And my dad was just laughing down the phone at me and saying, “You’ll be fine. Keep going.” So, it definitely didn’t start as immediately I was just blessed with skills in endo, but as I got out of undergrad, I started realising I quite enjoy the long appointments. I realised at the end of the appointment, “Well, I’ve actually found that quite relaxing.” And I found I wasn’t too bad at it.
Rob Jacobs: I definitely realised early on I wanted to specialise. I felt like I wanted to separate myself from that rat run of being an associate chasing UDAs. I just really didn’t enjoy UDAs from the outset, and I always felt I wasn’t in a very strong position job-wise because I’ve always felt there’s too many associates and it’s not a strong job position. I wanted to kind of separate myself and really get good at something. I don’t think I enjoyed being average at dentistry. I think I wanted to get good at something. And my dad never pushed me to do dentistry, but he did think it was a great idea to specialise. He didn’t push me, but he was very happy when I said that.
Rob Jacobs: But then in terms of mentor, I think really Sanjeev Bhanderi. My dad referred all his endo to Sanjeev. My dad didn’t love doing endo. And I started going to see Sanj I think in… I qualified in 2012. I think in 2014 or 13, I started going to see him for the dad and just spending a day there watching what he did, seeing all his gadgets and asking him lots of questions. And I then started building a portfolio of cases and things just snowballed from there. So, I think Sanj has been a massive part of my endo journey. I don’t tell him too often, but he’s a really good guy and he’s really helped me along the way.
Payman Langroud…: I think Sanj just got this sort of legendary status in endo, isn’t he? I don’t know. Why is that? We hear his name. He’s president of whatever, the Endodontic Society. What is it, BES, yeah?
Rob Jacobs: Yeah. Well, he’s been around in endo for a long time. Since the early ’90s, and he’s well-travelled. So, he qualified in London, then he did his endo bit and pieces in Manchester. So I think he already had a bit of a following in two places, and then in the North West, he’s done thousands of thousands of endo. So, pretty much every GDP knows him. He does really good endo, and he’s also still involved in quite a lot of teaching. Still teaches at Liverpool. He did teach at Manchester and UCLan. So, he’s just come across a lot of people. Got his fingers in many pies.
Rob Jacobs: And I think he does great endo, and he’s got really good standards, which he passed on to… He was one of our supervisors in the post-grad programme at Liverpool as well. And now working for him, which is great and I’m still learning from him. Even now it’s great, I can go up to his room five minutes before a patient comes in, throw a case over his eyes and say, “What do you think? This is what I’m thinking of doing. Would you do anything differently?” And it’s great to have that mentor still there as I’m still developing as a specialist.
Payman Langroud…: What would you say is the difference between a great endodontist and an average one?
Rob Jacobs: Well look, as an endodontist, you’ve got to get good results in terms of… The dentist judges you by the white lines on the x-ray, but I think endo’s moved on a lot from that, and looking at the whole picture of the tooth. I think endodontists are in a great position to make decisions on tooth restorability and how that tooth’s going to be restored. It’s moving on so much at the moment in terms of constellation, changing the way we access teeth, being a lot less destructive. We’ve got amazing files that help us do that in a much more predictable way.
Rob Jacobs: But I think a good endodontist is someone who’s staying up with the times and following all these modern developments, and not just thinking about the white lines, but thinking about the restoration, how that tooth is actually going to last a long time in the mouth, but on a basic level. Periapical lesions have got to heal up, and teeth have got to not be in pain and get better. Otherwise, you’re not going to be busy for long as an endodontist if your patients aren’t getting better.
Payman Langroud…: My sense of it working with endodontists was that there’s one lovely part about it. It’s that you don’t have to really sell anything to anyone, and that’s wonderful, isn’t it, not to have that problem?
Rob Jacobs: Yeah, the patient is usually… I mean, they’re not usually in acute pain because to refer to the dentist, they usually have to deal with the really acute pain, and we see them when they’re all in the chronic pain phase. But they’ve usually got their head around the fact that they’re spending money. It’s one of the most unenjoyable spends of money. It’s like a car puncture. There’s no joy when your car has a puncture or you need a new tyre, and you need to get back on the road. And in the same way, patients know they want to keep the tooth. If they didn’t want to keep the tooth, they wouldn’t be here. It’s as you said, there isn’t really a sale. It’s just this is the price. You do still get people trying to haggle.
Payman Langroud…: How often do you, Rob, hit a clinical wall where you’re not sure where to go and what to do? I mean, how of it is very routine and then how much of it is where you’re coming across something… I don’t know. Broken instruments, perforations, whatever it is. How much of it is that?
Rob Jacobs: I’m still really young in my journey. I only did my specialists training in 2015, qualified in 2018. So, I’ve only been in specialist practise for coming up to two years, but you can feel the change month by month. Coming home, I’m less stressed about things that have gone on in the day. I’m more and more satisfied with outcomes. I’ve got less stress on the way to work about what’s in for the day. I’m less worried about knowing what’s in the book coming up in the day. And more and more cases are going smoothly and kind of autopilot. I think the restorative part of endo sometimes can be more challenging. Obviously, really curved canals, ledges, broken instruments, calcified canals are all really difficult parts of endo, but I just try and follow processes and mental tick boxes.
Rob Jacobs: So, access the tooth, found the canals, have a little celebration in your head. Then get down the canals, little celebration in your head. Irrigate and everything’s gone fine. Operated, everything’s gone fine. And you break down each patient journey, and these things get more and more routine. But yeah, there’s still cases where we can’t get patency, we can’t get down the end of the canals, we can’t remove fracture instruments or everything goes perfectly but the lesion doesn’t heal. And any endodontist that says this doesn’t happen is lying.
Rob Jacobs: I’m really enjoying using Instagram to talk about endo, and there’s a really, really good endo community there, but one of the big things there is a lot of talk about recalls, failures. That wouldn’t explain cases of what is everyone else thinking. All the endodontists pile in from America, UK, Middle East, Australia. It’s great. So yeah, those challenges still exist and they don’t go away.
Prav: Is there any Instagram sort of audience patient-focuses, or is it all dental?
Rob Jacobs: We’re not in it for the patients. It’s not patient-focused. There’s no nice, shiny pictures. It’s nitty-gritty. My aim is to pick up followers that are interested in endo. So, my audience is primarily other endodontists and then there’s the audience of undergrads who I’ve taught and other people in the North West who have either sent a patient to me or come across me.
Prav: Referring GDPs?
Rob Jacobs: Yeah. And then I’ve still got about 50 friends who haven’t realised they really don’t need to be on this Instagram page because they’re never going to find that’s interesting because they’re not a dentist. So, I get a message every now and then saying, “I didn’t want to see that.” It’s not sexy dentistry, 5 out of 5 composite veneers and all that kind of thing targeted solely and younger patients. It’s completely different, but it’s still a thriving community. I’ve not got that many followers, but some of the guys have got between 15 and 30,000 followers, which for endo, it’s a niche environment, it’s pretty good. It’s not general population.
Prav: And just out of curiosity, does that Instagram dentist-specific content generate referrals for you?
Rob Jacobs: Yeah, I’ve had some referrals from it. To be honest, if I had one referral from it, I’d say it’s worth it. I do it on the couch in the evening. My wife finds it a bit annoying, but it takes probably five to 10 minutes to make a post. I think I probably find it quite relaxing in some ways. It’s like a good way to just round up your day, and have another think about it. Or if I get a gap in the day, maybe I’ll post something. I usually have a few things ready, and then when I get time I’ll post them. Can’t actually remember what you asked me now, Prav.
Prav: You answered my question. Do you get referrals, because a lot of people refer to Instagram as this business generator for them. They put some content out there, as you refer to sexy dentistry, and then that generates patients wanting that sort of dentistry. And just out of curiosity more than anything else, as a specialist in the field that’s not dental patient driven, but more referral driven, does it still work for you?
Rob Jacobs: Yeah, I mean last week I had a referral from a dentist, and I always find it really difficult when you need to get hold of the dentist. You phone then and the receptionist says he’s busy. Then they phone you, and you’re busy. I had a look and I saw he’s on Instagram, and I thought, “I’m just going to message him and say, ‘I just want to ask about this case. Do you want me to do the post or do you want to do the post?'” And we then followed each other, and I’ve actually tagged him today because I reviewed another tooth of that patient I’d already done, and he’s restored it really nicely.
Rob Jacobs: So, I’ve tagged him and said, “Lovely restoration.” And he’s really happy that I’ve done that, and we’ve probably kind of cemented a relationship there. He’s only referred this one patient who’s needed two teeth, but I suspect he’ll probably refer to me again now because we’ve opened up a communication-
Prav: A relationship. And I guess that you don’t have the issue of getting patient consent to show an x-ray and some white lines on Instagram, or do you?
Rob Jacobs: We do get consent for everything like that, just because why not? Yeah, we get it in advance. Every patient signs photographic consent. I don’t use them all, but it’s…
Prav: It’s still the same. Yeah.
Rob Jacobs: Yeah, it’s there in case.
Payman Langroud…: Rob, where are we with regards to is endo able to save more broken down teeth than it was 10 years ago? And the question of, “Do we save this tooth or not?” Bearing in mind implants are getting better. Where’s that heading? Are you doing more heroics or less?
Rob Jacobs: I think we went to a position probably just before I qualified where implants were replacing everything, and why bother with a tooth that has a poor prognosis? Let’s just whip it out and do an implant, but then I think we started to find implants weren’t the saviour of everything and they weren’t miracle workers, and they encountered problems as we got more and more follow-up on implants. I think dentists who place implants are getting much better at saying, “Actually, this tooth can be retreated. This is a good tooth. There’s still life in this tooth. You shouldn’t have the implant. Actually, you’ll get another 10 years out of the tooth.”
Rob Jacobs: And I always say to patients, “It’s all about delaying the next bit of dentistry.” So, if you have an implant at 40, you’re probably going to need to have another implant at 60 and it’s going to be more complicated. Whereas if we can get you to 55 before you have that first implant and you have another one at 75, you’re probably not going to be too bothered at 95 if you got some bone loss around that implant. And I think patients are very aware of that. They’re still very keen to keep their teeth, but I think we still have principles.
Rob Jacobs: If a tooth’s got a fracture then usually that’s done for, and I think we still know that if there isn’t a decent amount of tooth structure in ferrule, then we know we’re pushing the boundaries. It’s all about consenting the patients and giving them a prognosis and giving them an outcome. Every single patient I give a percentage, like 1-in-5 risk of this not working, 80% of it being successful, and try and tailor that to every patient. It goes in their letter before they come to see me, based on the radiograph from the dentist and the bit information we have. And then we I see them for the kind of consultation, if I see anything different then we’ll have a chat about that and adapt that.
Payman Langroud…: And Rob, are you having to nurture the referral relationship, the referring dentist relationship as a thing?
Rob Jacobs: In terms of getting referrals or…
Payman Langroud…: Yeah, as in you’ve got the dentist who’s referred you a couple of patients. Sure, you want to do that work really well. I don’t know. Do you guys sometimes send the patient back and say, “This could do with a crown,” and make sure you give that specialist seal?
Rob Jacobs: Every patient who comes, a letter goes back to the dentist and the patient detailing what we’ve done, what’s next. At the minute, we’re putting calls in all our teeth in terms of COVID because the guidelines are saying get as much done as you can when you’re doing an AGP. Max out on the AGP. But at Endo 61, we want to do good work every single time because that’s how you build your referral base. But at Endo 61, I really am piggybacking off Sanj because 90% or 95% of the referrals come to Sanj, and then he basically divvies them out between us based on who’s got space.
Rob Jacobs: There are some referrals that come directed to me and he then passes them on to me, but majority go to him. So really, we’re working on that together and we do open evenings. We do different things to keep that flowing. At Garstang, that practise was kind of… There was an orthodontist, Rachel, who’s married to Finlay Sutton who does the dentures, and there’s a periodontist. They haven’t had an endodontist for four or five years when I got there. So, we were kind of starting from scratch, but we had a really good catchment area.
Rob Jacobs: Garstang’s just north of Preston. It’s far enough away from Manchester, but it kind of captures the west coast like Southport, Blackpool, Lytham down towards north of Liverpool, because Liverpool’s quite busy with endodontists. And then there’s a late district in Lancashire. So, there’s a lot of people living in that area, and there’s many endodontists. So, it picked up really quickly and we’ve got not that many referrers, but a loyal band. And I started out there one day, and now I do two days and it’s busy. And the same with Sanjeev. I think with Sanj, I did one day and he said after my first day he went, “Can you do a second day if it’s not too much work?”
Rob Jacobs: He said, “We’ll review it soon.” And then after one day he was like, “Yeah. I think if you can do another day in a week, that would be good.” So, that just picked up from the get-go.
Payman Langroud…: So, how many patients do you see in a day?
Rob Jacobs: Pre-COVID, if we were just having a day of endo, I would usually see 4 and then there might be a consult or a review, that kind of thing. At Endo 61, I really just do the endo. It’s an endo practise. At Garstang, I’m doing a bit more restorative work alongside that, so I might place a call or call or restore the tooth if the dentists want me to, which is quite an interesting thing. My dad can never get his head around this because he can’t understand why a dentist would want the endodontist to restore the tooth in terms of a financial side of things, and just why wouldn’t the dentist do it?
Rob Jacobs: But we do get people that say, “Can you restore this tooth? Can you crown it?” Maybe they don’t like the patient, had a communication breakdown, trust issues, or they just don’t really want the hassle. They just want the whole tooth-
Prav: Job done.
Rob Jacobs: Yeah, and for us, that’s great. I mean, I think endodontists are in a brilliant position to restore. We see exactly what the tooth looks under a microscope and we’re in a great position to do it. And the training I had at Liverpool was very restoratively-driven. I mean, we can get onto that as we chat, but I think it was a brilliant programme for driving us to think like restorative dentists, not just to think about white lines.
Payman Langroud…: You treat four patients beginning to end, single visit endo, yeah?
Rob Jacobs: Yeah. Well, single visit endo, that’s a topic that’s been going on for 20 years or more about whether that’s a good idea or not, but most of us will do single visit endo if we finish the endo, there’s no leakage and we got time to obturate it. There’s some cases where… I mean, today I’ve had a case that I plan to do two-visit because it look like it was a fractured file, there was a big abscess. So we definitely wanted to do it over two visits. So, some cases we plan. Another case is you open them, planning to do it in one, but you get puss or you get leakage and you need to do it over two.
Payman Langroud…: What do you charge for a molar endo?
Rob Jacobs: So, at Sanj’s practise we charge 745 for every endo whether it’s primary or retreat or whichever tooth because if we get anterior teeth, there’s always a problem. Either there’s a perf, there’s a post or there’s a calcified canal. We don’t get the easy anteriors. So, even though they’re front teeth, there’s usually a reason to charge the same kind of fee, and then £100 more if they need a second visit.
Rob Jacobs: Garstang, very similar. Charge a little bit more for retreat. So, we’re probably going to go to the same model as Sanj. It’s easier for my brain to have the same thing every day and not have to change what I’m thinking on different days. I mean, I’ve now got the same microscope all four days, which is great. We want to streamline things.
Prav: Everyone knows what they’re getting as well, don’t they, when they refer a patient. They know how much it is. They know there’s no flexing the price or anything. It’s just…
Rob Jacobs: There’s other charges that come into things in terms of cores, taking off crowns because a quite a lot of the time, we have to dismantle things and investigate them. Consults, we do consults quite a lot. Wherever there’s any uncertainty, I’ll do a consult. I’ll only go straight to treatment if I don’t have missing information on the referral, or got enough information, but anything where you think there’s a bit of a guided prognosis or you need a chat with the patient. Then I have to give them a phone call or get them in for a consultation, which is another 100 quid or 145 at Sanjeeve’s.
Rob Jacobs: So, it does start to add up, but I think patients who want to keep the tooth, again as we’ve said, they accept that. It costs money. It’s expensive, business, isn’t it? So, I try and plan everything to an hourly rate that I’m trying to hit, and obviously, you don’t hit that hourly rate or that’s something that Fin’s really taught me in terms of valuing yourself and not underselling yourself. I still struggle with that a bit sometimes where I think, “Oh, it feels a bit expensive for the patient,” where actually, I should charge what is needed for the… Yeah. Yeah. Done a hell of a lot of training and it’s cost me a lot. So, I should .
Prav: A lot of dentists struggle with that, undervaluing themselves, and that comes across in their teams as well. So, let’s say it was one of the reception team or nurses, someone talking about you, but you didn’t feel comfortable with the price that you were charging for example, it’s reflected so much further down the line. Obviously, luckily in Sanjeeve’s practise and stuff, that’s probably all taken care of, but I think sometimes it just comes with confidence over time and experience that you can actually say, “Do you know what, I am worth this and I’m worth this hourly rate, and I’m exceptional value for money.”
Prav: I think we interviewed one of the most expensive implant dentists in the UK, and I asked him the question, “Obviously you are at the top premium end of the market, and you’re one of the most expensive, aren’t you? And how’d you deal with that?” And he goes, “No. I think we’re exceptionally good value,” and even though… It’s a mindset thing, isn’t it?
Rob Jacobs: It’s still something that I’m working on in terms of just… Sometimes I put together a treatment plan and it’s kind of edging up towards 1200 quid for if there’s other bits and pieces, and if they have say, an endo onlay at Garstang, then they pay 800 quid for the onlay and a 145 quid lab fee and the patient pays the lab fee. So, it then becomes kind of 1700, £1800 treatment for that tooth. And then you’re very near to an implant, but they get a really high level of treatment. Everything done properly, and a lot of time in the chair. So, I think it’s a fair price to get the job done well.
Payman Langroud…: And what about the way the system’s affected all of this with the NHS stent as being scared of GDC referrals, all of that. Are you getting people coming to you who can’t afford to give you £1000 and finance it, and all of that? Is there finance?
Rob Jacobs: We don’t really get that. I think I’ve had one patient in 2020 do it through finance. It was two teeth that she needed doing and she wanted to do finance. We really don’t get asked to do it. I think it’s probably a clientele thing if I’m honest. I think we get more middle-class patients that have just got a little bit more spare cash.
Prav: Is finance actively promoted?
Rob Jacobs: Not really because we don’t need to, so we don’t. Yeah, we don’t mention it because cooks into the fear in terms of someone’s got to pay that 8 or 9% fee that you generally got attached to it. A lot of our treatment plans are around about the £1000 mark, so most people don’t ask for it. It wouldn’t a barrier, but we don’t actively promote it because we’re busy enough without it.
Prav: And I guess they’re coming in pre-sold, aren’t they? It’s a recommendation from another healthcare professional.
Rob Jacobs: Yeah, and they get their treatment plan and all their information before they come, so they know the price before they arrive at the front door. So, there’s no surprises when they get here. Especially with COVID, we’re really just getting on with the jobs, so they kind of come in, do their mouth rinse and then we crack on because we’re trying to limit all the other bits and pieces that happen.
Rob Jacobs: Yeah, and I think we want to make it a smoother journey for the patient. If they can have an endo in an hour and 20 minutes instead of an hour and 50, I think every single person in the world would go for the hour 20.
Prav: And your hourly rate goes up, mate.
Rob Jacobs: Yeah. Well, you sounded like Sanjeev now.
Prav: You were just talking about hitting your hourly rate, that’s all.
Rob Jacobs: No, you’re absolutely right.
Prav: You’ve got to look at it that way, don’t you?
Rob Jacobs: I think part of that is as you gain more experience, you can pick exactly which case is going to take an hour and 15, an hour 30, an hour 45. Earlier in your career, you book your standard time because you’ve not got that experience to know what challenges are ahead and you don’t want to be running late. Whereas when you’ve done enough kind of sitting on your bum for 40 minutes, you think, “Next time I get this one, I’m going to book an hour and 20 because there’s no need to book two hours anymore.” So, that’s just part of the experience and learning.
Prav: Rob, moving on from saving teeth. Sort of personally how COVID has affected you and obviously your family as well. Do you want to just give us a rundown on that?
Rob Jacobs: Yeah, so like everyone else, COVID didn’t massively touch us early on. Me and my wife went on a pre-baby holiday to Tenerife at the end of February and we were two hotels down from the… If you remember the first hotel that got coronavirus. I don’t know why that none of us in the UK actually realised it was coming for us next, but we felt, “Bloody hell. It’s kind of interrupted our holiday. I’m not quite as relaxed on my sunbed,” and we didn’t really realise what was coming. But then a few weeks later, my dad got ill and we don’t know where, we don’t know if he got it from a patient or… He did go to a wedding the week before and quite a few people at the wedding got ill, but basically, my mom and dad both got coronavirus and we were getting more and more ill.
Rob Jacobs: As my mom was getting better, my dad was getting worse, and he was pretty stubborn. Pretty hard to get him to listen. We felt he needed to go to hospital, but he was adamant that he needs to follow the guidance, phone 111. I mean he was on the phone to 111 for an hour and a half one night and then it cut off. He was like, “Well, it’s cut off. There’s nothing I can do.” And then basically, eventually his doctor said, “You need to go to A&E.” And he went to A&E at about 1:00 on the Friday, and he was on a ventilator by about 6:00 PM. So, it was very, very intense.
Rob Jacobs: So, they did let my mom go in and see him that day because she… Well, they hadn’t tested her. It was in March, so they weren’t up to speed with testing at that stage, but they hadn’t tested her but my mom had all the classic symptoms, and they let her go in and see him. We were able to FaceTime him, and then we didn’t know what was coming next.
Prav: I mean, in terms of the severity of his symptoms and your take on everything in terms of how bad it was, what’s the reality of it all in terms of how things felt at the time when you were FaceTiming?
Rob Jacobs: I mean, we really didn’t know if he was going to make it. My wife’s a doctor as well, and we were both really reading a lot about coronavirus and as well informed as you could be. If you remember at that time in March, there really wasn’t that much information, and it was so early we didn’t know what was what really, but that was when there was that real rush for ventilators and that belief that ventilators are the only way you’re going to survive this if you get it bad. And so, to hear that he was going on a ventilator was just crazy.
Rob Jacobs: I mean, he went in at about 1:00 and he was texting us, and he was saying, “Oh, I’m actually feeling a bit better. I’m on oxygen. Doing okay.” I mean, his oxygen stats were like 80-odd, they were really low. And he did bounce back a bit, and they kind of said, “We think he’s going to need to go on a ventilator.” Then they said, “He doesn’t. We’re going to hold off.” And then you get that relief, and then about an hour later they’re like, “No. He does actually.” Because he’s needing more and more oxygen, and he’s not responding.
Prav: And who was communicating with who at this time, Rob? Were you speaking with the hospital staff? Was it through your mom?
Rob Jacobs: My dad. My dad was like, “I might be going on a ventilator. I might not.” He doesn’t remember anything from March now at all, but he was remarkably with it that day, and he knew exactly what was happening that day. He knew he was going on a ventilator, he was having a tube down his troat and he was getting into a deep sleep, and he knew everything that was happening. My dad was really well-read on it as well, and he knew how serious it was. So yeah, it was awful and we really didn’t know if he was going to make it. He did have quite a lot of the risk factors in terms of being over 60, male, overweight. We say a bit of high blood pressure, but hypertension.
Rob Jacobs: And yeah, it was so unknown we didn’t… I read every study there was to read in March from China about everything. I said to my programme director for my endo specialty programme, I said, “Think I’ve read more papers in the last week than I did in the last three years,” but I really just wanted to know as much as I could. I don’t know if it did me good, but for me, that felt like the only thing I could really do. And then it was just a case of phoning the hospital. That took over life. So it was wake up, my mom would call in the morning. My mom’s not medical, my mom would just get the kind of, “He’s okay.” Kind of job, and then we’d call in the middle of the day, and then later in the day, but you’re have this guilt phoning because it was so clearly overrun. They were in all this PPE. It was a big effort to come to the phone, so we had this constant battle of…
Rob Jacobs: Two hours after a phone call, you were desperate to phone again, but you didn’t want to interrupt the staff. About 10 days in, they requested that every visitor stops calling and they were going to start calling us instead because they couldn’t keep up with it, but that didn’t work out too well because they were too busy to do that as well. So then communication dropped for about a day, and then every family thought, “Screw this! I’m phoning up because you didn’t actually keep your end of the bargain,” which was because they were so overrun. But yeah, every day we got as much information as we could. We had a lot of help because my wife’s medical friends… We had doctors in ICU in other parts of the country. They were amazing. They gave a lot of information of what to ask because it’s really hard to know what to ask.
Rob Jacobs: You would jump on things. They’d say, “His oxygen requirements are a little bit lower,” and you think, “Oh, that’s good.” Then you’d phone up three hours later and, “So, he’s oxygen requirement’s have gone up a bit.” Oh, shit. That’s not good. So, everything was just-
Payman Langroud…: You realise when you get involved with hospitals and doctors that even when you’ve got all the connections that you’ve got all. Prav is a doctor himself, or my brother’s a doctor and all my best friends are doctors. Even with all our connections, you’re left in the dark and it makes you helpless. Someone who hasn’t got any of this. It’s almost like ignorance is bliss in a way, but just a member of the public who doesn’t know any doctors, where do they stand?
Rob Jacobs: If it was my mom, she would have just phoned up for 21 days, saying, “How’s he doing? Is he okay?” But all they ever said was, “He’s very poorly, but he’s stable.” That was all we really ever got.
Payman Langroud…: So was he on the ventilator for 21 days?
Rob Jacobs: Yeah. He was on a ventilator for 21 days, and I saw him about a week in because they were talking about getting iPads so that we could see him, because obviously we couldn’t visit, but then eventually one of the nurses said, “Do you know what, I’ve actually got my phone on me now. You can FaceTime my phone number,” which was amazing. It was awful seeing him on the ventilator, but I don’t know if I regret it or not, but anyway, we got a happy ending. I think my brain needed to see what was actually going on, what he look like, but then we got to FaceTime him when he was on coming off the ventilator, which was amazing in a different way.
Rob Jacobs: When I knew my dad was coming off the ventilator, I was just waiting for him to come on his phone because he loves his phone as much as me. And the WhatsApp was saying, “Last seen: 27th of March,” and it was April the 19th or something. And then he just came on one night, and when it said, “Online,”.
Payman Langroud…: The blue ticks, eh?
Rob Jacobs: Yeah, though he came back to WhatsApp in a funny… He came on and said, “Yo. Yo y’all,” which is not the way my dad speaks. He had a lot of hallucinations coming out of it, but he’s now doing really, really well.
Payman Langroud…: What’s he left with? Is he left with some…
Rob Jacobs: Well, he went for a follow-up last week to ICU, which was really good for him, I think. His lungs are completely fine by the looks of it. Well, we don’t know the long terms, but everything’s been okay. He was the ninth person to go on ICU in North Manchester, which is a big hospital in Manchester, and he was the first one not to have kidney failure. And they said they based a lot of their treatments off what worked on him. So, I think he feels quite happy about that. We found out that they were experimenting a bit on him, which is fine, and they also ran out of sedation drugs. So, thankfully we didn’t know this in April.
Rob Jacobs: So, there was quite a lot of challenges, but his main issues he’s got now is he’s got neuropathy in his legs. So, both of his legs are not feeling right, which is a consequence of a long stay in ICU rather than coronavirus. It’s a post-ICU complication, but it’s effecting his walking. He’s not back at work. He’s not ready to go back at work, but he’s walking more and more, and he’s walking quicker and quicker. He’s really determined. He did a 20 minute mile a few days, which he was happy with. I think he would have been doing four miles an hour before this, and now he’s struggling to do that. He’s not played golf all year. He tried to go to the driving range yesterday. I mean, he was crap before coronavirus. I think he’s done for now, but he’s due to be captain next year at the gold club, so he wants to get back to playing golf.
Payman Langroud…: Do you find it’s redefined your relationship with your parents in any way?
Rob Jacobs: Well, in the middle of that, we’ve also had a baby.
Payman Langroud…: Of course.
Rob Jacobs: So, we had a baby on May the 20th, so dad was home for that, which was just amazing because that was obviously weighing heavy.
Payman Langroud…: God. Difficult time for you. You have a pregnant wife. Both parents, corona. Difficult time. Sanj.
Rob Jacobs: Yeah, but no. You appreciate your parents and we’ve had an incredible kind of summer in the garden, really. I mean, even when my dad was in ICU, we did break the rules. We went down to see my mom every day in the garden because she was by herself. We had an incredible time. I’ve never seen my mom so much, and she saw my wife every day more and more pregnant. My sister and my sister-in-law are also pregnant. So, we’ve got three babies… They’re due in about two weeks. So, we’ve got three babies arriving in three months, and my dad is now loving it, and he’s
Payman Langroud…: So, wow. 2020 is going to be defined in your family as such a crazy, interesting year overall.
Rob Jacobs: Yeah, a lot has happened. But no, my relationship with my dad has just kind of gone back to normal. We had that week of absolute euphoria that he was here, and then I got my first telling-off. I think I was pulling leaves off his plants in the garden. “What are you doing?! What are you doing that for?!” And I was like, “Oh, good. Dad’s back.”
Prav: Dad’s winding you up.
Payman Langroud…: How many brothers and sisters are you?
Rob Jacobs: I’m the youngest. I’ve got an older brother, five years older, and a sister in the middle. My brothers got a three year old and another one on the way in three weeks. My sister’s got two and another one on the way in a week, and we’ve just had a baby. So, there’s a nice busy family developing. And we all live within about five minute walk, the three siblings. So, we see a hell of a lot of each other.
Payman Langroud…: So, I know Jonny. He was involved with GDPUK for a while.
Rob Jacobs: Yeah, so my brother, he was doing the advertising with my dad, but he’s moved on and he’s now working in sales, kind of a different world. And my sister, she’s trained in law, but she does HR now in a smaller company, but she’s been in maternity leave for years, so on and off.
Payman Langroud…: So, did you kind of think, “Do you think one of us could be a dentist?”
Rob Jacobs: Well, it wasn’t going to be my brother. He’ll admit that himself. I think he’s just smoking weed when he was 16 or 17.
Payman Langroud…: Good on him.
Rob Jacobs: He still denies that, but we all know it’s true. My sister was kind of very academically driven, but not in any way interested in being a dentist or anything medical. Didn’t like blood or giving local. It just wasn’t for her. I think it just suited me, suited my brain, but it was never like an ongoing joke, “One of you needs to be a dentist,” or “One of you needs to follow in the dentist.”
Rob Jacobs: Yeah, and even becoming a dentist, there was never really any talk about working at my dad’s practise or taking over, which some people find crazy. In summer, I wouldn’t take over my dad’s practise, but I’ve always thought my dad’s worked hard for that practise. He deserves to get a good price for it in the end that he’s done all that graft for. And then if I was going to buy a practise, it wouldn’t be the one to buy for me because I’m going in a different direction. So, we had a very brief talk about it, about could we convert this into an endo practise, but the whole goodwill of the practise is based on the general practise. So, it never really made sense to us.
Prav: Is practise ownership in the sort of peripheral vision for you in the future? Is that where your ambition is? Have you got that in your blood in terms of where you want to go, do you think?
Rob Jacobs: I think it’s something that everyone thinks about. It’s not something I’m in a rush to do at all. There’s so many other things going on in life. As an associate, obviously you don’t take as much of the fee home, but you don’t take all the stress, all the other stuff that comes with being a practise owner. And I look at the job, and I think it looks stressful. I think Sanj always said, “Get good at your endo, and when you get bored of endo because it’s kind of subconsciously happening and you’re on autopilot in 10 years times.” I think that’s when he thought, “I’ll buy a practise now just for a fresh challenge.” Reinvigorate your career.
Rob Jacobs: But right now I don’t feel the gain financially would be worth it for the loss of quality of life, for what I have because I have a great quality of life at the moment. I do my paperwork at work. I dictate my letters, they go to a friend’s mom on Dropbox, then she gets them back to me within about four hours. She’s awesome. And I usually read them the next morning, and then they get sent off, and that’s that day gone, consigned to history. On a Friday when I finish that, that’s it. I leave and I come back to work Tuesday.
Rob Jacobs: So, I love that element of it. I really want to make sure I spend loads of time with Sammy and also with kids in the future. We’re looking to move house at the moment. So, there’s just other stuff going on in life, and I’m really happy with the jobs that I’ve got and just continuing my development. Right now, I think it’ll come when I need a fresh challenge in my career maybe, but right now, and of course Sanj keeps me busy during the day, still thinking.
Prav: And it’s very, very easy from the outside looking in to sort of maybe think about how lucrative it is, practise ownership, but you’re right, there’s so much stress that comes with it, but also losses. Let’s say you go from now to practise ownership, there’s the investment. You’ve got so much positive time to spend with your little one, and other new ones coming into the family, right?
Rob Jacobs: Yeah, and doing specialists training was a massive investment. I done three years of dentistry after dental school, and then my wife took a little bit of time to get onboard because the course was £17,000 a year at Liverpool and that was without a job. So, three years times that without a job. I think it was at least £300,000 investment and when I told my in-laws, they thought I was a bit crazy at first, but everyone came around to it very quickly and saw why it was going to be a good career move.
Rob Jacobs: At my wedding day, my brother said, “What Monica got, she got engaged to a dentist and she’s marrying a student.” It’s worked out in the end. It was a tough few years though. We made a lot of life changes to do the specialist training. We moved house. I had got myself an A-Class. I had a Corsa, got myself an A-Class and I was happy, then I went back to a Corsa, which was really shit. Well, I eventually managed to get back in a car that I enjoyed driving, but we made life changes to make it work. And Monica’s work kept us going. Managed to do a bit of endo along the way and did a bit of teaching at Liverpool, which I would have just not got by without those extra bits alongside it, but it was tough.
Rob Jacobs: So now, I’m earning well now, but I’m not having that pressure. I get to leave the work behind. I’ve got a good relationship with all the staff because I’m not the boss. I’m the person they can have a laugh and a joke with, and tomorrow we’ve got an early start, early finish. Finish at 2:00 and I’m playing golf at 3:30. Not told the wife yet, but… It means I get some quality of life. Work takes over too much anyway, so I think with that it would take me over the edge. I am looking at it. I’m reading about endo, looking at stuff too much in the evening and that’s something I still need to work on, but I think I’ve got the balance as good as I could at the moment.
Payman Langroud…: Rob, we’re asking everyone about clinical errors, like a Black Box Thinking, to try and learn from them.
Rob Jacobs: From an endo perspective, I’ve done everything.
Payman Langroud…: Everything wrong?
Rob Jacobs: From missed canals, perforations, fractured files. Touch wood, I’ve not had a hypo accident yet, but I will have one.
Payman Langroud…: That’s always a nightmare, isn’t it, that.
Rob Jacobs: And it terrifies me for the day that it happens, and every endodontist-
Payman Langroud…: Prav, you know what that means, Prav?
Prav: Got no idea.
Rob Jacobs: Sorry, Prav.
Payman Langroud…: The bleach they put in the tooth, sometimes it comes out the end and then you’ve got Domestos in the…
Rob Jacobs: Yeah, you get a severe kind of immediate reaction. It’s very painful, very unpleasant. And the problem is as well as the patient shitting themselves, the dentist would also shit themselves, and every endodontist admits that it’s the one thing you really don’t want to happen because it’s really unpleasant for the patient. It’s usually resolved in a few weeks, but it’s a lot of bruising, bleeding, lot of pain.
Prav: So, just explain that again. You clean the teeth out with some pretty powerful stuff, and what-
Payman Langroud…: Bleach.
Prav: Bleach, and that leaks into the oral cavity basically?
Payman Langroud…: No, into the bone.
Prav: Oh, into the bone?
Rob Jacobs: Yeah, so if you extrude that irrigant out of the end of the tooth, you get a very big reaction immediately. So, we use the irrigant really safely. The difficulty is you want to get that bleach as close to the end as you can, because you want to get the end of the tooth clean but without having any instances. So, there’s a lot of things that you do to make things safer. You do those every day and it’s something that I’m always very careful of how I use the irrigant, but you have to also make sure you’re not just tickling it up at the top of the tooth or you won’t.
Prav: Got to be thorough, right?
Rob Jacobs: Yeah, you got to be thorough.
Payman Langroud…: Have irrigants not moved on? Is it still hypochlorite?
Rob Jacobs: Still hypochlorite, yeah. Other things have come in the market, but hypochlorite’s tried and tested. No one has moved away from that. Different things come along the way in terms of activating that, but at the end of the day, bleach is what fixes the problems.
Prav: And you know that’s going to happen one day, don’t you?
Rob Jacobs: Yeah, it will. It’s like a car crash. If you do enough driving, you probably will have a car crash.
Prav: So, is that something that’s happened… Obviously you speak to people like Sanj. Has it happened to Sanj before? Or you can’t speak on his behalf?
Rob Jacobs: I can’t be sure. Any endodontist that work a long time, it will have happened. There’s a really great Instagram endo podcast, another podcast.
Prav: Flipping heck. That’s niche.
Rob Jacobs: Last week they did… Yeah. They did endo mishaps and it was two guys in America. Really, really prominent endodontists talking about their hypochlorite accidents and how much it stress it was. It’s something that I think any endodontist isn’t secretive about it. It’s something that will happen. It’s like some kind of implant-
Prav: Implant failure.
Rob Jacobs: It’s like implant. Yeah. I think if you do enough implants, you’ll have that catastrophic failure that’s just really stressful and awful, but for me, dentistry is all about being open and not… I think maybe in the past, people hid behind these things and say, “Oh, no. Nothing bad’s ever happened to me,” but we’ve become a lot better at one, having open disclosure with the patients, and when you have something go wrong, tell the patient straight away. I’ve learnt that myself. Whenever something happened and I didn’t disclose it, it caused me much more stress when I got home, if something hadn’t gone as perfectly to plan.
Rob Jacobs: And then my wife would say to me, “Why don’t you just tell the patient and you won’t be talking about it on the couch. You’ll just tell them. They’ll accept it because procedural errors happen. It’s difficult sometimes. And then you’ll carry on with your night.” And I’ve learnt that it’s much better to be open and then move on, and also tell patients before. If you tell a patient before, it’s part of a plan. If you tell them after, it’s just an excuse.
Payman Langroud…: Yeah. Look, hopefully you’re going to have a long career. In that long career there’s going to be a few disasters, and there’s going to be a few mistakes and things outside your control even.
Rob Jacobs: There’s stuff that happens that you can’t prevent. I mean, I did an endo in my second year of practise. Everything went well. Two years later, a bit of his tooth broke off and he made a complaint against me. It was in my first week of my specialists training, and it was just like, “What the hell?” So, just at the start of endo specialist training, someone made a complaint about an endo. And then it turned out that we just gave him back whatever I was charging at that time, 400 quid I think it was and said… It wasn’t really my fault that a bit of his tooth broke off two years later, but I think I was still at my training and I thought, “Move that problem away and carry on.”
Payman Langroud…: If I was a young dentist and I wanted to specialise, give me the case for specialising in endo number one, and number two, your best advice after that. I’ve decided I want to be an endo specialist, I’m two years out. Or even before that. Let’s say I decided I want to be a specialist in uni. Are you one of those that believes that you should have a few years of generalist and then move on, or get as quickly as you can into the specialist like the Americans do?
Rob Jacobs: I think in terms of why to do endo, well, there’s many questions there, Prav. But why to specialise I think, as I said at the start, separating yourself, having a niche. I think in 2012, the kind of cosmetic dentist hadn’t really come around as a… We saw implants as the kind of specialty that wasn’t officially a specialty. We now have really the kind of cosmetic dentistry as almost a specialty now. So many people, that’s what they drive towards from an early part of their career and the whole kind of Instagram dentistry didn’t exist. That wasn’t really an option, and that’s what’s really enticing people at the moment.
Rob Jacobs: But for me, I love endo because you fix people, you get a kind of immeasurable improvement very, very quickly. They’ll phone you the next day and say, “That tooth has been hurting me for a long time and it’s better today,” which I love. If you do ortho, you don’t really find out if they’re happy for two years. Perio never really interested me at all. I wasn’t set out for implants. So, endo was just the thing that suited me. You have a nice relationship with the patient, but you also have in some ways quite a nice in that you see them. Then you put the rubber dam on, you get on with your work and then you move on.
Rob Jacobs: And also, I’m a bit OCD. I like the protocol, the procedural steps. It suits my brain and I suppose I liked being spoon-fed. I went to school where you got told, “Do this. Do this. Do this and you’ll have success.” I love with endo, if you’re a good rule-follower and you can follow steps you get good success as well. So it suits my brain.
Rob Jacobs: In terms of specialising, I think most unis want at least 2 to 3 years experience. They want varied portfolios, did some hospital jobs, maybe some MaxFax. You’re going to try and get to do an audit or some kind of paper. If you can get your name on a publication, that helps you massively. But for me, Liverpool started that programme in 2014 just as I was gaining interest in it. London was the only other place really to do endo training, and that was just not viable financially for us. Moving to London would have just been a step too far, and so that Liverpool programme just came at the perfect time, but I didn’t really have the CV that you should’ve had.
Rob Jacobs: But basically, I went to Liverpool and met the programme director Fadi Jarad, who’s been another massive influence on my career, and we just got on really well. And that was probably what got me into the programme, to be honest. We just clicked and then I survived the interview, it went okay, and I think because I was an early adopter there wasn’t so many people applying. Whereas now, six, seven years later, everyone knows about it. You need a lot more on your portfolio.
Payman Langroud…: And on the imaging side, is it something… Back in my day, there was no talk of doing these CBCTs on teeth for endo.
Rob Jacobs: Yeah, so CBCTs are coming more and more into endo and probably-
Payman Langroud…: Just explain that to me. You sort of take a volume and then sort of visualise the canal as you go up and down it, is that what it is?
Rob Jacobs: Yeah, so traditionally, we only had a 2D image of the tooth. So we just had an image that you sometimes didn’t know exactly what was going on with the tooth. You were left with answers. You try and take multiple radiographs to get as much information as you could. The CBCT gives you way more information about… For example resorption, it’s becoming pretty much a must resorption because you can picture so much better where that lesion is, what it’s involving, whether it’s treatable, finding canals, lesions in terms of how big they are, which teeth they’re involving.
Rob Jacobs: So, I’m probably doing a few scans a week that I’m sending off. Currently, I send to a place in Altrincham and the patient goes there and comes back, and then the scan gets reported by a radiologist, but ideally, you’d want to have a scanner in your practise. I think the cost of them is coming down and-
Payman Langroud…: Is it the same scanner as they use for implants?
Rob Jacobs: Well, you want very, very good resolution for an endodontic scan, whereas for an implant you don’t need as much fine detail, but the scanners are getting better all the time. The endo scanners are expensive, but the best of the market for endo you’re looking at 70 to 100,000 quid. So, it’s big money.
Prav: It’s a lot of 750 quids that, isn’t it?
Rob Jacobs: Yeah, but I think they work best in practises that have a lot going on. But I think they’ll get cheaper and they’ll become more mainstream. The place in Altrincham’s a bit of a conveyor belt. They’ve got quite a few scanners. They’ve got appointments every 10 minutes. You book it online, the patient gets an email. It’s very slick. And they’ve got parking there. The patient goes, they have the scan, they leave. So, it works pretty well, but obviously it would be a lot better if we could have it onsite.
Rob Jacobs: The Americans use it. They use it like sweets. They do a CBCT at the start of the case and they do another one at the end just to see how nice the white lines are, but the UK, we’re a lot more… In terms of radiation, we’re a lot more careful. We really justify its use because it is a bit of a higher dose of radiation, but the more you use it, the more… It’s like a microscope. It gives you eyes into a new world of information, and the more you use it, the more you think, “I need this on my next case.” So, it’s going to become bigger and bigger, and eventually it will be a routine thing in endo. Probably by the end of my career or even earlier.
Payman Langroud…: What’s one thing that general dentists don’t know about endo that you wish they did?
Rob Jacobs: So much. I mean, I did a lot of teaching on the undergrad clinic, which is the closest I could come to kind of working with GDPs. In some ways, they’re probably in a better position than GDPs because the teaching’s fresh in a mind. They’re not taking shortcuts, and they loved having… The endo programme at Liverpool, it just had general dentists coming in to supervise it and the general dentists… I remember from my own undergrad days, the general dentists is kind of hanging it on with you during the endo because they don’t probably love endo either, whereas having us looking after them, they loved it, and we give them a lot of tips.
Rob Jacobs: But I think the key things, rubber dam is not difficult to put on. You can learn how to do rubber dam in a few hours. I think COVID has had a great impact on people finally getting more routine with rubber dam because it keeping them safe from saliva, but it’s an essential. I think it’s crazy when people don’t use rubber dam because you do drop files, and with a rubber dam it just goes onto the sheet and you pick it up. I had a mate in fourth year uni, my housemate dropped an F tooth hand file, which Prav, it’s a big file for a non-dentist and it went down the patient’s throat, into his chest and he was with the patient till 11:00 PM on a Friday night. He won’t mind me talking about this. He took it well.
Prav: Just give me an order of magnitude of this thing in terms of… Can you compare it to something?
Rob Jacobs: It’s about an inch long. It’s got a big handle. You wouldn’t want it in your left or right lung.
Prav: Right, okay.
Payman Langroud…: Like a serrated edge.
Rob Jacobs: And I think he needed surgery to get it out. Surgical procedures to remove it from his lung. Actually, the funny thing was he had rubber dam on, but he’d left a gap just between the patient’s upper lip and the rubber dam, and then it slipped out his hand and got through the gap. When you put rubber dam on, make sure you cover the whole mouth. That’s the other thing. It also allows you to use hypochlorite. Without rubber dam, you can’t use hypochlorite and you can’t get the tooth clean. One thing I would say is up skill in your rubber dam. It makes your life so much easier. And not having tongues, saliva, or the patient chatting to you makes your life easier as well.
Payman Langroud…: But what about regarding the endo itself?
Rob Jacobs: Regarding the endo itself, I think again, so many steps, but magnification. You’re not going to have a microscope, but having loops of a light gives you a much better chance of success. Just investing in some decent equipment, going on courses, up skilling and being confident to actually tackle the kind of simpler cases in endo because a lot of people have been scared off by the litigation. They just don’t really to touch endo and it is something that everyone can do. There’s a lot of good courses you can do just for refreshers, and it’s not a kind of dark arts that people see it as that they don’t ever want to go near.
Payman Langroud…: Is there an endodontist that teaches GDPs, like a Tif Qureshi of endodontics, a Hatem Agathy, Ian Dundith, someone who’s ruining it for the rest of you.
Rob Jacobs: There’s a few of them. There’s a few of them. I mean, Sanjeev is one of them.
Payman Langroud…: Sanj is one of them, yeah.
Rob Jacobs: In the North West, there’s Sanj. James Darcey is a younger guy who’s really doing well. Kreena Patel down in London, she’s doing great. So yeah, there’s quite a lot of us who are doing stuff and there’s a lot of weekend courses for the dentist, and they’re brilliant. You can pick up a lot of tips and get a lot more comfortable doing endo just from a weekend course. Everyone just wants to go on the composite courses or the implant courses, but there’s a lot to be said for going on your more everyday-dentistry courses. Especially earlier in your career. I did them and that’s part of where I get my interest in endo.
Payman Langroud…: Do we look forward to the Rob Jacobs year course?
Rob Jacobs: Yeah. Definitely something that’s in my plans.
Payman Langroud…: Is it?
Rob Jacobs: Yeah, there’s also kind of Jon Cowie down in Bath, they do a brilliant programme, and Massimo. Yeah, Massimo Giovarruscio.
Prav: I know Massimo.
Payman Langroud…: Is that in Bristol?
Rob Jacobs: So, Massimo’s got a great programme, Delta Dental Academy. So these things are happening, and yeah, there’s no reason not to have that up in the North West as well. Just waiting for Sanj to retire.
Payman Langroud…: Does he work with Alfonso?
Prav: Yeah, he’s a character and a half, Payman.
Rob Jacobs: Yeah, he’s a great guy.
Payman Langroud…: Same as Alfonso. What Prav, do you think he’s too young? He’s too young for your final question.
Prav: Far too young, mate.
Payman Langroud…: No, mate. No, mate. No, mate. Corona.
Prav: All right. So Rob, it’s your last day on the planet and just as you were in that situation where you thought maybe it would have been the last time you saw your dad on a nurse’s iPhone, imagine it being the last time somebody sees you, whether it’s your kids, your future kids, your parents. What three pieces of advice would you want to leave them with?
Rob Jacobs: I’d say put your family first because we all get drawn into the work, work, work part of life, but your family is the most important bit when it all comes down to it.
Prav: For sure.
Rob Jacobs: Be kind and generous, and just be a good person. Be compassionate. Care about other people. And I think third lesson for Sammy would just be be a big United fan. I’m encouraging him already, started brainwashing and very important part of life.
Prav: Brilliant. Brilliant.
Payman Langroud…: It’s been lovely having you, mate.
Prav: It’s been great, Rob, and me walking away from this conversation what is truly, truly clear to me is obviously the first thing that you mentioned is family is everything, right? Well, the second thing which is without question, you are a rising star in dentistry and you are so fricking passionate about endo, so geeky about it that you will make a name in this industry. I know you will, whether it’s as an educator or practise owner and stuff, because you are so driven and passionate about it. Whether it’s sitting on the couch reading about it or-
Payman Langroud…: I’ve been on his Instagram. You should have a look at that. That’s a little endo on there.
Prav: I’ll check his x-rays out, mate.
Payman Langroud…: It’s actually impressive. It’s actually impressive.
Rob Jacobs: Yeah, I am an endo geek and I’m proud of it.
Prav: Good. Good.
Payman Langroud…: Thank you so much for doing this, Rob.
Prav: Thanks for your time, mate. Really appreciate it.
Rob Jacobs: Thanks very much.
Payman Langroud…: And really, the next time you see dad, do certainly send him my regards.
Rob Jacobs: I will do. He’s got time to listen to this, so I’ll make sure he does.
Payman Langroud…: Brilliant. I hope you tell him that.
Rob Jacobs: Cheers, guys.
Outro Voice: This is Dental Leaders. The podcast where you get to go one-on-one with emerging leaders in dentistry. Your hosts Payman Langroudi and Prav Solanki.
Prav: Thanks for listening, guys. If you got this far, you must have listened to the whole thing and just a huge thank you both from me and Pay for actually sticking through and listening to what we’ve had to say and what our guest has had to say because I’m assuming you got some value out of it.
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