- Email: [email protected]
Caring for Ms. Class II Amalgam
C O M M E N T A R Y
E D I T O R I A L
EDITORIAL Let’s start to reflect on and challenge procedural approaches to patient evaluation and to adopt a more critical method that can accommodate both new information and novel clinical advances.
Michael Glick, DMD Editor E-mail “[email protected]”
Caring for Ms. Class II Amalgam hrough the years, many of us have developed work habits that prevent us from achieving an objective assessment of our patients. Some of these habits, unfortunately, were learned during our years in dental school. Others were picked up later in life, in the course of treating patients. Effective patient assessment is central to pinpointing a patient’s oral health care needs, to determining appropriate clinical interventions and to predicting treatment outcomes. It is essential, therefore, that strategies for patient evaluation be flexible and forwardthinking, not rigid and narrow-minded. Applying a flexible approach to everyday practice is not easy, but it can be accomplished if we are willing to challenge and redefine traditional conventions. Many dental schools still have clinical “requirements” that are used to determine students’ progress and even competence. Without arguing the merits or disadvantages of such a system from a clinical learning perspective, this approach to dental education often includes a representation of patients that can be dehumanizing. Ms. Smith, who has presented with an irreversible pulpitis, is labeled according to the intended dental procedure and is henceforth identified as “a root canal.” Instead of treating people with oral health care needs, students are treating “a Class II amalgam patient,” “a denture patient” and “a three-unit fixed prosthetic patient.” Labeling patients by the required procedure is not unique to dentistry. In medicine, patients often are further classified according to an underlying disease. A patient not only has bulimia, but he or she also is “a bulimic.” Labeling can be convenient and provide a sense of security, but pigeonholing patients in specific categories inherently diminishes the clinician’s ability to discern other comorbidities that may not be associated directly with a given “classification.” Grouping patients into easy clusters also lessens the clinician’s capacity for critical analysis and assessment. This type of branding also affects the patient; he or she may develop a distorted self-image and even unconsciously take on characteristics associated with a medical diagnosis that otherwise are not present. One of the more disturbing outcomes stemming from labeling patients according to a procedure is the impact on a practition-
T
JADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
June 2007
705
C O M M E N T A R Y
EDITORIAL
er’s sense of compassion. It is definitely easier to feel more empathy for Ms. Smith than for “a root canal.” Categorizing patients according to procedures facilitates the use of algorithms by which diagnostic or therapeutic pathways are predetermined. On the one hand, the use of algorithms provides a sense of reassurance by relying on standardized protocols that may have been promulgated widely and used by a large number of practitioners, but it also lends itself to limitations that can best be characterized as inflexible. This approach lacks the input of innovative, critical and independent thinking and takes away the oral health care professional’s ability to use his or her clinical judgment in unexpected situations that are beyond routine. To increase flexibility, a more hypothesis-based deduction strategy needs to be adopted. A hypothesis-driven strategy centers on making clinical decisions supported by a series of suppositions drawn from a patient’s chief complaint, his or her medical history and the examination. For this method to work, assumptions need be based on knowledge—and the broader the knowledge, the greater the number of options that become available. This methodology may be problematic for novices, but it is more appropriate for postgraduate residents and participants in continuing education courses. Even experienced practitioners often rely on pattern recognition: a specific pain complaint is associated with a specific diag-
706
JADA, Vol. 138
nosis, a particular visual trauma to a tooth should be treated in a specific fashion. This approach works in most cases but will fail for atypical or rare cases. The hypothesis-driven approach also can fail when the wrong terminology is used or when patients are classified into familiar groups. Although the presence of an inflammatory infiltrate may be present, an edematous and erythematous gingiva should not be described as an “inflammation.” An inflammatory process may be used to develop a differential diagnosis, but more data must be amassed to determine a diagnosis of gingivitis or periodontitis. By using a diagnosis instead of appropriate terminology to describe clinical findings, an important pathological condition easily can be overlooked. Practitioners, unfortunately, sometimes convert clinical protocols into rigid algorithms. The opportunity to invoke clinical judgment is not embraced and flexibility is lost. Words like “consider,” “may” or “could” give way to “need” or “must.” Exactly why clinicians do this is unclear, though it may have something to do with safety in numbers. Some clinicians also may believe that using time-tested protocols relieves them of the need to know the scientific rationale behind those protocols. Some, for example, wait six months before providing routine dental care to patients who have experienced a myocardial infarction. These recommendations are based on research that dates back 30 years,1 and much has
changed in the past three decades. More recent research has seriously challenged this long-standing treatment protocol.2 Clinical decision making determines outcomes, successes or failures, measuring our accomplishments as professionals. Yet we seldom look at critical thinking and decision making as a process, preferring instead to accept their effect as a given. Only by recognizing the process as an entity unto itself will we broaden and improve our approach to clinical decision making and diagnostic methodology. Our traditional approach to patient care needs to be refined. Established protocols need to be reassessed in a timely fashion, and clinical algorithms must be based on the latest scientific evidence. Every patient is unique and has distinct problems and characteristics. Therefore, any clinical guideline needs to embrace the opportunity for critical evaluation and clinical judgment. We dentists possess tremendous clinical skills. We are not automatons but professionals, each with our own unique talents. Let’s start to reflect on and challenge procedural approaches to patient evaluation and to adopt a more critical method that can accommodate both new information and novel clinical advances. ■ 1. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 1977;297(16):845-50. 2. Roberts HW, Mitnitsky EF. Cardiac risk stratification for postmyocardial infarction dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91(6):676-81.
http://jada.ada.org June 2007 Copyright ©2007 American Dental Association. All rights reserved.
E D I T O R I A L
EDITORIAL Let’s start to reflect on and challenge procedural approaches to patient evaluation and to adopt a more critical method that can accommodate both new information and novel clinical advances.
Michael Glick, DMD Editor E-mail “[email protected]”
Caring for Ms. Class II Amalgam hrough the years, many of us have developed work habits that prevent us from achieving an objective assessment of our patients. Some of these habits, unfortunately, were learned during our years in dental school. Others were picked up later in life, in the course of treating patients. Effective patient assessment is central to pinpointing a patient’s oral health care needs, to determining appropriate clinical interventions and to predicting treatment outcomes. It is essential, therefore, that strategies for patient evaluation be flexible and forwardthinking, not rigid and narrow-minded. Applying a flexible approach to everyday practice is not easy, but it can be accomplished if we are willing to challenge and redefine traditional conventions. Many dental schools still have clinical “requirements” that are used to determine students’ progress and even competence. Without arguing the merits or disadvantages of such a system from a clinical learning perspective, this approach to dental education often includes a representation of patients that can be dehumanizing. Ms. Smith, who has presented with an irreversible pulpitis, is labeled according to the intended dental procedure and is henceforth identified as “a root canal.” Instead of treating people with oral health care needs, students are treating “a Class II amalgam patient,” “a denture patient” and “a three-unit fixed prosthetic patient.” Labeling patients by the required procedure is not unique to dentistry. In medicine, patients often are further classified according to an underlying disease. A patient not only has bulimia, but he or she also is “a bulimic.” Labeling can be convenient and provide a sense of security, but pigeonholing patients in specific categories inherently diminishes the clinician’s ability to discern other comorbidities that may not be associated directly with a given “classification.” Grouping patients into easy clusters also lessens the clinician’s capacity for critical analysis and assessment. This type of branding also affects the patient; he or she may develop a distorted self-image and even unconsciously take on characteristics associated with a medical diagnosis that otherwise are not present. One of the more disturbing outcomes stemming from labeling patients according to a procedure is the impact on a practition-
T
JADA, Vol. 138 http://jada.ada.org Copyright ©2007 American Dental Association. All rights reserved.
June 2007
705
C O M M E N T A R Y
EDITORIAL
er’s sense of compassion. It is definitely easier to feel more empathy for Ms. Smith than for “a root canal.” Categorizing patients according to procedures facilitates the use of algorithms by which diagnostic or therapeutic pathways are predetermined. On the one hand, the use of algorithms provides a sense of reassurance by relying on standardized protocols that may have been promulgated widely and used by a large number of practitioners, but it also lends itself to limitations that can best be characterized as inflexible. This approach lacks the input of innovative, critical and independent thinking and takes away the oral health care professional’s ability to use his or her clinical judgment in unexpected situations that are beyond routine. To increase flexibility, a more hypothesis-based deduction strategy needs to be adopted. A hypothesis-driven strategy centers on making clinical decisions supported by a series of suppositions drawn from a patient’s chief complaint, his or her medical history and the examination. For this method to work, assumptions need be based on knowledge—and the broader the knowledge, the greater the number of options that become available. This methodology may be problematic for novices, but it is more appropriate for postgraduate residents and participants in continuing education courses. Even experienced practitioners often rely on pattern recognition: a specific pain complaint is associated with a specific diag-
706
JADA, Vol. 138
nosis, a particular visual trauma to a tooth should be treated in a specific fashion. This approach works in most cases but will fail for atypical or rare cases. The hypothesis-driven approach also can fail when the wrong terminology is used or when patients are classified into familiar groups. Although the presence of an inflammatory infiltrate may be present, an edematous and erythematous gingiva should not be described as an “inflammation.” An inflammatory process may be used to develop a differential diagnosis, but more data must be amassed to determine a diagnosis of gingivitis or periodontitis. By using a diagnosis instead of appropriate terminology to describe clinical findings, an important pathological condition easily can be overlooked. Practitioners, unfortunately, sometimes convert clinical protocols into rigid algorithms. The opportunity to invoke clinical judgment is not embraced and flexibility is lost. Words like “consider,” “may” or “could” give way to “need” or “must.” Exactly why clinicians do this is unclear, though it may have something to do with safety in numbers. Some clinicians also may believe that using time-tested protocols relieves them of the need to know the scientific rationale behind those protocols. Some, for example, wait six months before providing routine dental care to patients who have experienced a myocardial infarction. These recommendations are based on research that dates back 30 years,1 and much has
changed in the past three decades. More recent research has seriously challenged this long-standing treatment protocol.2 Clinical decision making determines outcomes, successes or failures, measuring our accomplishments as professionals. Yet we seldom look at critical thinking and decision making as a process, preferring instead to accept their effect as a given. Only by recognizing the process as an entity unto itself will we broaden and improve our approach to clinical decision making and diagnostic methodology. Our traditional approach to patient care needs to be refined. Established protocols need to be reassessed in a timely fashion, and clinical algorithms must be based on the latest scientific evidence. Every patient is unique and has distinct problems and characteristics. Therefore, any clinical guideline needs to embrace the opportunity for critical evaluation and clinical judgment. We dentists possess tremendous clinical skills. We are not automatons but professionals, each with our own unique talents. Let’s start to reflect on and challenge procedural approaches to patient evaluation and to adopt a more critical method that can accommodate both new information and novel clinical advances. ■ 1. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in non-cardiac surgical procedures. N Engl J Med 1977;297(16):845-50. 2. Roberts HW, Mitnitsky EF. Cardiac risk stratification for postmyocardial infarction dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91(6):676-81.
http://jada.ada.org June 2007 Copyright ©2007 American Dental Association. All rights reserved.