Heeding the advice of others

The other day, I was sitting in the doctors’ lounge at the hospital having a cup of coffee before clinic was to start. There on the table was the May 2015 issue of the Bulletin of the American College of Surgeons . Flipping through the pages, I found an article by a surgeon, Dr Henry Buchwald, discussing 10 principles that have guided his professional life. I was struck because of the analogies that could be made between surgery and orthodontics. Buchwald stated that he has been in practice for almost 50 years and during his academic career has mentored hundreds of residents in terms of surgical care, techniques, and the attributes of practice that govern the discipline of surgery. To me, what he was saying ran the gamut from risk management to practice management to patient management and finally to personal management. It started me thinking that risk management is merely a reflection of how we manage ourselves. Some of us are footloose and fancy-free, having a high risk tolerance in general. Others of us have a more conservative nature and eschew risk as much as possible. Whatever our bent, we then go into our offices and develop risk management principles, policies, and protocols that in essence are reflections of who and what we are: our professional gestalt. I have analogized Buchwald’s musings to orthodontics and wish to share them with you. I do so with the idea that if we were able to more closely reflect some if not all of his guiding principles, we would all be better at managing the multitude of risks we encounter in our practices.

It’s always your fault

We have to accept responsibility for all that happens in our practices. He bases this idea on the fact that, as doctors, we must anticipate exigencies and attempt to thwart untoward events. We either were taught or learned via the school of hard knocks about things that can go wrong during orthodontic treatment. Because of this, we have an obligation to look for these potential missteps. We must be aware of the subtle clinical and radiographic findings that indicate that an untoward occurrence is right around the corner. It requires us to assume the mindset that if something can go wrong, it will. Not a happy thought, to be sure, but a very protective one for the patient.

He also noted that we must accept that we will all, at one time or another, make a bad decision, even though our actions at the time seemed quite rational according to what we thought was sound reasoning for the decision. It matters not that we thought we were doing the right thing. There is a long-standing axiom that the road to hell is paved with good intentions. Usually this occurs when we fail to take a long enough view of a chosen treatment plan, an alternative plan, or a particular mechanotherapeutic approach.

His final admonition was that we should recognize and accept that bad outcomes happen. Sure, we have many successes, but on the flip side, not every case works out. Not every treatment is successful. Some factors at play are out of our control, but the bottom line is that this is still our patient, we diagnosed his problem, planned his treatment, treated him, and retained him. However, because of such things as growth or lack thereof, physiologic and anatomic limitations, environmental, habitual, and systemic influences, and cooperation shortcomings, every now and then we become the proud owners of a failure. We need to own every result we produce and deal with them all while keeping the patient’s best interest in mind.

Posttreatment complications or shortcomings can often be addressed before or during treatment

You should treat your patients in your mind before ever treating them in their mouths. With a little practice, it is easy to “be the wire” or “be the tooth.” Look at the mechanotherapy you have set up. You should be able to know with relative exactitude how the hard and soft tissues will respond to the wires you have placed. When a patient returns and something doesn’t look right, or it doesn’t look the way you expected it to look, take the time to find out why. If you need to repair, replace, or reposition something, just do it. Yes, it might upset your schedule, but this patient needs your skill and expertise right now. At the end of a case, if the result is not what you had expected, go back over it, step by step, visit by visit, chart entry by chart entry. Try to figure out how and when the predicted outcomes morphed into something else. It might be too late for this patient, but it’s not too late for the next one.

Posttreatment complications or shortcomings can often be addressed before or during treatment

You should treat your patients in your mind before ever treating them in their mouths. With a little practice, it is easy to “be the wire” or “be the tooth.” Look at the mechanotherapy you have set up. You should be able to know with relative exactitude how the hard and soft tissues will respond to the wires you have placed. When a patient returns and something doesn’t look right, or it doesn’t look the way you expected it to look, take the time to find out why. If you need to repair, replace, or reposition something, just do it. Yes, it might upset your schedule, but this patient needs your skill and expertise right now. At the end of a case, if the result is not what you had expected, go back over it, step by step, visit by visit, chart entry by chart entry. Try to figure out how and when the predicted outcomes morphed into something else. It might be too late for this patient, but it’s not too late for the next one.

Gentleness, not speed, is the cardinal virtue

Paraphrasing a 15th century English proverb, Dr Buchwald noted that a doctor should have the eye of an eagle, the heart of a lion, and the hands of a woman. Today, we need to have a keen eye to make not just a diagnosis, but a differential diagnosis. For instance, not all Class II malocclusions are cut from the same cloth. There are at least 5 different and distinct types of Class II presentations. Discerning one from the others is the key to choosing the most appropriate mechanotherapeutic approach. It takes a brave heart indeed to face today’s helicopter parents; uncooperative, overindulged, and pseudo-entitled children; Internet-enlightened demanding patients; and pushy orthodontic vendors promoting specious claims concerning the never-ending revolving door of the newest and best gizmos and widgets. Today, we all know that dentofacial hard and soft tissues respond exceedingly well to light continuous forces, and a heavy hand has almost no place in contemporary orthodontic therapy.

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Apr 6, 2017 | Posted by in Orthodontics | Comments Off on Heeding the advice of others
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