15

The point was made in chapter 1 that the decisions a dentist or a dental student makes involve not only questions about “oughts” and “shoulds” but also questions like “What kind of dentist am I? What kind of dentist do I want to become? What kind of person am I? What kind of person do I want to become?” Throughout this book, the concept of professionalism has been invoked to remind the reader of the importance of these questions. A few suggestions have been made about growing in professionalism. But there are ways to make one’s reflections on these questions more and more formative of how one lives and practices as a professional. For the sake of dentistry’s future—as well as to try to help every dentist and every dental student keep growing as a dental professional—this final chapter will focus on the process of self-formation in professionalism.

Professionalism was described in chapter 1 as the internalized and habitual ways of thinking and acting that characterize the life and practice of the most admirable members of the profession. This is an aspirational concept, one that identifies a long-range goal. But that does not mean it is something that a dentist should attend to later rather than now. Rather, it is something to be reflected on and actively aspired to from the first days of dental school—or even before—until the last days of one’s professional career. But what professionalism as a goal means and what it asks of the dental student is not the same as what it means and asks of the dentist in the first years of practice or of the more mature career dentist now well experienced in caring for patients.

This chapter will try to describe what professionalism as a goal means and what it asks during each of these stages of personal and professional development. It will also try to describe what needs to be learned and practiced and turned into a habit at each stage in order to be ready to move into the next stage. In addition, it will describe some of the most obvious challenges to growing in professionalism that are relevant to each stage in the process.

Many of these challenges connect with the book’s numerous contrasts of dentistry’s ethical norms and commitment to professionalism with the ways of thinking, valuing, and acting characteristic of the competitive commercial marketplace. These contrasts are important for two reasons related to the theme of growth in professionalism. First, as explained in chapter 10, the dental landscape has changed greatly since the final decades of the twentieth century. Some of these changes, in the science and technology of oral health care, have resulted in significant improvements in dentists’ ability to respond to patients’ dental needs. But many of these changes have incorporated the attitudes and activities of the commercial marketplace and brought them into much closer contact with the provision of professional dental care than was previously the case. These changes have brought new challenges to dentists at every stage of their growth in professionalism. They require dentists to think more carefully and more often about how to stay true to dentistry’s ethical commitments to the larger community. As previous chapters have often noted, these changes have also added greatly to the urgency with which dentists must ask “What kind of message does the influence of the commercial marketplace on my practice send to the larger community?” For dentistry’s authority and status as a profession depends on the larger community continuing to see a sharp contrast between dentistry’s professionalism and the commercialism of the marketplace.

A second reason for stressing the difference between dentistry’s ethical norms and commitment to professionalism with the ways of thinking, valuing, and acting in the competitive commercial marketplace is the fact that this book will likely have some use in educating dental students in ethics and professionalism. That is, it would be a mistake for this book to not look to the future of dentistry as well as its present and recent past.

There is a strong tendency for many people who are growing into a complex social role to focus on learning and habituating the technical skills necessary to practice it effectively and, in matters of ethics and conduct, to regard the practice of the role’s established members as simply the way such things are done. But there are a number of patterns of practice in US dentistry today that, even if not strictly violating dentistry’s ethical norms, are at serious risk of sending a commercial message about dentistry to the larger society. It is important that dentists entering the profession, those still in their early years of practice, and also those who are well experienced to take serious note of this issue and begin thinking carefully about how to address it. For dentistry’s authority and status as a profession depends on the larger community continuing to see a sharp contrast between dentistry’s professionalism and the commercialism of the marketplace.

These are challenging times for every one of the professions, and this is especially true for dentistry. Everyone who hopes to grow in dental professionalism needs to learn to look beyond his or her own development and reflect carefully on the impact of his or her actions on the future of dentistry. In addition, if there are any in dentistry who look at the description of professionalism and conclude that it is permanently beyond their reach or who have somehow entered the profession without a concern for its commitment to ethics and professionalism, they too should take these challenges seriously if they want there to be a dental profession where they can continue to practice in the future.

A CASE FOR CONSIDERATION: FEAR OF DROWNING

Jonathan Levinson is an eight-year-old patient who recently came to the practice of Dr. Nathan Silverman. From his first visit to a dentist at age four until two months ago, Jonathan’s dentist has been a young pedodontist, Dr. Edwin Samuels. Jonathan’s parents find Dr. Samuels considerate and caring, and a neighbor had recommended him, so they assumed that Jonathan would relate to him easily, just as they had when interviewing him. But Jonathan claims from the first visit that Dr. Samuels is “mean” and “doesn’t like me.” Every checkup is resisted, and it takes great persistence by Jonathan’s parents to get him to go. Routine diagnostic work and prophylaxis in the office are traumatic, and restorative work requires one or both of Jonathan’s parents to be at chairside restraining him. Eventually, Dr. Samuels speaks to Jonathan’s parents after a particularly difficult visit and recommends that they call Dr. Silverman.

“Dr. Silverman is one of my heroes,” Dr. Samuels explains to Jonathan’s parents. “He was a young pedodontist when I was a kid and my parents just happened to take me to him. I didn’t give dentists trouble when I was young, but as I grew up I became aware that many kids needed a dentist with a special gift for reaching them, and Dr. Silverman has it. He is one of the reasons I am a pedodontist. I think about him often and I hope that someday I will be able to help kids the way he does. So I’m sure he will know how to help Jonathan.”

Jonathan’s mother mentions to Dr. Silverman’s receptionist that Dr. Samuels has recommended that they contact Dr. Silverman and that Dr. Samuels has found Jonathan “difficult,” even though he is a very nice child. This prompts Dr. Silverman to call Dr. Samuels to talk about Jonathan.

“Both of Jonathan’s parents have high dental anxiety,” says Dr. Samuels. “I think they passed it on to Jonathan unconsciously before he ever set foot in my office. He was distrustful from the start. I talked to him a lot, as I do with all my patients, explaining things and trying everything I could to get him to relax in the chair, but I’m afraid he had it in for me from day one.

“He would clamp his mouth shut, turn his head away, even push me away with his arms, just for routine probing and examinations of his dentition. Heaven help us when it came to cleaning! He wouldn’t actually push Joyce away, maybe because she is a woman, but he would shout and yell out whenever he could feel her instruments touching tissue of any sort. Thank goodness I didn’t have to do much restorative work, even though his hygiene was not very good. He must have very strong enamel. But when restorations were needed, he would resist and resist until finally I would give up and bring in his mother or father—once, actually, both of them—to try to calm him down and a couple of times to actually hold him down so I could get the work done. After a few rounds of that—plus he’s eight years old now, and you’d expect more understanding and self-control—I decided I’d better refer him to you. He needs someone with a lot more experience than I have at this point.”

“Well, we certainly need to find other ways to help him,” says Dr. Silverman. “Thanks for sending his records over. I’m going to see him tomorrow afternoon.”

“Well, I wish you luck with Jonathan,” says Dr. Samuels. “Starting over with a new dentist is probably a good idea in any case, and he’s a pretty smart kid. But you’re the best pedodontist I know, so I hope it goes well.”

“Thanks for the compliment, Ed,” says Dr. Silverman. “I’ll do my best.”

At his first visit, Dr. Silverman meets Jonathan in the waiting room, shakes his hand and his father’s, and invites Jonathan into his office. “These are more comfortable chairs for talking,” he says, “and I’d like to get an idea of what you think of dentists before we talk about anything else.”

Jonathan’s opinion of dentists is not very high. Dr. Silverman asks him what he thinks of regular dental self-care and whether he has ever had a toothache and what that was like.

Jonathan admits that he has had a couple of toothaches and doesn’t like them and that Dr. Samuels’s work had ended the pain. He says that he knows brushing his teeth is something he should do, but he says he doesn’t like having anything in his mouth except food, so he only brushes his teeth when his mother or father are actually watching him, and that still makes him gag.

“Does it hurt your mouth to have a toothbrush in it?” asks Dr. Silverman. “I only ask because a lot of people, even people with very small mouths, don’t usually find it a problem. Do you have any idea why it bothers you?”

“When I was four,” says Jonathan, “I fell off a pier where I was playing with my friends at a lake, and I almost drowned. Whenever anything blocks up my mouth, I think about that and it scares me and it makes me gag. I was really scared. I was under the water a long time, and I couldn’t breathe.”

“That sounds terrible,” says Dr. Silverman. “You must have been very frightened. How were you saved? Did someone dive in and pull you out, your parents or someone?”

“My parents never knew about it. I haven’t told anyone about it before you because when I got out—I finally climbed up the logs that made up the pier—I was screaming that I almost drowned and my friends were laughing at me. They said that the water was only up to my waist, but I was so bent over that I just thought I was drowning, and all I had to do was stand up. They thought it was funny. So I never told anyone about it. I was really scared, but I thought anyone else would just laugh at me like they did.”

“Well, I appreciate your telling me about it, Jonathan,” says Dr. Silverman. “I certainly can understand how frightened you were, no matter how deep the water was. Not being able to breathe is one of the most terrifying things that can happen to a human being. I am very sorry that your friends laughed at you; they certainly wouldn’t have laughed if the same thing had happened to them. It was mean of them to laugh at it.”

“That’s how I felt,” says Jonathan. “But I couldn’t tell anyone. If they had been there, maybe they would have understood, but I figured anyone else would just laugh at me.”

“Would you be willing to try out some special, small-sized toothbrushes that I’ve got? We could try them out here, where you can experiment without anyone knowing, and if we can find a brush that’s comfortable for you, you can just take it home and use it and no one will ever know that you were really concerned about suffocating. Would that be a good idea?”

Jonathan agrees and follows Dr. Silverman into one of the operatories, where Dr. Silverman pulls out a box of toothbrushes of different sizes and styles. Jonathan experiments with a couple of them and finds one he is comfortable with. Dr. Silverman asks him if he would mind hopping into the chair so he could take a quick look to see how hard he would need to brush, since Jonathan hadn’t been doing it very regularly lately. “I won’t put any instruments in your mouth, I promise. You just open wide and I’ll take a look around,” Dr. Silverman says. Jonathan gets into the chair and opens his mouth.

“Well, everything I can see looks pretty good, Jonathan. Why don’t you take a look?” He gives Jonathan a mirror so he can look into his own wide-open mouth.

“Now I want to show you something, back here in my office,” Dr. Silverman says. They return to the more comfortable chairs. “What you saw in the mirror is just what I saw, looking in. It’s pretty much what you can see if I hold this model of a set of teeth right in front of you, except this doesn’t have any cheeks in the way. But let me ask you something, how would you go about looking at the back side of the teeth.”

Jonathan reaches out to turn the model around, and Dr. Silverman says with a laugh, “You’re now looking through the back of this patient’s head. I haven’t had a patient yet that would let me do that. What do you think?”

“I don’t know,” says Jonathan.

“Do you think it would be good if a dentist could see the back sides of the teeth?”

“Sure,” says Jonathan. “What if they have something wrong with them?”

“Right! Now let me show you something else,” says Dr. Silverman, picking up a pediatric mouth mirror. “This mirror is actually smaller than that toothbrush you chose, but it is plenty big enough to let you see most of the back of the teeth. Here, try it.”

Jonathan inspects the back of the model’s teeth using the mirror. “Let me ask you something, Jonathan,” says Dr. Silverman. “The next time you come in, could I use a mirror like this to look at the back sides of your teeth, to make sure there’s nothing wrong with them?”

“You can look right now if you want,” says Jonathan.

“Are you sure?”

“Yeah. But do I have to sit in that weird chair in the other room? It smells funny in there.”

“If you wouldn’t mind,” says Dr. Silverman. “I know it’s a strange chair and the room smells funny. The smell is because of what we have to clean it with, and the chair has a special light we can use to see into your mouth. Regular room lights don’t light up the inside of your mouth enough.”

They return to the operatory and Dr. Silverman inspects Jonathan’s teeth with the mirror, reporting in detail on what he sees, which is a mouth in need of cleaning but otherwise nothing that needs immediate attention.

“I have some more instruments here in this cabinet,” says Dr. Silverman, “all of them smaller than that toothbrush. If it turns out—after you try it out at home—that the toothbrush is okay to use, then I’d like to ask you to come back and I can show you how some of these other instruments are useful for checking out your teeth, too.”

Jonathan nods.

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