Another second opinion consultation, you whisper to yourself as you prepare to greet the young patient who is awaiting your initial evaluation. Ben Stevenson was referred by a member of your study club. You recall reviewing this 11-year-old boy’s radiographs early this morning. The film shows approximately 50% root development of the succedaneous teeth with immobile deciduous canines and molars. The maxillary arch is bracketed, and an archwire is in place. As you greet Ben and his parents, you have the feeling that the first few minutes of the consultation will be devoted more to listening than speaking on your part.
Mr and Mrs Stevenson explain that the braces were placed last week by Ben’s pedodontist, after Mrs Stevenson was told that her son would be receiving an appliance to “help Ben’s lower jaw grow.” She said she had scheduled Ben for what she thought was a brief appointment, but he emerged from the operatory with brackets on his teeth. She wanted to know whether treatment was necessary, because she “just didn’t feel right about the whole thing.” Your clinical evaluation shows mild maxillary incisor crowding with normal overjet and overbite for a boy of Ben’s age. He has a well-coordinated dentoskeletal pattern, mirroring his parents’ balanced profiles.
As you remove your gloves and place the dental mirror aside, you explain that treatment philosophies among practitioners commonly differ, but you’d like to communicate with the pedodontist to discuss the case background before making a recommendation. In a polite but firm reply, Mrs Stevenson says that she knows you have the recent panoramic film, and she would think that Ben’s clinical presentation, combined with the film, would give you enough information to answer the question regarding his immediate need for treatment. You diplomatically concede that you would not yet treat Ben but would rather await further growth and development. Mr Stevenson then pipes up to ask what the family’s next step might be. As a consultant, should you offer to advocate on the family’s behalf by communicating with the pedodontist to explain your recommendation?
The patient’s vulnerability in a second-opinion consultation places him at a significant disadvantage. A doctor’s in-depth knowledge is no match for even the most informed parent or patient. Patient vulnerability is compounded by the consultant’s skill in persuasion, regardless of whether it is blatant or subliminal. Yet the consultant’s perceived responsibility to the patient might compel him to act as a liaison or an advocate to the original provider. Most patients and families would gladly welcome this gesture. Is it appropriate for the consultant to act as an advocate on behalf of the family to ensure that the patient receives only necessary and timely treatment? Or is it an act of excessive beneficence given the consultant’s potential time investment in communication? Is the risk of possible conflict between the original practitioner and the consultant justified?
Despite the consultant’s best intentions and the patient’s appreciation of your effort, the risk of paternalism looms. Paternalism involves a doctor’s decision to decide what is best for the patient, regardless of the patient’s preferences or values. If the goals of advocacy are “clarification, education, and advice,” an attempt to fulfill these objectives could even inadvertently be used to manipulate the patient for the benefit of the consultant. For example, reinforcing the patient’s skepticism about a treatment plan could benefit the consultant by diverting the patient away from the original orthodontist and toward the consultant’s practice. Such an action, whether intentional or not, might be considered paternalism. The consultant avoids paternalism when he or she acts in an informative yet nondirective manner. Denigrating comments are inappropriate regardless of how bizarre the treatment plan appears to be and irrespective of the patient’s occasionally unrealistic objectives. The consultant’s mission is to protect the patient by interpretation of the pros and cons of treatment.
If you choose to become involved, communication with the pedodontist will involve tact and diplomacy. Your responsibility toward the family is simple: clarification and education, complemented by your advice. Then the decision is theirs.