“There is nothing permanent except change.”

—Heraclitus, Greek philosopher (d. 475 BCE)

Maybe sometimes that doesn’t have to be the case.

The Seven Wonders of the World

To the Greeks, the number seven was a lucky number. As ancient Greeks traveled through Persia, Egypt, and Babylonia (now modern‐day Iran and Iraq), they were in awe of the magnificent structures that were constructed solely by brilliant ingenuity and mere muscle power. Depiction of these creations by photography and other methods was nonexistent until centuries later, and therefore their experiences were recorded by drawings and written accounts. The second‐century Greek writer Antipater of Sidon is credited with cataloging the most exquisite structural accomplishments in the vicinity of ancient Greece. Although accounts of these achievements excluded those of Africa, Europe, Asia, and the Americas, these remarkable creations were labeled the Seven Wonders of the World (National Geographic, n.d.).

Each of these magnificent creations was more exquisite than the next. The Seven Wonders were as follows:

• Reigning as the tallest manmade creation for over 4000 years is the Great Pyramid of Giza, erected on the Nile River in approximately 2500 BCE. It stands over 450 ft tall (138 m). Laborers needed over 20 years to assemble the 2.3 million blocks of stone that comprise it. The pyramid was erected to glorify the burial site of the great pharaoh Khufu (Cheops).
• The Hanging Gardens of Babylon were assembled around 600 BCE by Nebuchadnezzar II, who was king of Babylonia between 605 and 562 BCE.
• The Statue of Zeus was a 40 ft, gold‐plated statue of Zeus, the father of all gods in Greek mythology. Zeus holds a smaller statue, Nike, the goddess of victory, in one hand, and an eagle in the other.
• The Temple of Artemis, a magnificent temple built in what is now modern‐day Turkey, was intended to commemorate Artemis, the Greek goddess of hunting. The structure was decorated with the most ornate artwork of the day.
• The Mausoleum of Halicarnassus, also in Turkey, was created to honor the wife (and coincidentally the sister) of a governor named Mausolus, and also houses beautiful works of art.
• The Colossus of Rhodes was a 110 ft statue that welcomed seafaring visitors to the island of Rhodes.
• Finally, the Lighthouse of Alexandria guarded Alexandria Harbor in Egypt. Standing over 350 ft tall, it has been considered the prototype of lighthouses that were built since its construction.

All Seven Wonders were examples of superb intellect and creativity, as testimony to humankind’s dedication and ingenuity, created in an age devoid of mechanization.

At about the time these ancient wonders arose, so emerged the concept of professionalism. One of the early role models of professionalism was Hippocrates, who lived and practiced medicine between the third and fourth centuries BCE. He is considered the “Father of Medicine,” and helped transform the medical profession from a philosophical discipline to one of observation and reasoning. Although little is known about the extent of his contribution to the famous Hippocratic Oath, that document still serves as a conduct guide for the profession. We know that Hippocrates believed that disease was not caused by superstition but by natural causes, and that his emphasis on the physician’s ethics was emphatic. His writings entitled On the Physician stressed that the physician should be “well kept, honest, calm, understanding and serious” (https://en.wikipedia.org/wiki/Hippocrates). At about the same time that Hippocrates was practicing medicine, Alexander the Great established the Alexandria Medical School in Egypt in 311 BCE. This institution continued the medical tradition of Hippocrates as well as that of Aristotle, who is credited with being the founder of the study of anatomy (https://en.wikipedia.org/wiki/Hippocrates).

During the Middle Ages the only three professional disciplines were the church, law, and medicine. Although many physicians of the time had no formal education, the Italian medical school of Salerno was established in the twelfth century in an attempt to formalize medical education. Founded by a Christian, an Arab, and a Jew, this diverse and innovative medical school accepted women for study and remained independent of clerical dominance (Bishop et al., 2002). This was a rare circumstance for that epoch.

The concept of professionalism

The concept of professionalism continued to thrive as medical schools were founded over time. Dentistry eventually elevated its status from that of a trade. Originally practiced by unskilled individuals as an adjunct to other business endeavors such as barbering or blacksmithing, dentistry rose to a level where it was considered to be a specialized branch of medicine (https://en.wikipedia.org/wiki/Seven_Pillars_of_Wisdom). In the early 1800s in the United States there were approximately 1200 dentists, of whom 300 were physicians who decided to concentrate on practicing dentistry. They had learned clinical procedures by completing dental apprenticeships.

The nationwide financial collapse of 1837 affected dentistry as severely as the rest of the country’s economy. Unemployed workers paid tuition fees to some dentists who touted themselves as dental educators, and graduates of these “programs” entered the profession with suboptimal skills, negligible clinical experience, and deficient knowledge of the profession. Yet those whose interest was to protect the profession saw the ensuing loss of public trust in dentistry as an opportunity to reinforce the level of professionalism. They established the first dental journal in 1839, the American Journal of Dental Science. These men also established a formal program for teaching dentistry in 1840 that was housed in the Baltimore College of Dental Surgery. This institution later evolved to become the University of Maryland’s School of Dentistry. These same devoted dentists also formed the American Organization of Dental Surgeons as the nation’s first dental society. Those who remained affiliated with the organization were considered the elite of the profession. All three of these efforts to establish dental professionalism occurred in a mere three years and elevated the status of dentistry as a profession. Although these events took place in the United States, they exemplify the rise of professionalism on a worldwide scale.

Fast forward to the twenty‐first century. If professionalism evolved as an exemplar in healthcare, does the concept of professionalism prevail today? If it does, is it held in the same high esteem as it used to be, or is it doomed to deteriorate? And what is the pertinence of professionalism in the delivery of orthodontic care and in orthodontic education?

Most simply, professionalism is essential because our patients are placed in a position of vulnerability. Our patients readily place their trust in us, despite our initially brief contact with them as a stranger. Within a short period, they give us their physical selves, their emotional trust, and often a significant financial commitment despite their minimal initial exposure to us. Contrast this to the vast time and effort invested in establishing trust in an acquaintance in a social context. The vulnerability of the patient mandates that the provider commit to a fiduciary relationship, in which the provider holds the patient’s interests and well‐being above his or her own in an enduring, persistent fashion.

The seven pillars of professionalism

In 1926, the British colonel T.E. Lawrence, the fabled Lawrence of Arabia, wrote an autobiographical book entitled Seven Pillars of Wisdom. In his book, Lawrence recounted the experience of his military command of Bedouin forces in battle against the Ottoman Turks spanning 1916 through 1918. The book’s title was developed from the Book of Proverbs (Proverbs 9:1), which states that “Wisdom hath builded her house, she hath hewn other seven pillars” (Scarlett, 1991).

If there were a majestic Seven Wonders of the World and Seven Pillars of Wisdom, might there be Seven Pillars of Professionalism that we can keep at the ready throughout our careers (Scarlett, 1991)? As time constraints, educational loan demands, family and financial obligations, and our quest for new cases start to loom over us, can we maintain the level of consistent professionalism and ethical discipline that has taken centuries to evolve?

Admittedly, the pressures the young practitioner or academician faces are unprecedented in the history of the specialty. In a 2015 letter to its members, the American Association of Orthodontists listed the salient factors that have strong contemporary influence on the orthodontic profession. Many were minimal or nonexistent a decade or two ago. Issues such as the decrease in restorative needs that entice nonorthodontists to provide orthodontic care, an increased number of orthodontic graduates, an increase in deceptive advertising, and an increase in self‐treatment are examples. In this chaotic arena, a prominent dental educator asked an everlasting question almost a century ago: can we “combine the new economy with the old morality?” (Nash, 2014). The question is a global one. That is, can we maintain our elite professional stature, despite the financial demands we face in managing a practice or addressing the challenges of ascending the ranks of academia?

The Seven Pillars of Professionalism are intended to provide a practical framework for maintaining ethical conduct in parallel to our success, amid a world of temptations, distractions, and occasionally insurmountable pressures (Figure 26.1).

The First Pillar: Knowledge, technical skill, and a sense of pride in what we do

An old orthodontist once told me that most often our patients don’t know what we do in their mouths. They judge us instead by obvious criteria: our demeanor, our staff’s accommodation of their needs, the decor of our office, or whether we run on time. We can change elastomeric ties for months on end and tell them they are progressing nicely – even if the archwires have long since ceased to be active. We can ignore the position of their second molars. If they are scheduled for scans for retainers after a lower canine has rotated since its bracket was displaced, we can ignore it when they ask whether treatment is truly complete. Our patients might think that canine guidance is a veterinary term, and certainly cannot judge the harmony of marginal ridge relationships. Yet we know when we’ve done the best we can, or whether we have compromised case quality. The patient does not. Authentic professionals will push themselves to the limit and always feel they can do more – even when no one is overseeing or judging their performance or their result.

We spend years finessing our clinical skills and honing our diagnostic acumen during our lengthy educational process. But once in practice or at the podium as academics, our most severe critics should be ourselves. The more critical we are of the care we provide, the closer to the goal of excellence will be the result.

It has been said that a good orthodontist is an unhappy orthodontist (Greco, 2011). Those who can admit that they can always do better are those who realize that perfection is impossible, but excellence is within reach. That is the mark of an artist – and it should be the aspiration of every member of our specialty.

He who works with his hands is a laborer.

He who works with his hands and his head is a craftsman.

He who works with his hands and his head and his heart is an artist.

(St. Francis of Assisi, disputed as the authentic source)