Young Eric’s diagnostic records confirm that treatment of his crowding and facial convexity will necessitate the extraction of 4 premolars. His maxillary canines are palpable but have yet to emerge. You begin fixed therapy but refrain from placing brackets on the first premolars. You then refer Eric to your trusted oral surgeon for the extraction of the first premolars. The extractions are completed later that week.
Three months later, the left canine has begun to emerge, but the right canine seems to be stalled in position. After explaining to Eric’s dad that exposure of the canine should expedite your ability to bracket and align the tooth, you again refer the patient to the oral surgeon for exposure of the maxillary right canine.
The call from the oral surgeon comes 2 weeks later during a very busy afternoon. He tells you that he has uncovered the canine, but it is severely hypoplastic. He describes the integrity of the scarce, pockmarked enamel that comprises the crown as discolored and brittle. Your heart sinks as you realize that you could have substituted the premolar for that feeble canine.
Errors. Perhaps our most memorable—and searing—learning experiences are the errors we commit ourselves.
An interesting classification of errors observed in a surgical residency could pertain to orthodontic practice. Technical errors involve the practitioner’s genuine effort to conduct a procedure properly, but the outcome is inadequate due to an error in technique or execution. An example might be a patient’s sudden aspiration of a band during a banding appointment. Technical errors must be addressed promptly and should not occur repeatedly by the same person. The second type is judgmental errors, in which the provider has a lapse in judgment or chooses an incorrect strategy to address a clinical problem. In the surgical arena, this might involve the failure to react to an intraoperative complication. In the orthodontic setting, it might involve permitting adverse profile changes by failing to extract teeth when indicated. Your error in Eric’s extraction prescription is an example of a judgment error in which the canine should have been extracted instead of the premolar. The clinical result rather than scientific reasoning leads the provider to believe that an alternative course of action might have been more appropriate. The third is type of error is normative and involves the provider’s failure to act conscientiously. Normative behavior is an indicator of the clinician’s “honesty and responsibility”—virtues that describe the provider’s character. Breach of such virtues involves normative errors. Failure to give a patient autonomy and neglecting to advise a patient of a therapeutic error and its consequences are examples. The fourth type of error is quasi-normative and involves a subordinate’s intentional refraining from performing as requested by a superior. This type of error is minimally applicable to the practicing orthodontist.
Errors are an unfortunate part of clinical care delivery. Infrequent errors are inevitable, and the only way to totally avoid errors is to abstain from practice. Although technical and judgmental errors are often harmful, they are viewed as far less egregious than normative errors. The former are usually readily forgiven as an aspect of human fallibility. Normative errors, however, are viewed as the most serious because they can reveal the corrupt nature of the person who commits the error. A person who fails to provide transparent disclosure of an error is neglecting a most important ethical obligation and is undermining trust in himself and in the profession.
Now, the oral surgeon wants to know what to do about your patient with the hypoplastic canine. You ask him to close the incision so that you can personally explain the situation to Eric’s parents. Sure, you’ve got some explaining to do, but your lapse in judgment was part of a conscientious effort at treating Eric the best you know how. Both you and Eric will live with this error for a long time.
A wise old orthodontist once told me that a physician’s advantage is that he buries his mistakes. Unfortunately, ours can follow us for a lifetime.