Dr Michael Sernik, December 2003 - If this type of question were asked of a medical practitioner, the answer would be straightforward. Explain the various pros and cons and let the patient choose.

This would certainly be the simplest approach for dentists. It removes us from the decision making process and gets us off the moral hook. But most dentists understand that it’s really not so simple.

There are reports in the press of journalists having consultations with 10 dentists and getting 10, widely varying opinions. When dentists attend clinical educational sessions, they will usually observe that not everyone will share their views of what treatment is necessary. If it were a simple question of correct diagnosis and incorrect diagnosis, then one dentist is right and nine dentists are wrong.

The reality is that patients want to know what the dentist recommends. Even if the dentist tries to educate the patient to the point of being able to make an informed decision, there still remains the question in the patient’s mind, “OK, I understand what you have told me, but what do you think I should do?” This question can leave the dentist squirming in a moral dilemma.

Take a typical situation. What should be done? The answer might be found in the mouth of the dentist. It’s likely that the dentist will recommend for his/her patients, what he/she would recommend for his/her own mouth.

I remember an interesting study where doctors were asked what they recommended as a healthy diet. There was a wide range of responses, but a strong correlation between what the doctors recommended and what the doctors ate. Vegetarian doctors recommended vegetarian diets. Meat eaters recommended meat; overweight doctors were less concerned if their patients were overweight and so on.

If a dentist has a mouth full of heavily filled amalgams, they are less likely to recommend milled porcelain restorations. In fact they are likely to advise the patient to leave things as they are and to ‘watch’ the teeth.

I’ve met dentists with ‘cosmetically challenged’ teeth who don’t do a lot of cosmetic dentistry and will strongly defend their philosophy. In a sense, this is the way it should be. If every dentist diagnosed according to the following rule: ‘What would I want in my mouth if I were the patient’, then we would have some sort of ethical guideline to follow. (It is in harmony with the well accepted biblical philosophy of “do unto others” etc.) This attitude would allow the dentist to have a formula for how to ethically diagnose. It then leaves the dentist with the ‘money issue’ to struggle with. Sometimes we steer patients towards sub-optimal treatment because we feel this is all they can afford. This filtering process puts a lot of pressure on the dentist. We are now making clinical and financial judgements on behalf of our patients. This process can even expose the dentist to litigation because, for instance, the patient was not given the choice of an implant and ended up with a fixed bridge or removable denture.

There is only one logical solution to the ‘money issue’: diagnose according to what you would want for your own mouth and diagnose as if money were not a factor.

Now you have offered what you truly believe is the appropriate treatment and if they cannot afford it, they can choose other options. Your conscience is clear.

There will always be differences in opinion as to what constitutes appropriate diagnosis. (As different as the standard of dentistry in the dentist’s own mouth.) But now that we have solved the ethical issues we have created a new problem. If a dentist offers patients optimum dentistry, and the patients reject that diagnosis, or worse, feel that the dentist is trying to ‘sell’ expensive dentistry, the dentist will very quickly shrink back to steering patients towards cheaper, sub optimum dentistry in order to avoid rejection.

There is a solution. Get advanced verbal skills training. It is possible to offer high quality, optimum dentistry in such a way so as to never offend and never be accused of ‘selling’. Those that believe this is not possible remind me of the patients who say they don’t want a crown because “you can always see them”. Like many skills, we are most aware of them when they are done badly. Patients do not feel they are being ‘sold’ to and you wont feel you are ‘selling’ when you have advanced communications skills.

The original question was ‘Should we influence the patients decisions?’ The answer is irrelevant because like it or not, you always do. The objective of communications training is to create an environment where more patients demand a higher standard of dentistry.

So who would benefit from these skills? It’s been my experience that dentists with the highest standards of clinical ability are looking for ways to have their patients desire the standard they can deliver. I believe it’s a step forward when we acknowledge that for better or for worse, we the dentists, through our communications, influence the patient’s decisions. There is a direct relationship betweenyour communications skills and your output of high quality dentistry.

We will be judged by what we do… not by what we can do.

[Published in Australasian Dental Practice, December 2003]