A Question of NEED in Dentistry: Part II

To read Part I of this series, click on the link.


One of the patients in my practice was a veteran of Vietnam who lost his leg in the service of our country. We hit it off immediately, developing a rapport during his initial visit that made the discussion of findings and solutions conference an appointment I really looked forward to.

Bob had significant dental problems. While caries and periodontal disease would never really threaten his dental health, the destructive forces created as Bob placed tooth against tooth had made his dentition that of an old man. I wondered what he would want to do about it?

Autonomy and Dentistry

I place very high value on autonomy. I do not want others directing my life, and have always operated under the belief that I should not direct others. Bob had options. Wear is normal in dentistry after all. My responsibility to Bob was to fully inform him, to educate him, and let him decide what was optimal for him. We talked, well, in truth, I talked. Bob listened courteously. He sat back in his chair and studied me curiously. "What do you want me to do?" he asked.

"We could… , or we could …, or we could do nothing," I answered. At this point I was comfortable in the knowledge that understanding the options he would choose the best option – for for him.

"No," he said, "What do you want me to do?"

"I want you to do what's best for you, Bob," I said and sat back to listen for questions.

Bob thought for a moment and looked me in the eye. "Gary, I spent almost eight months in military hospitals after being wounded in Vietnam. From just above the ankle my leg was gone, from there to my knee was a shredded mass of muscle, skin, and shattered bone. The medics in the field saved what they could and sent me back to the states. When I met the doctors who examined and evaluated me stateside no one suggested that I could wait until more destruction had occurred and then replace the whole leg. No one asked me to decide what to do beyond agreeing that I wanted to be restored to whatever state the science of restorative medicine could bring me to, and no one advised me I could do nothing. I guess that those decisions were in my power but not one of those doctors saw those as options. What do you want me to do?"

I realized at that moment that I did not have enough information to answer Bob's question. There was really only one option for Bob, and I didn't know enough to inform Bob what that was. I didn't know enough about Bob to tell him what I wanted him to do.

The word doctor traces back to the Greek for teacher. I saw that as a deliverer of information. Teaching a student the sounds made by the 88 keys on the piano does not teach him or her music. The keys pressed will be those that create music appropriate to an individual song, or to a unique person. Bob had asked for a doctor to recommend the appropriate notes to play his song, for a doctor to expect that he would choose to play it and assist him in that endeavor. I had given him the scales and said "pick from these notes". I had failed to be his doctor.

Bob did not expect his surgeons to talk about wheelchairs or crutches when a prosthesis was within the possibilities and then ask him to choose. He did not want me to consider that a stocking over his stump might be what he wanted. He wanted me to believe he expected to, he needed to, be restored. Why should I, how could I, expect or want other than that for him?

How have dentists stifled the expectations of the public through our attitude about the best dentistry as an elective procedure? When I expect that every patient wants to be whole, to be restored to health, comprehensive dentistry becomes the only path I see, the only option. No medic would stop at saving what he or she could in the heat of battle without fully expecting that the next step, the restoration, is the inevitable outcome of those efforts on the patient's behalf. As professionals, we have an obligation to hold out for what's in our patient's best interest, even in the face of resistance.

Walter Haley of Boot Camp fame once said that dentists are addicted to being liked. I am. I wanted Bob to like me and I believed that by placing all the choices with him he would see that I wasn't trying to "sell" him something (something elective). I believed that Bob wanted a dentist who would give him complete control over all decisions about his dentistry. He wanted more.

Bob wanted me to be his doctor, he wanted me to be a professional who would never imagine that he could want or expect less than my best. A professional who would seek to understand what optimal treatment was for him and tell him what that was. In simply offering him the available choices, I created the impression that the multiple solutions were all roads to Bob's goals for himself. Bob wanted to keep any of his teeth that he could. He wanted to go to dinner with his grandchildren and order what he wanted, not what he could chew. He wanted me to tell him what he needed to do to accomplish that and assist him in getting there. He needed a doctor, he needed a leader.

Patients look to us daily for assistance with problems. I wish I could tell you that knowing WHAT the choices are for your patient will somehow make them want the best that dentistry has to offer, that logic conquers all. It doesn't. Clinical excellence in diagnosis and therapy must be a given. It's knowing your patient that will direct you to their optimal solution, knowing WHO they are and WHY they are in your chair. The WHAT always appears when I can be the leader and the doctor they seek and deserve.




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