Whose choice is it?
I watched an inexperienced dentist working with patients. This dentist had pretty big gaps in their skills, particularly in endodontics and crown and bridge. But they were good with extractions.
What I saw time and again was that dentist steering patients towards extraction. Their often-used tactic was to wildly overestimate the odds of failure, the cost and the difficulty of saving a tooth. Then, the moment the patient wondered if the tooth should come out, the dentist enthusiastically embraced that option.
It struck me as unfair. Very unfair.
The patient thought they were making a choice based on the condition of their tooth. In reality, the dentist’s limitations were influencing how the alternatives were presented.
The same thing can happen in the other direction. Imagine a dentist who enjoys crown and bridge work discussing options for a missing tooth. A bridge may be a reasonable option. But suppose an implant is also worth considering and the dentist doesn’t provide implants.
The dentist spends several minutes explaining how straightforward a bridge would be. The implant gets a brief mention, along with its cost, the surgery and how long it might take. There’s little discussion of its possible advantages or the option of a referral.
Which treatment is the patient likely to choose?
The dentist might tell themselves that they offered both options. Technically, they did. But one got an enthusiastic explanation and the other got a list of drawbacks. That’s hardly a fair comparison.
As dentists, we all have preferences. We enjoy some procedures more than others and we’re better at some than others. There’s nothing surprising about that. The problem comes when our preferences distort the advice we give.
Something that’s difficult for me may be quite manageable for someone with more experience. My lack of confidence in performing a procedure doesn’t, by itself, tell the patient much about the prospects of that treatment.
We need to distinguish between “I wouldn’t be comfortable doing this” and “This isn’t a good option for you.” They mean very different things.
Patients generally don’t know enough about dentistry to spot the distinction. They rely on us to explain it. If we sound doubtful about one option and confident about another, that carries considerable weight.
Of course, giving patients a fair choice doesn’t mean pretending all options are equally good. If I think one is better suited to their situation, I should say so and explain why. But the reasons need to come from their clinical circumstances and what matters to them. They shouldn’t come from which procedure I’d prefer to do.
It’s our duty to give honest assessments of the options, their costs, their limitations and their prospects of success, then let patients decide. If a suitable option is outside our skills, we still need to discuss it. If the patient chooses it, we can refer.
We can also build up our skills in deficient areas through appropriate courses and further training. But while we’re doing that, patients shouldn’t miss out on options simply because we don’t provide them.
A useful question to ask yourself is: “Would I explain these options the same way if I were equally comfortable providing all of them?” If the answer is no, it’s worth thinking about what your patient is actually being asked to choose.
Our limitations shouldn’t become theirs.
