Taking Responsibility

A few days ago, while my wife and I were getting ready for work and my 16 year-old son was getting ready for school, he suddenly confronted me with: “Dad! I can't find my wallet and cell phone! I've looked everywhere and I can't find them! Where are they?” Well, I try to be an understanding parent, so I swallowed the retort that first came to mind and went through the litany of questions: Were they in his possession last night…“Yes!” Had he checked his room, the couch cushions and all the pockets in the clothes he was wearing yesterday…“Dad, I've looked everywhere twice!” With these assurances in hand, I immediately found his cell phone in the pocket of a pair of jeans lying on his bedroom floor, but it wasn't until he came home from school that he sheepishly told us that he had evidently dropped his wallet in the locker room at basketball practice the day before and one of his teammates found it and kept it for him. The end result was a lengthy discussion on responsibility and an idea for an editorial.

My parents taught me that each of us has to assume responsibility for our actions and be prepared to accept any associated consequences. Unfortunately, at least from my perspective, society today has a tendency to always find some way to place blame rather than accept responsibility for their actions and to absolve themselves from faulty decisions by shifting that responsibility somewhere else. Have any of you ever glossed over a failed restoration, improper diagnosis, criticism by a colleague or disgruntled patient with any of the following?

• That (insert name of dental material or manufacturer) is a terrible material. I certainly won't buy anything else from that company.

• They've always been a problem patient. They're never satisfied with anything.

• If you had followed my instructions to the letter, this would not have happened.

• My patients demand this type of restoration/service, they would not accept anything else.

• I know it's not in the patient record, but I always follow the same routine on this procedure. You'll just have to take my word for it (I suggest never using this approach with an attorney).

• I have to agree with you, “soft teeth” just run in your family.

• I didn't have any information about the patient that would have indicated the potential for that kind of problem. How could I have known?

• I was short staffed and overbooked that day, and I did the best I could under the circumstances (not something you would like to hear from your cardiologist following surgery).

The list could go on and on and can take different forms, but the bottom line is abrogation of responsibility. Let's review for a moment. As health care providers, we make (or should make) the final decisions related to restorative treatment in the following areas:

• We are responsible for a complete health/medical history, including discussing areas on our forms that may be confusing to the patient or that he or she may be embarrassed or hesitant to answer.

• We are responsible for a thorough clinical and radiographic examination that will lead to an accurate diagnosis of the condition of existing restorations, caries activity and risk factors and the health of soft and supporting tissues in the oral cavity.

• We are responsible for formulating a treatment plan based on the information we have gathered and the wishes and needs of the patient and discussing this plan with the patient (however, we are the trained professionals and cannot allow patient wishes to result in treatment that is not in the best interest of long-term health and function).

• We select the most appropriate material for a given restoration based on our knowledge of the properties of our restorative materials, their clinical performance in the refereed literature and our own experience, and not solely on the advice of a colleague, lecturer or manufacturer.

• If we are planning a tooth-colored restoration, we perform the necessary color analysis and selection, including appropriate diagrams for any laboratory involvement.

• We control the patient, his or her comfort and cooperation, type and degree of anesthesia, the working environment and the necessary isolation of the operating field during the restorative process.

• We remove the caries and damaged tooth structure and execute an appropriate preparation for the selected material, including selection of all necessary equipment and instrumentation.

• We clean, condition (if necessary) and generally ready the tooth for either the placement of a restoration or making an impression.

• We perform all mixing, manipulation, matrixing, placement, contouring polymerization, etc, including selection of the necessary equipment and instrumentation.

• We shape, finish, polish, ensure functional occlusion and soft tissue compatibility and provide instruction for the patient in terms of precautions, maintenance, potential problems and oral hygiene techniques.

If you pay attention to this information, you should see how extremely difficult it is to blame anyone but ourselves for failures in our restorative treatment. Certainly, there are things beyond our control—accidents, parafunctional incidents that exceed the limits of even the strongest materials and long-term abuse and neglect—but these are responsible for only a small percentage of failures, and even some of these are avoidable with proper diagnosis and treatment planning.

We are all loath to criticize a colleague's treatment, because we often do not know the circumstances under which it was delivered…and we all understand the extremely challenging environment in which we work. However, the rising litany of “I do this because my patients demand it” is becoming increasingly bothersome to me. Although anecdotal, I have had numerous patients enter my practice with failed or failing all-ceramic posterior crowns in areas that I would not consider of esthetic visibility or concern. When I ask the patient why he or she wanted this type of restoration in that location, the response has been universally “my dentist told my that's what I should have.” This has been confirmed in my mind by their willingness to have me replace these failed restorations with gold. My main regret is that if this had been the original treatment, a considerable amount of tooth structure could have been saved.

Obviously, this editorial reflects my opinion…but that's what editorials are for. My suggestion is that we all spend a little more time looking in the mirror rather than looking for something or someone on which to place the blame for failures that are really our responsibility. For those of you who are musically inclined, I suggest listening to one of my favorite songs by the Eagles, Get Over It! Pay close attention to the words…they say what I have just stated, but perhaps in a more harmonious way.