Ethics and Economics
They just don't teach ethics in the schools any more! Is this a perception or is it real? One feature that distinguishes a profession from a business is the consumer's trust that a profession gives advice and makes decisions based on the best interests of the individual. Business is often understood to give advice and make decisions based on the best interests of the business. A recent example is in the accounting profession where a struggle arose over these very same issues.
Leaving aside the valid argument that morality and ethics are learned at an early age, are we doing every thing possible to promote ethical standards for orthodontics? Are we teaching ethics effectively in our educational programs?
Walk for a minute in the shoes of the new kid on the block today. Imagine yourself in a not too untypical scenario when you have just completed an orthodontic program. It is not uncommon for you to have acquired six figures of debt in dental school alone, not including the cost of the orthodontic program that followed. You have just opened an office, you are married and maybe have a family. You want to buy a home and you need to finance a purchased or start up practice.
A young parent walks into your office with a 7–8 year old child. Think of the push pulls that act on you when the parent of that mixed dentition child expresses concern about the incisor alignment. How does the new orthodontist make a decision that is right for that person, right for the practice and ethical? This is especially difficult if your recent educational program was focused only on technical orthodontic issues and never put you in a position of having to deal with ambiguous real life decisions. Some patients you treat and others you do not. Some that you will not treat may go to another office and be told that treatment is mandatory.
We all ultimately learn that, like much of health care, orthodontic questions often do not have a single correct answer. We hope this new practitioner had an opportunity somewhere to develop an ability to deal with decision-making in the face of uncertainty. Orthodontics requires a tolerance for ambiguity and the absolute and unfailingly correct answer is rare. Sure the outcomes of different answers may be different, but these are just differences and one is not necessarily better than the other.
Teaching ethics to an orthodontic student is very complex question. I have worked at it and know I cannot do it by simply adding a few lectures or seminars to the curriculum. This very sophisticated question needs major attention and the focus needs to occur in the context of real life applications. A classroom discussion of ethics is often perceived of as an answer seeking a question until real life applications are apparent.
Like most of education, the best questions are those that arise during normal behaviors, in this case orthodontic care. Obviously the issues are not raised in front of the patient, but they are raised promptly thereafter in a group discussion format. Here the questions have real applications and an able, but inexperienced orthodontist can begin to understand the options and consequences involved in these complex issues.
When new orthodontic graduates are asked about their program strengths and weaknesses, they often cite a feeling of technical competence, but a discomfort in how to run a practice. The traditional view of orthodontic education is to focus on having the residents do a few treatments well. Most clinical faculty have, as their frame of reference, their own experiences in dental school. There it often has been common to have a student do a perfect restoration no matter how long it takes. This is an incomplete goal since, upon graduation the neophyte dentist, with no counsel, must make the terribly difficult decisions involved in deciding how to properly modify his or her behavior in order to become economically viable.
Technical excellence is a sine qua non, but the graduate today doesn't feel a need for more tools to fix a Class II. They do feel a need for more experience in how to deal with running a practice and surviving with their ethics intact in the face of strong competition. They need experience and experience cannot be taught in a lecture format alone. Experience comes with doing and seeing applications. Answers are only answers when the student has a question and the question arises best when it arises naturally in the course of usual and customary patient care. The best time to answer any learner's question is at the time it arises. A program's job is to create an environment that will allow these questions to arise naturally. Then you have a motivated and interested student.
In many orthodontic programs orthodontic education has changed and the clinical experience attempts, as far as is possible, to emulate real life behavior and, therefore, real life ethical experiences. Patients are the primary focus and they get treated just as you would expect them to be treated in your office. The same behaviors and standard of care exists for the school and for the private office. In order to create the office environment in school, a significant increase in patient care often occurs. The view that increases in patient care during orthodontic education is solely a function of an insatiable university appetite for income might sometimes have a grain of truth. However, the introduction of major increases in patient care into orthodontic programs began long before today's economic issues arose.
Increases in patient care were introduced originally to increase the clinical experience afforded to the resident. Sure, more patient care should spin off increased revenues, but the original intent was that such revenues would result from, rather than cause, increased patient care. The intent was that the revenues resulting from increased patient care would be available to further enhance the program by making available increased auxiliary and laboratory help. This serves the same goal of modeling ethical behavior because it causes the student to use auxiliary and laboratory help properly in school, a behavior we want carried over into practice.
Today's world rigorously tests the ethical standards of the new orthodontist. New orthodontists are better prepared than ever before, but they need experience more than ever before. An orthodontic program is time limited and programs must model excellence in ethics as well as in technical tasks. The educational model is incomplete if we omit one of the most difficult of all practice challenges, how to deal with uncertainty and ambiguity in an ethical way. To satisfy this goal will contribute towards earning the trust of the patient and meeting the definition of a professional.