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Journal of the American College of Dentists

Dental Honorary Organizations

Spring 2011 Volume 78 Number 1 499379_cover:Layout 1 5/6/11 4:00 PM Page ii

Journal of the American College of Dentists

A publication advancing excellence, ethics, professionalism, Mission and leadership in dentistry he Journal of the American College of Dentists shall identify and place The Journal of the American College of before the Fellows, the profession, and other parties of interest those issues Dentists (ISSN 0002-7979) is published quarterly by the American College of T that affect dentistry and oral health. All readers should be challenged by the Dentists, Inc., 839J Quince Orchard Journal to remain informed, inquire actively, and participate in the formulation Boulevard, Gaithersburg, MD 20878-1614. of public policy and personal leadership to advance the purposes and objectives of Periodicals postage paid at Gaithersburg, MD. Copyright 2011 by the American the College. The Journal is not a political vehicle and does not intentionally promote College of Dentists. specific views at the expense of others. The views and opinions expressed herein do not necessarily represent those of the American College of Dentists or its Fellows. Postmaster–Send address changes to: Managing Editor Journal of the American College of Dentists 839J Quince Orchard Boulevard Objectives of the American College of Dentists Gaithersburg, MD 20878-1614

The 2011 subscription rate for members HE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in of the American College of Dentists is $30, health care, advance the standards and efficiency of dentistry, develop good and is included in the annual membership T human relations and understanding, and extend the benefits of dental health dues. The 2011 subscription rate for non- to the greatest number, declares and adopts the following principles and ideals as members in the United States, Canada, and Mexico is $40. All other countries are $60. ways and means for the attainment of these goals. Foreign optional airmail service is an additional $10. Single-copy orders are $10. A. To urge the extension and improvement of measures for the control and prevention of oral disorders; All claims for undelivered/not received issues must be made within 90 days. If B. To encourage qualified persons to consider a career in dentistry so that dental claim is made after this time period, it will health services will be available to all, and to urge broad preparation for such not be honored. a career at all educational levels; While every effort is made by the publishers C. To encourage graduate studies and continuing educational efforts by dentists and the Editorial Board to see that no and auxiliaries; inaccurate or misleading opinions or state- ments appear in the Journal, they wish to D. To encourage, stimulate, and promote research; make it clear that the opinions expressed E. To improve the public understanding and appreciation of oral health service in the articles, correspondence, etc. herein are the responsibility of the contributor. and its importance to the optimum health of the patient; Accordingly, the publishers and the Editorial F. To encourage the free exchange of ideas and experiences in the interest of better Board and their respective employees and officers accept no liability whatsoever for service to the patient; the consequences of any such inaccurate G. To cooperate with other groups for the advancement of interprofessional or misleading opinions or statements. relationships in the interest of the public; For bibliographic references, the Journal H. To make visible to professional persons the extent of their responsibilities to is abbreviated J Am Col Dent and should the community as well as to the field of health service and to urge the acceptance be followed by the year, volume, number and page. The reference for this issue is: of them; J Am Col Dent 2011; 78 (1): 1-52. I. To encourage individuals to further these objectives, and to recognize meritorious achievements and the potential for contributions to dental science, art, education, literature, human relations, or other areas which contribute to human welfare— by conferring Fellowship in the College on those persons properly selected for such honor. 499379:jacd 5/6/11 4:30 PM Page 1

Editor David W. Chambers, EdM, MBA, PhD Dental Honorary Organizations

Managing Editor 4 American College of Dentists: An Overview Stephen A. Ralls, DDS, EdD, MSD Stephen A. Ralls, DDS, EdD, MSD, FACD Editorial Board 12 International College of Dentists—USA Section: A Brief History, 1934–2011 Laura Bishop, PhD Richard G. Shaffer, DDS, and Richard J. Galeone, DDS, FACD Susan Bishop, DDS Herb Borsuk, DDS 16 The Academy of Dentistry International Marcia Boyd, DDS Robert L. Ramus, DDS Fred Bremner, DMD 19 Omicron Kappa Upsilon: A Historical and Current Perspective Kerry Carney, DDS Theresa Gonzales, DMD, MS, MSS Jon B Suzuki, DDS, PhD, MBA, FACD William Leffler, DDS, JD Michael Meru, DDS Peter Meyerhof, PhD, DDS Kirk Norbo, DDS Martha S. Phillips Manuscript Marcia Pyle, DDS Cherlyn Sheets, DDS 24 Dental Students Choosing Licensure Path Give More Consideration to Philip E. Smith, DMD Career Flexibility Rather Than Ethical Dilemmas Jim Willey, DDS Heather J. Conrad, DMD, MS, and Eric A. Mills, DMD Design & Production Annette Krammer, Forty-two Pacific, Inc.

Correspondence relating to the Journal should be addressed to: Issues in Dental Ethics Managing Editor Journal of the American College of Dentists 33 A Case of Collegial Communication and a Patient Who Does Not Pay 839J Quince Orchard Boulevard Bruce Peltier, PhD, MBA, FACD, Alvin Rosenblum, DDS, FACD, Gaithersburg, MD 20878-1614 Muriel J. Bebeau, PhD, FACD, and Anne Koerber, DDS, PhD Business office of the Journal of the American College of Dentists: Tel. (301) 977-3223 Fax. (301) 977-3330 Departments Officers Thomas F. Winkler III, President Patricia L. Blanton, President-elect 2 From the Editor W. Scott Waugh, Vice President Great Readers Jerome B. Miller, Treasurer Thomas J. Wickliffe, Past President 44 Leadership Decision Making Regents Thomas J. Connolly, Regency 1 Robert A. Shekitka, Regency 2 Geraldine M. Ferris, Regency 3 Robert L. Wanker, Regency 4 Bert W. Oettmeier, Jr., Regency 5 Cover photograph: Symbols of Professional Excellence. Carl L. Sebelius, Jr., Regency 6 ©2011 MBPPHOTO, INC., istockphoto.com. Logos provided by organizations. Steven D. Chan, Regency 7 All rights reserved. R. Terry Grubb, Regency 8 Kenneth L. Kalkwarf, At Large Linda C. Niessen, At Large Eugene Sekiguchi, At Large Richard C. Vinci, At Large Lawrence P. Garetto, ASDE Liaison 499379:jacd 5/6/11 4:30 PM Page 2

Editorial

From the Editor

Great Readers

hirteen years ago, the ACD convo- get up out of the chair and put down the cation speaker was publisher Knight book, report, or newspaper or navigate Good readers are those TKiplinger (see his remarks in the away from the Internet screen. whose lives are changed winter 1997 issue). As the platform party If you want to be a great communi- assembled off stage, he remarked that cator, there are two essential skills: in meaningful ways when he had enjoyed my JACD essay on the taking information in and getting it out. they get up out of the “clean desk.” He noted that I had refer- The first may be more important. Art enced Barbara Hemphill’s book Taming Dugoni, past president of the ADA and chair and put down the the Office Tiger, a Kiplinger publication. most other dental organizations, is a book, report, or newspaper We almost missed our entrance cue talk- great reader. Just one testimony to his ing about finding good writers, picking awesome readerness came years ago from or navigate away from topics, and deciding what to say when an ADA staffer. She said, “Dr. Dugoni is the Internet screen. turning down an inadequate manuscript. a dream to work with. He actually reads Finally, I just had to make the obvious the reports before the meetings.” remark, “I am wonderfully surprised Is that a characteristic shared by all that you would come across my paper.” persons of responsibility in organized Here is the priceless free gift he gave me: dentistry? That is what I set out to deter- “All editors are great readers.” mine at the 2009 Hawaii meeting of the I have heard of great writers, and I American Association of Dental Editors. know quite a few folks who aspire to be As a speaker, I presented a series of 16 at least adequate. But a great reader? PowerPoint shots of the headlines or That implies that reading is a skill, that titles and first few paragraphs of articles mastery requires years of time and and ads appearing in the previous year effort, and even that some people are not in the Journal of the American Dental actually very good at it. Initially I held Association and The ADA News. The the common view that good readers editors in the audience rated each turn pages more quickly than the rest in terms of their personal interest in the of us or can answer more questions topic generally and their recollection of correctly about the material. Really, having seen or read the piece. The audi- good readers are those whose lives are ence noted the last four digits of their changed in meaningful ways when they social security numbers on the papers and passed them in. Then “Devious Dave” went through the same 16 PowerPoints and asked the audience to take a multiple- choice test on each using a sheet distrib- uted for that purpose. The questions were straightforward, such as “Was Dr. Löe

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Editorial

honored for his work in research, concrete examples of what worked. Occasionally, a colleague will say to humanitarian efforts, or politics?” The If I add anything about what I have been me in the nicest way, “I read that thing average score was just 40.5%, not espe- doing in that area or offer suggestions you wrote recently.” I always smile and cially impressive since there were only about other points of view or missed gratefully acknowledge the comment. three alternatives, so chance would be resources, the chances of a reply fade. In reality, I have no idea what “thing” is 33%. Being interested in the material Once I asked for a copy of a paper that being referred to, where it was published, was a good predictor of high scores; had been read at a philosophy meeting, or why it was of value. Sometimes I get thinking one had read the item was not. saying that I was interested in the topic the feeling that the colleague is really And I can save industry a lot of money. based on the published abstract. The bragging about having been doing a bit Average score for the two advertisements reply, apparently stimulated by my of current reading. They should brag! was 31%, and that on questions such as return address on the e-mail, was “I will The only way to improve the writing in “what is the name of the product?” send it when I get it in a more perfect dentistry is to improve the reading. I am not trying to cast aspersions state, although I am curious why a Communication is difficult; a worthy on my colleagues. Good aspersions are dentist would be interested in ethics.” goal is to become a great reader. in short supply, what with the present I recently sent a note to some situation in Washington, and I need to researchers in the field of management keep all I have. After all, what I discovered concerning their paper, “Conference by means of that little experiment in paper sharing among academicians.” Honolulu was that I am probably not as They reported that expressed willingness effective a writer as I fancy I might be. to share prepublication papers is a result I have a habit of commenting on of authors calculating the benefit to good writing when I encounter it. Good their reputations and their identification readers can promote better writing that with the norm of information-sharing way. A few times each month, when I among academics. One researcher con- read a journal article or book that helps ducted the survey about intent to share; me, I look up the author on the Internet another (from a different institution) and send off an e-mail. That includes actually requested papers from those notes to obscure academics and best- who said they were willing to share. selling authors. Only 61% of those who said they sup- I usually get a reply, and often it is ported sharing actually did so. The very warm. I continue to correspond authors of the research paper and I have with some of these experts and even had a nice correspondence. collaborate with one now. Effective messages need only say that I found the materials useful and give several

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American College of Dentists An Overview

Stephen A. Ralls, DDS, EdD, he American College of Dentists at the Copley Plaza Hotel in Boston on MSD, FACD was the first honorary professional August 20, 1920, by the then leaders of Torganization for dentists of a the profession to elevate the standards Abstract national scale. The purpose of this paper of dentistry, to encourage graduate study, The American College of Dentists (ACD) is to provide a descriptive overview and to grant Fellowship to those who is the oldest national-level honorary of the American College of Dentists, have done meritorious work. The early organization for dentists. Its members including its early history, Fellowship, focus was on improving dental educa- have exemplified excellence through outstanding leadership and exceptional publications, projects, and future. The tion, journalism, and research, and on contributions to dentistry and society. mission of the College is to advance curbing commercial influences. Practice- The ACD is nonprofit and apolitical, and excellence, ethics, professionalism, and related issues received more emphasis has long been regarded as the “conscience leadership in dentistry. The mission over time. Those desiring more informa- of dentistry.” The ACD has a record of guides its activities. tion on the early history and activities involvement in a wide range of activities of the College are referred to two related to its mission and has played Early History a vital role in positively shaping the publications in particular (Brandhorst, profession and oral health care. To properly understand the American 1970; Chambers, 2006). College of Dentists, it is important to The concept of an organization understand the context of its founding. without political ties that could shape The early twentieth century was a period dentistry was first envisioned by four of great change in the health professions leaders of the profession: John V. Conzett, and dentistry. The Flexner Report had H. Edmund Friesell, and Otto U. King, been recently published and was having who were the top three officers of the a profound effect on medical education, American Dental Association (ADA)—then raising questions about lack of scientific called the National Dental Association— foundations for practice and excessive and Arthur D. Black, son of G. V. Black commercialism. Dental education and the president of the National Asso- appeared vulnerable to similar challenges. ciation of Dental Faculties, a precursor Proprietary dental education was also of the American Dental Education quite common and was tarnishing the Association (ADEA). It is significant that profession. Advanced education and these leaders of organized dentistry training were extremely limited. Dental found it necessary to form another research was rare, and the little work organization—the College—to address that was being done had few avenues their concerns. for being effectively communicated. The four organizers and ten other Commercial control of dental journalism leaders of the dental profession met in was rampant. In short, dentistry had very serious problems. Dr. Ralls is the executive In response to these problems, the director of ACD; saralls@ American College of Dentists was founded acd.org.

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Boston to found the American College Dentists in 1934. He was also the author of Dentists. While unable to attend in of the famous report on the status of person, nine other distinguished leaders dental education in 1926. Dr. Gies has The mission of the College from around the country also joined the the distinction of being the only non- founding ranks in absentia, 23 in total. dentist admitted to regular Fellowship. is to advance excellence, This was literally a “Who’s Who” of den- On March 14, 2011, The American ethics, professionalism, tistry for the time. Their actions resulted College of Dentists was recognized by in the formation of the oldest and most the ADEA Gies Foundation with its and leadership in dentistry. influential organization of its type. prestigious Gies Award for Achievement The College has played a vital role in —Public or Private Partner. positively shaping the profession. After The American College of Dentists its founding, the College immediately Foundation was formed in 1972 and immersed itself in the most critical and essentially serves as the fundraising arm complicated professional issues, begin- of the College, providing financial support ning with direct involvement with the for many of the College’s projects. Carnegie Foundation to reshape dental Fellowship education. It was the first organization to promote what we today call “continu- The College was founded as an apolitical, ing education.” It also was instrumental independent organization with mem- in organizing and incorporating the bership by invitation only. Fellowship American Association of Dental Editors. developed as a means to recognize In the 1930s, the Journal of Dental outstanding dentists who could serve as Research was foundering and on the role models to a struggling profession— verge of collapse. The journal was literally a process of promoting excellence by saved through College intervention. The recognizing excellence. Fellowship was funds raised by the College to save the not created so a small group of elite journal formed the basis of what was to dentists could pass awards around to become the William J. Gies Foundation each other. The College has maintained for the Advancement of Dentistry. As a deep interest in ethics and profession- detailed below, the College is currently alism and has long been regarded as the involved in a wide range of activities, “conscience of dentistry.” Even at the both nationally and locally, to help dawn of the organization, there was an accomplish its mission. emphasis on the ethical conduct of its A name closely associated with the members, as evidenced by the early history of the College is Dr. William J. qualifications required for Fellowship: Gies. Besides his other dental interests, “The candidate…must be of good moral Dr. Gies was very active in the College character, and have a reputation for and served in a number of capacities, ethical conduct and professional standing including as the first editor of the Journal of the American College of 5 Journal of the American College of Dentists 499379:jacd 5/6/11 4:30 PM Page 6

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that is unquestioned. Personality, workshops, ethics courses, and a variety news of Fellows, Sections, College integrity, education, unselfishness, of outstanding speakers. Convocation events, projects, foundation news, and and high professional ideals as well as speakers have included the secretary more. Issues are published in April, freedom from mercenary tendencies of health and human services, the August, and December. shall be considered.” surgeon general, the assistant secretary Ethics Handbook for Dentists Candidates for the College are selected of defense, senators, congressmen, The Ethics Handbook for Dentists was for Fellowship based on demonstrated industry leaders, and others. first published by the American College leadership in some aspect of dentistry Organizationally, the College is under of Dentists in 2000. It is made available or community service, e.g., organized the governance of a Board of Regents. The on a complimentary basis to educational dentistry, research, education, journalism, College is divided into eight Regencies institutions and other qualifying dental etc. Leadership has been a common covering the United States and Canada, organizations. The College annually dis- thread in the character and composition with a small international component. tributes about 5,000 Ethics Handbooks of the College since its inception. There There are 51 local components called for Dentists (and Ethics Wallet Cards) to are about 7,400 Fellows and about 4,000 Sections within the Regencies. Sections all first-year dental students in the U.S. of these are in an active status. Only generally correspond to states, but not and Canada on a complimentary basis. about 3.5% of dentists in the United always. Sections conduct numerous Nearly 60,000 handbooks and cards States and Canada are Fellows of the local projects and activities in support have been distributed to date. College. A new Affiliate Member category of the College’s mission, including Ethics Wallet Cards has recently been added to accommodate White Coat Ceremonies, dental school Ethics Wallet Cards include “The ACD members of the American Society for awards, ethical dilemma programs, Test for Ethical Decisions” and the Dental Ethics Section who are not sponsored lectures at state dental College’s core values. They are made Fellows, regular or honorary. meetings, and more. available to dental students, dentists, The selective and confidential nomi- and organizations on a complimentary nation process makes the College unique Publications basis. The cards are normally offered among dental organizations. In order The College has a record of important to dental schools with the to have a system free from political publications and it continues to have Ethics . influence, the College incorporates three publications related to its mission. Handbook for Dentists Miscellaneous layers of confidentiality into the process: Journal of the American College Aside from its primary publications, (a) nominees should not know that they of Dentists the College also publishes White Papers, have been nominated for Fellowship; (b) The Journal of the American College of reports, and brochures involving a members of the Credentials Committee Dentists was started in 1934 under the variety of subjects. These include, as do not know the identity of candidates’ editorship of Dr. William J. Gies. It is examples, the position paper on the nominators or seconders; and (c) designed to identify and place before ethics of quackery and fraud in dentistry members of the Board of Regents do the Fellows, the profession, and other (Board of Regents, 2003), the White not know the identity of those serving parties of interest those issues that affect Paper on dental managed care in the on the Credentials Committee. Nominees dentistry and oral health. Issues in context of ethics (Board of Regents, are approved for Fellowship based on Dental Ethics is essentially a publication 1996), and an awards brochure, an their own merits, not on any special within the Journal of the American information brochure, a foundation connections or “who you know” criterion. College of Dentists. It is the only major brochure, a gallery (gifts) brochure, and The nomination process has been forum for the publication of scholarly other more intermittent works. described in detail (Anonymous, 2008). articles in dental ethics. It is coordinated The College holds an Annual Meeting by the American Society for Dental and Convocation that confers Fellowship Ethics Section and has its own associate Projects on approximately 300 dentists each editor and editorial review board. The College continues to build on its year. The meeting includes leadership history of important activities through ACD News its ongoing involvement with a number The College publishes a tri-annual color newsletter, ACD News, which contains

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of meaningful local and national projects Texas Dental Journal and are available related to its mission. Some of its current online at www.dentalethics.org or on projects are described below. CD from the Executive Office.

Online Presence Dental Leadership This is a comprehensive online leader- The College has an impressive online ship resource for dentists, now available presence covering four Web sites, at www.dentalleadership.org. The www.acd.org, www.dentalethics.org, resource includes education, assessment, www.dentalleadership.org, and www. and library modules. There are 27 dentalhistory.org. ADA CERP-recognized courses and several self-assessment continuing education credit is available leadership tools. for courses taken on the dental ethics The College has maintained Dental History and dental leadership sites. The courses Dental History, a Multimedia Dental a deep interest in ethics involve a very simple registration process History Resource, is a Windows®-based and there are no fees—the courses are program and is available for download and professionalism and has provided on a complimentary basis. at no cost from www.dentalhistory.org. long been regarded as the ACD Web Site The resource uses external video files The College has a comprehensive Web that can be viewed with an Internet “conscience of dentistry.” site at www.acd.org that includes a connection. It was initially designed for wide variety of information about the dental students and formerly available College and its activities. There is also only on CD. It has been slightly modified a members’ section, which includes a for online distribution and has been membership directory, and the capability well received in underdeveloped areas. to pay dues online and to make donations to the Foundation. Other Projects Courses Online Dental Ethics Professional Ethics Initiative The College has developed Courses The Professional Ethics Initiative (PEI) Online Dental Ethics (CODE), a series is a major ethics initiative composed of of online courses in dental ethics and four programs—individuals, practices, professionalism available at www. organizations, and resources (the dentalethics.org. There are currently Ethics Resource Clearinghouse). It is a 25 courses with over 25 hours of contin- cooperative initiative among the ACD, uing education credit available. The first ADA, ADEA, and the American Society course is based on the Ethics Handbook for Dental Ethics (ASDE, now the ASDE for Dentists. More than 18,000 courses Section) and has a goal of improving in dental ethics have been taken by the ethical climate of dentistry and dental students, dentists, and hygienists enhancing its ethical base. PEI has an from around the world. aspirational focus and character that Ethical Dilemmas strive to motivate, encourage, and inspire A series of 52 ethical dilemmas was rather than regulate and penalize. published in the Texas Dental Journal Excellent progress is being made. between 1993 and 2005. The lead author Introduction to Dental Ethics (course) of these dilemmas was the late Dr. Part of the individual program PEI Thomas K. Hasegawa. The dilemmas involves training more dentists in ethics have been digitally compiled in PDF format by the American College of Dentists with permission from the

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and professionalism. A seven-hour entry- against norms are used to direct prac- level course has been conducted in tices toward the areas most in need of 2009 and 2010 as part of the College’s improvement. At no time are outside Annual Meeting and Convocation in evaluators involved in this process. The Honolulu and Orlando, respectively. PEAD program has been approved for A follow-up course that concentrates development by the ADA House of on facilitation techniques and more Delegates. The program was reviewed by advanced content will be presented in a panel of four experts and pilot-tested the fall of 2011 in Las Vegas. by a group of practices in the fall of Ethics Scholarships for Dentists 2010. It is currently in the final stages of refinement before an anticipated release The College stands for Beginning in 2011, the Dr. Cecelia L. Dows Scholarship Fund of the American later this year. the best in dentistry and College of Dentists Foundation will be Ethics Resource Clearinghouse will continue to champion funding two $10,000 scholarships to The Ethics Resource Clearinghouse dentists who are pursuing a graduate constitutes the resources program of PEI. initiatives involving quality, degree (masters or doctorate) in ethics. The clearinghouse is envisioned as a continuous improvement, The scholarships are one-time grants major collection of ethics-related and not repetitive. Selection of scholar- resources that dental schools and dental high standards, and ideals. ship recipients is competitive. At least organizations could use (or contribute one scholarship is planned annually, to). This program is designed to collect but the scholarship amount may vary. ethics resources and make these available The scholarships are also part of the to other schools or dental organizations individual program of PEI. that have a need. For example, if one Practice Ethics Assessment and school has developed an outstanding Development resource, the clearinghouse would The Practice Ethics Assessment and provide a vehicle to share it with others. Development (PEAD) program is part Resources could include video-taped of the practices element of PEI. A pilot lectures, curriculum guides, workbooks, version of PEAD has been developed by ethics dilemmas, course materials, tests, the College in cooperation with several self-assessment activities, and books. other dental organizations. PEAD is a To date, cooperation to obtain resources set of self-assessment instruments, diag- has not been overwhelming, but this nostic feedback, and suggested resources will continue to be pursued. New that dentists can use to improve the ethi- resources will be developed, as necessary, cal climate of theirs practices. PEAD is to supplement existing offerings, and the intended to be voluntary and customized current focus is on developing the central to individual practices. It is based on ethics resource for the clearinghouse, evidence showing that organizations which is described immediately below. that have a more positive ethical climate Interactive Dental Ethics Application are also more congenial and productive, The newest project of the College is the as well as doing the right thing. The var- Interactive Dental Ethics Application, ious exercises in the PEAD packet are to also known as IDEA®. IDEA® will be the be used by the dentist and, in a number central ethics resource of the Ethics of cases, by the office team and even Resource Clearinghouse mentioned patients. Self-evaluation and comparison above. IDEA® was developed in response to the need for a comprehensive digital dental ethics resource that had both interactive and multimedia capability. 8 2011 Volume 78, Number 1 499379_jacd 5/11/11 4:02 PM Page 9

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Founders of the American College of Dentists It was designed from the beginning for Henry L. Banzhaf Milwaukee, Wisconsin Portable Document Format (PDF) to increase compatibility and portability. J.F. Biddle Pittsburgh, Pennsylvania The PDF format offers several advantages Arthur D. Black Chicago, Illinois for this application: (a) portability; John P. Buckley Los Angeles, California (b) compatibility with computers; (c) Harvey J. Burkhart Rochester, New York formatting maintained on printing; (d) interactivity through scripting; and (e) John V. Conzett Dubuque, Iowa the reader software is a free download H.D. Cross Boston, Massachusetts (or is provided on newer computers). Julio Endelman Los Angeles, California An Internet connection is required to H. Edmund Friesell Pittsburgh, Pennsylvania play the videos. From the beginning, the goal has been to provide IDEA® on a William A. Giffen Detroit, Michigan complimentary basis for dental students, Clarence J. Grieves Baltimore, Maryland practicing dentists, dental hygienists, Thomas B. Hartzell Minneapolis, Minnesota educators, and others with an interest Thomas P. Hinman Atlanta, Georgia in dental ethics. IDEA® is not designed like a book to be used from front to Milus M. House Indianapolis, Indiana back. Rather, it is more like a digital V.H. Jackson New York, New York ethics cafeteria. The working prototype C.N. Johnson Chicago, Illinois is finished and release is anticipated in E.A. Johnson Boston, Massachusetts the summer of 2011. IDEA® will be C. Edmund Kells New Orleans, Louisiana distributed as a download from the ACD Web site, www.dentalethics.org, and Otto U. King Chicago, Illinois possibly on compact disc. There are Albert L. Midgley Providence, Rhode Island currently eight sections, Overview, Frederick B. Noyes Chicago, Illinois Fundamentals, Single Concept, Large Roscoe H. Volland Iowa City, Iowa Concept, Cases, Development, CE Courses, and Resources. Self-assessment C.E. Woodbury Council Bluffs, Iowa activities, quizzes, and videos are included in some sections. Section Projects Ethics Summits Regional College components, known The College has directly sponsored four as Sections, support a number of local Ethics Summits since 1998, the last two projects, including White Coat involved “Truth Claims in Dentistry” Ceremonies at dental schools. Section (2004) and the “Ethics Summit on projects also include dental school Commercialism” (2006). The latter and awards, ethical dilemma programs, most recent Summit was co-sponsored sponsored lectures at state dental with the American Dental Association. meetings, and more. Sections also The College was also involved with the support Student Professionalism and access to care conference in the summer Ethics Club (SPEC) chapters, now at of 2005 and also helped sponsor the over 20 dental schools. June 2007 symposium on integrity and ethics in dental education coordinated by the ADA.

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Miscellaneous Awards • Ethics and professionalism— American Society for Dental Ethics The College has a comprehensive lineup Virtually all major issues confronting Section of national awards, including the William dentistry have a significant ethics On January 1, 2011, the American J. Gies Award, Ethics and Professionalism and professionalism component and Society for Dental Ethics (ASDE) became Award, Outstanding Service Award, the College will continue to live up the 51st Section of the College. Dental Honorary Fellowship, and the Award of to its reputation as the “Conscience ethics is a comparatively small field, Merit. Sections administer the Outstanding of Dentistry” through its programs, and a coordinated voice would be an Student Leader Award, the ACD’s national- publications, and activities. advantage for two different organizations level award for dental students based on • Leadership—The College is composed having complementary missions. ASDE leadership and scholarship. The College of leaders and has a leadership was established in 2004 to succeed also sponsors the ACD-AADE Prize for role. It will continue to develop and PEDNET (Professional Ethics in Dentistry Dental Journalism awarded annually utilize leaders to meet the important Network, founded in 1987). to an outstanding contribution to dental challenges ahead. journalism that best promote the mission Dental Symposium at the Intensive As it has for so many years, the of the College. Bioethics Course, Kennedy Institute College is working hard to continue to ■ of Ethics Future make a difference in dentistry. The College, in collaboration with the What does the future hold for the Joseph P. and Rose F. Kennedy Institute References American College of Dentists? There of Ethics and the ASDE, developed the Anonymous. (2008). Fellowship process are many very important issues facing insights. ACD News, 37 (3), 16-19. first dental ethics satellite symposium to dentistry that will ultimately define the Board of Regents of the American College better integrate professional ethics in profession. These issues include com- of Dentists (2003). The ethics of quackery dentistry with bioethics. It was held in mercialism, access to care, and mid-level and fraud in dentistry: A position paper. June 2010 in conjunction with the Journal of the American College of providers, among others. The College Institute’s highly renowned weeklong Dentists, 70 (3), 6-8. has never been an organization to sit on Intensive Bioethics Course. The Kennedy Board of Regents of the American College the sidelines and watch the parade go of Dentists (1996). White Paper: Dental Institute of Ethics is one of the world’s by. As it has from the beginning, the Managed Care in the Context of Ethics. premier institutes for research in College will be engaged in the dialogue Journal of the American College of bioethics. The special addition of a Dentists, 63 (4), 19-21. concerning these issues. The American dental ethics symposium was a return Brandhorst, O. W. (1970). The American College of Dentists will continue the to the Institute’s longstanding interest College of Dentists history: The first fifty work that advances the elements of years. St. Louis: The College. in dentistry and was a direct outcome of its mission. Chambers, D. W. (2006). History of the the College’s work with the Professional • Excellence—The College stands for the American College of Dentists. Journal of Ethics Initiative. best in dentistry and will continue the American College of Dentists, 73 (1). to champion initiatives involving quality, continuous improvement, high standards, and ideals. It will oppose forces that degrade the cor- nerstone of professionalism, that a patient should unambiguously be the foremost concern of the dentist, not financial compensation or prestige.

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Selected Publications of the American College of Dentists

Gies, W. J. (1926). Dental Education in Gurley, J. E. (1960). The evolution of McBride, T. F., & Brandhorst, O. W. the United States and Canada: A Report dental education including a chronologi- (1969). Workshop on dental manpower: to the Carnegie Foundation for the cal history of the Dental Educational A summary. St. Louis, MO: The College. Advancement of Teaching. Bulletin No. Council of America, the Dental Faculties Reprinted from the Journal of the 19, New York, NY: The Foundation. Association of American Universities, American College of Dentists, 35 (April) (This was not an official publication reorganized Dental Educational Council 98-237, 35 (July) 243-256; 36 (January) of the American College of Dentists, but of America; report of the historian. 28-33, 36 (April) 76-90. Dr. Gies did acknowledge the College’s St. Louis, MO: The College. American College of Dentists (1973). assistance in the report.) Gurley, J. E. (1961). The evolution of Self-assessment and continuing educa- Johnson, E. A., O’Rourke, J. T., Partridge, professional ethics in dentistry. St. Louis, tion in dentistry: A program for the B. S., Spalding, E. B., & Palmer, B .B. MO: The College. practicing dentist. Bethesda, MD: (1932). The status of dental journalism The College. American College of Dentists (1961). in the United States: Report on the A dental health plan for the American Ross, M. (1981). George Corbly Commission on Journalism of the people: A panel discussion presented at Paffenbarger, D.D.S.: His life and career American College of Dentists 1928–1931. the 1961 convocation of the American in dental materials. Bethesda, MD: New York, NY: The College. College of Dentists, Philadelphia, PA, The College. Beck, D. F., & Jessup, M. F. (1943). Costs October 15, 1961. Reprinted from the Dummett, C. O., Dummett, L. D. (1986). of dental care for adults under specific Journal of the American College of The Hillenbrand era: Organized clinical conditions. Lancaster, PA: Dentists, 28 (December), 243-296. dentistry’s glanzperiode. Bethesda, MD: The College. More, D. M. (1961). The dental student. The College. Gurley, J. E. (ed.) (1947). Dental educa- St. Louis, MO: The College. Reprinted tion: Objective and purpose. Presenting from the Journal of the American College schools of Canada and the United States. of Dentists, 28 (March), 5-94. St. Louis, MO: The College. Reprinted More, D. M. (1962). The dental student from the Journal of the American College approaching graduation—1962. St. Louis, of Dentists, 14 (1-4) March, June, MO: The College. Reprinted from the September, December. Journal of the American College of American College of Dentists (1958). Dentists, 29 (September), 113-208. An Evaluation of the ILWU-PMA Dental Committee on Social Characteristics, Care Programs and some socioeconomic American College of Dentists (1965). factors related to dental practice. St. Proceedings of a workshop on enhancing Louis, MO: The College. Reprinted from the image of dentistry. St. Louis, MO: the Journal of the American College of The College. Reprinted from the Journal Dentists, 25 (September), 145-240. of the American College of Dentists, 32 Commission on the Survey of Dentistry in (July), 130-170. the United States (1960). The recommen- American College of Dentists (1968). dations of the Survey of Dentistry. St. Caries prevention and control: A panel Louis, MO: The College. Reprinted from discussion presented at the meeting the Journal of the American College of of the American College of Dentists, Dentists, 25 (December), 222-268. Washington, DC, October 28, 1967. St. Louis, MO: The College. Reprinted from the Journal of the American College of Dentists, 35 (January), 15-91.

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International College of Dentists—USA Section A Brief History, 1934–2011

Richard G. Shaffer, DDS and t happened over dinner… body, or society of persons engaged in Richard J. Galeone, DDS, FACD That’s true. The 1920 dinner was a common pursuits of having common Ifarewell gathering in Tokyo, Japan, for duties and interests.” That was exactly Abstract Dr. Louis Ottofy. Dr. Ottofy was getting what he was looking for…The Inter- Inspiration for the International College ready to return to his native United States national College of Dentists had a name. of Dentists can be traced to a Tokyo dinner to resume the practice of dentistry after He made the draft of the rules and in 1920, with the College being founded 23 years in the Orient, Japan, and the organizational structure. The ICD was in 1927 and the USA Section following in 1934. The College has always held a focus Philippines. During the remarks, one of created on December 31, 1927. on international relations and service. The the speakers, Dr. Tsurukichi Okumura, Originally the membership was to USA Section has also developed a firm made the point that it was unfortunate be limited to 300. Every country in the commitment to leadership. The origins of there was no definite means for dentists world was to be represented by at least the College are traced in this article, and living in distant places to ascertain what one dentist. The constitution was indeed the organizational structure and a sampling was occurring in the dental profession. brief. The four original objectives are of its many programs are also presented. A suggestion was made that there should still supported and valued today: be an international organization through • To foster cordial relations among which individuals could meet with fellow dentists in all parts of the world practitioners from even the remotest • For cooperation among dentists in points. The nearest thing to an interna- the interest of progress in the science tional organization at the time was and art of dentistry, especially with the Federation Dentaire International dentists who are located in less (FDI), a wonderful organization that frequented parts of the world worked with dentists from countries • To aid in education of all peoples with a national dental society. concerning the importance of Upon Dr. Ottofy’s return to America, dentistry as a health measure he began to formulate this new organiza- • To assemble and publish data tion. The initiative resurfaced again at the pertaining to dentistry in all parts Sixth International Dental Congress in of the world 1926. The officers of FDI were consulted, and they assured Dr. Ottofy that they did not consider his proposed organization Dr. Shaffer is historian of the to be in conflict with the Federation. USA Section, International Dr. Ottofy then revealed plans for an College of Dentists and Dr. Galeone is the Editor organization to be composed of leading of the USA Section; dentists from all over the world. When [email protected]. researching an appropriate name he looked up the word “college.” He found the first definition to be, “a collection,

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The USA Section Association in Saint Paul, Minnesota, The objectives and the territory covered in August of 1934. As an aside, the by the College was so different and so association with the ADA has been very The International College of strong over the years. In 1953, the formal unique among dental organizations that Dentists is a leading honorary it could not in any sense be construed as vote was taken to have our Annual USA opposing any other laudable dental Section Meeting in conjunction with organization dedicated to the the ADA wherever they meet. effort or organization. As interest in the recognition of outstanding ICD grew, so did the organization. The During the 1934 Minnesota meeting, original worldwide quota of 300 grew the draft constitution and bylaws were professional achievement, to 500. In 1930 during an American presented and all the members of the Dental Association meeting in Denver, International College of Dentists residing meritorious service, and the Colorado, the proposition was made to in the United States at that time were continued progress of the increase the usefulness of the College invited to become members of the USA and allow the increase of membership by Section. The Section was divided into13 profession of dentistry for the Districts, and Regents were selected for organizing into Sections. The Sections benefit of all humankind. were to adopt rules and regulations and each. Currently, there are 17 Districts to establish entrance requirements, dues, and Regents. The Districts are logistically and admission fees in order to afford the distributed consistent with the ADA opportunity for Fellows on a larger scale Trustee Districts. to comment on the solution of problems During the Chicago meeting of of vital interest to dentistry. At this point 1938, the following resolution was nearly one-half of the dentists in the adopted: “The aim and purpose of the world were practicing in the United International College of Dentists is to States. It was proposed that the Fellows recognize conspicuous and meritorious in the United States organize the service to the profession of dentistry. American Section of the International All worthy and qualified recipients of College of Dentists. The concept of the Fellowship in the ICD shall be consid- first Section of the International College ered, regardless of previous affiliations of Dentists was formed on July 22, 1930. with other honorary organizations.” During the February 1934 Chicago Back in 1938 this was called a Midwinter Meeting, a group assembled resolution; in today’s terms it is called a to launch a permanent USA Section. mission statement. Today our mission The USA Section was chartered in statement reads: “The International Washington, DC, on February 26, 1934. College of Dentists is a leading honorary The first officers were: President—Oren A. organization dedicated to the recognition Oliver, Vice President—Boyd S. Gardner, of outstanding professional achievement, Secretary, Registrar—Justin D. Towner, and Treasurer—Edward C. Mills. These officers conducted their first meeting in conjunction with the American Dental 13 Journal of the American College of Dentists 499379:jacd 5/6/11 4:31 PM Page 14

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meritorious service, and the continued According to our Section Office records, Each Fellow of the College shall either be progress of the profession of dentistry the first USA woman was inducted into a member of an Autonomous Section or for the benefit of all humankind.” Fellowship in 1970. of the International Section. Any area The design for the College key, drawn The USA Section Foundation was not in an Autonomous Section is admin- by Dr. Towner, was adopted in 1939. formed on January 22, 1986. The istered by the Executive Committee or While the USA Section was being Foundation was chartered as a 501(c) the International Council of the College. organized, Dr. Ottofy was gradually (3) nonprofit corporation. This opened There are 14 Autonomous Sections: building up the College at large. In 1929, an important avenue for ICD Fellows to I USA, II Canada; III Mexico; IV South 250 Fellows were awarded Fellowship; make tax deductible gifts, donations, America; V Europe; VI India, Sri Lanka; these were scattered throughout 162 bequests, and other such contributions to VII Japan; VIII Australia, New Zealand, countries, states, and provinces. During scientific and charitable causes selected Fiji, IX Philippines; X Middle East; XI World War II, the College at large was and supported by the USA Section. Korea, XII Chinese Taipei; XIII China; seriously held back. The USA Section Contributions to the Foundation qualify and XIV Myanmar. Autonomous Sections handled most of the affairs during the as tax deductible to the maximum may further subdivide into Districts. war until 1947. Attention was drawn to limits allowable by existing legislation Section I, the USA Section, has 17 the critical needs of the members of the governing charitable giving. Districts. Section XX is the International dental profession in those countries A fuller account of the history of the Section and is divided into 18 Regions. recently involved in the war. Hope was College can be found in R.G. Shaffer’s The International Section is composed expressed that ways and means would International College of Dentists USA of countries that do not have enough be found for the USA Section to make a Section History 1920-1996 (1997). Fellows to become a Section of their tangible contribution to the reconstruc- own, and so are grouped geographically. tion of dentistry in those countries, Activities of the USA Section of ICD There are approximately 10,700 which the USA Section did. The International College of Dentists, current Fellows spread throughout 101 As the College grew, the Canadian USA Section has a long and proud Countries. The USA Section currently section became the second Autonomous history of dedication and service to the has 6,319 members: 4,035 active, 244 Section of the College in 1948. Other field of dentistry. As our 2011 President, retired, 1,988 life, and 52 honorary. Sections began to organize; today the Dr. Jack Clinton says “Be a better leader— there are 14 Autonomous Sections to Make a bigger difference.” Humanitarian Projects the College. China and Myanmar are Today the USA Section is active and Kenya (PCEA Kikuyu Hospital the latest, approved for Section status invigorated. The mission statement Dental Clinic) in 2009. quoted earlier along with our vision is: The International College of Dentists, In 1956, at the request of the USA Mission Statement—The USA and Fellows from North Dakota, Section, a recommendation was made International College of Dentists joined a mission partnership in the to accept an official ICD Cap and Gown. is a leading honorary dental development, construction, and equip- The gown is fine grade black poplin organization dedicated to the ping of a dental clinic at the PCEA with velveteen trim. It has three front recognition of outstanding profes- Kikuyu Hospital in Kenya. The ICD, USA panels—lilac, the traditional hue of the sional achievement, meritorious was one of the principal partners and dental profession; gold and dark green, service, and the continued progress provided financial support to build and the official College colors. Regulation of the profession of dentistry for equip the sterilization room and one black velvet bars are on the sleeves, with the benefit of all humankind treatment room. There are 700 dentists a three-inch gold band below the bars. Vision Statement—Being the for 40,000,000 Kenyans and a 1-260,000 Women were first considered for leading honorary dental organization dentist-to-population ratio for the rural Fellowship in the Section in 1959. providing service worldwide population. The project was initiated in June 2000, and the clinic was turned Structure of the International over to the hospital in September 2009 College of Dentists and is now owned and operated by The organization of the International Kenyans. Due in no small part to the College of Dentists is divided geographi- dedicated commitment of the ICD USA, cally into Sections, Regions, and Districts. 14 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:31 PM Page 15

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this fully staffed and fully equipped mentoring program that calls on peer eight treatment room facility provides influence to help guide students toward immediate, preventive, and comprehen- professional and ethical conduct. sive dental services for Kenyan people and beyond. The clinic also offers volun- International Dental Student teer opportunities. Dental schools from Exchange Program the USA and UK have sent students for This project was initiated in 1990 to educational and mission experiences at improve and increase international the clinic’s outreach projects at orphan- relations at the student level by provid- ages, schools. and remote villages. ing a professional and cultural exchange between dental schools in the USA and Tanzania The International College To get dental care to two refugee camps other countries. Participating dental with over 175,000 people, we have joined schools are the University of Alabama at of Dentists, USA Section with the ADA and Health Volunteers Birmingham, Case Western Reserve Overseas to form and staff two clinics. University, Medical College of Georgia, has a long and proud We have installed two full operatories and University of Maryland—Baltimore, of history of dedication provide free service to those with serious University of Minnesota, University of dental needs, in addition to providing a Oklahoma, University of Medicine and and service to the field treatment clinic in each of the camps. Dentistry—New Jersey, and University of of dentistry. NC, Chapel Hill. Students have traveled Southeast Asia to Meikai and Asahi in Japan; Arhus, We have supported programs in Denmark; Nice, France; Dublin, Ireland; Southeast Asia for nine years. This proj- and Moldova, just to highlight a few of ect provides a three-year course in public the exchanges. health dentistry and awards a Masters Degree to local students. We have had Peace Corps Dental Exams three classes in Vietnam and have Many USA Section Fellows are providing expanded to Laos and Cambodia. a complete dental examination, including Leadership Initiatives a periodontal exam, and a full mouth series of radiographs (or a panorex with Annual Dental Journalism Awards, bitewings) if called upon. The Peace recognizing achievements of dental Corps appreciates our program for publications, are presented during the several reasons. Applicants to the Peace annual ADA meeting. Corps receive quality, thorough evalua- Support is provided to the American tions from ICD Fellows. Due to budget Association of Dental Editors for their limitations, dental exam reimbursement meeting needs. is only $60; for those applicants without The Annual Outstanding Student dental insurance, the savings afforded Leadership Award are presented to a by visiting an ICD dentist is significant. senior student in each dental school in Additionally, the Peace Corps saves the USA, recognizing professional money when an applicant visits an ICD growth, development, and leadership. dentist, which in turn helps them place The Audiovisual History Program is more volunteers. ■ a growing library of recorded interviews of world leaders of our profession that preserves the thoughts and wisdom of these visionaries. Support is provided to dental schools conducting White Coat ceremonies. Great Expectations is a professional 15 Journal of the American College of Dentists 499379:jacd 5/6/11 4:31 PM Page 16

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The Academy of Dentistry International

Robert L. Ramus, DDS he Academy of Dentistry Structure for International Activity International (ADI) was founded in Abstract The activities of the Academy are directed T1974 by its first president, Dr. Albert by its Central Office (headed by the The Academy of Dentistry International Wasserman of San Mateo, California, executive director), the president and was founded to promote the art and following which it became incorporated science of dentistry, especially through officers of the Executive Committee, and as a legal entity within that state. As a research and continuing education. Its by its governing body of the Academy, mission is international in the sense past president of both the American the International Board of Regents. The of promoting exchange and service. College of Dentists and of the Academy Regents, who with the members of the The organizational structure of ADI is of General Dentistry, Dr. Wasserman Executive Committee constitute the discussed as well as its membership. recognized the need to extend the ideals Board, are elected by Fellows resident A defining characteristic of the Academy of these two organizations, particularly is an array of programs around the world within a number of defined geographic that of continuing education, to dentists supported by the Academy of Dentistry areas of the world (identified as Sections), International Foundation. internationally. From this, the mission which currently number 18 persons. of the Academy grew, to encompass the In general, most of the Sections of the ideals which are written within its bylaws Academy represent more than one and which embrace such issues as: country. To ameliorate the language, • Advancement of the science and cultural, and fiscal variations that arise art of dentistry from this, some of the Sections contain • Stimulation and encouragement subgroups which are known as Chapters. of research It is through discussion within the • Promotion of continuing education Sections and Chapters that Fellows of • Stimulation, encouragement and the Academy may advance comment to promotion of service projects their representatives and thus to the • Promotion of the international International Board. In effect, by this exchange of information and culture democratic process the International • Promotion of ethical relations Board of Regents is able to address issues between dentists of global significance, while local matters • Recognition of conspicuous service which are of direct interest to Fellows to dentistry fall within the province of the Sections In addition to these ideals, the and Chapters. All service performed by Academy confers Fellowships upon the Officers of the Academy is voluntary worthy individuals from within the den- and without financial reward. tal world at large, who have contributed As the ADI evolved, it became obvious to the advancement of the profession that the formalization of the funding and in one or more ways through clinical practice, research, education, public Dr. Ramus is the Executive service, journalism, and service to Director of the Academy the profession. of Dentistry International and maintains a private practice in Hicksville, Ohio; [email protected] 16 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:31 PM Page 17

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administration of volunteer programs, in the USA compared with the rest of being only a part of the remit of the the world is 40% to 60%, which seems Academy, would be best served by the to validate the founder and inaugural From its modest beginnings formation of a separate entity, and President Albert Wasserman’s vision of in 1974 the Academy has accordingly the ADI Foundation was reaching out to the dentists of the world. formed. It operates in parallel with the The global extension of the Academy grown in both numbers ADI, but its responsibility is solely to and of its work provides a broad spread review requests for funding and to of interest for its Fellows, as well as the and substance, from a small provide grants for projects that meet its commensurate coverage of the salient nucleus of dedicated requirements, according to those funds points contained within its mission, as which are available at that time. It is developed by its founders. members of the dental administered by an elected Board of profession. Directors drawn from members of the Service Programs Supported by Board of Regents and from senior the ADI Foundation members of the dental industry, with According to the ideals listed previously, all administrative support being provided the Academy has been able to participate by the Central Office of the Academy. formally in all of the principles enunciated As with the ADI Board of Regents, all therein, excepting for that of research. work carried out by its members is As an entity which lacks funding, as well provided pro bono. as the “bricks and mortar” establish- ADI does not have a restricted ment which may provide the key to the membership list, although the very successful pursuit of research, for the process of peer review, which may lead present ADI is only able to follow this to acceptance of prospective Fellows, path in a peripheral sense. Nevertheless, tends to confine its numbers. At the time with the encouragement of ADI, many of of this publication, the total number of its Fellows have provided aid in develop- Fellows of the Academy is approaching ing pathways for individuals to further 3,000, and this figure has been fairly the pursuit of research. constant in recent time. However, follow- Continuing education programs are ing the opening of geographic borders provided at Convocations of Fellows, throughout Europe at the end of the which are held throughout the world last century and despite the barriers of under the auspices of the appropriate language and culture, there has been a Regional authorities as well as through surge of interest in the ADI by dentists the Central Office. In addition, at such who are resident within the three ADI Convocations, specific Awards of the Regions of Europe (Northern, Southern, Academy may be conferred upon persons and Eastern Sections), and accordingly the of distinction, as well as to honor others membership of the Academy is increasing. Expressed in terms of percentage, the present number of Fellows resident 17 Journal of the American College of Dentists 499379:jacd 5/6/11 4:31 PM Page 18

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of significance through the conferral of “fallen through the cracks” of the social their example, have made major contri- Fellowship. systems which prevail in their communi- butions to the ongoing work of the Since its inception, much of the drive ties. For a number of years an ongoing Academy in recent times. These are: of the Academy has focused upon the project of the Union Gospel Mission in • Dr. Terry Tanaka (USA), ADI Past work of volunteers to provide service for Seattle has been supported by the ADI President, for his philanthropy, CE disadvantaged groups throughout the Foundation, whereby dentures are programs, and the development and world, and, because of obvious need, provided for disadvantaged persons who funding of the Tanaka Award much of this has centered upon those who are edentulous. The facial and functional • Dr. Burton C. Conrod (Canada), reside in nonindustrialized countries. transformation which is achieved for Immediate Past President of the A recent example of such work is that these people not only opens opportunities FDI World Dental Federation, for his which has resulted from the support for them to reenter mainstream society contribution to the dental profession given by the Academy to the entity but also helps them to regain the self- at a global level “Tooth Aid,” created by Fellow, Dr. Paul esteem which is necessary for them to • Dr. Reg Hession (Australia), ADI Kotala (Australia). Dr. Kotala and a team obtain gainful employment. Past President, Member of the FDI of volunteers make a minimum of three Other projects which have received List of Honor, Past Chairman of visits to Laos each year to provide diag- support from the ADI Foundation in the Australian Dental Research nostic, clinical, and preventive dental recent times have been the Thousand Foundation, and sole donor for its services for the people who are resident Smiles Foundation in Mexico (cleft lips Biennial Traveling Scholarship in remote areas of the country. On Dr. and palates), the support provided for Kotala’s early visits to Nambak Province library facilities in dental schools in • Dr. Gerhard Seeberger (Italy), and in addition to his field trips into Cambodia, Mongolia, and Vietnam, President of the European Regional remote rural regions, he saw a need for and in more recent times, following Organization of the FDI, for his the establishment of a permanent dental the disastrous earthquake in Haiti, the presentations of CE programs and facility adjacent to the Nambak Hospital. provision of financial assistance to the the development of the ADI within With the financial assistance of the Haitian Dental Institute. Southern Europe Academy and much ingenuity on Dr. • Dr. Philippe Rusca (Switzerland), Kotala’s behalf, a permanent dental International Leaders in the Vice-President of the European clinic has now been constructed and Profession Regional Organization of the FDI, for fitted out with equipment to provide Through its recognition of eminent his contribution to the development treatment which is beyond that which dental persons throughout the world, of the ADI within Northern Europe may be performed in the field and this the Academy is fortunate to count within • Mr. Friederich Herbst (Germany), clinic bears the name of the Academy. its ranks many from the profession and Honorary Fellow, Executive Director Further, through the ongoing support related disciplines, such as the health of the International Dental Manufac- of ADI Past President, Dr Terry Tanaka sciences and the dental industry. It turers, for his outstanding leadership (USA) and a group of his colleagues who numbers among its members many in driving the prospective establish- wish to remain anonymous, a Laotian who have been at the forefront of their ment of an ADI German Chapter. dentist has been funded to manage the national dental associations, leaders In summary, from its modest begin- clinic on a permanent basis, as well as in dental teaching and research, and nings in 1974 the Academy has grown to provide ongoing treatment for those prominent clinicians who are regarded in both numbers and substance, from a in need, between the visits of Dr. Kotala by their peers as having achieved locally small nucleus of dedicated members and his team. and internationally at the highest levels. of the dental profession. Through its By contrast and as a paradox, it It is indeed an embarrassment to name evolution, it has embraced the principles has been found that there are many only a few of these persons, particularly enunciated by its forefathers and in disadvantaged groups who are resident those who have undertaken leadership doing so, it has attempted to develop within almost all countries in the world roles throughout the lifetime of the and spread globally the sound principles where advanced or developed economies Academy, while omitting so many who which drive the many fine societies of prevail. These are people who may have are equally worthy of mention. honor which exist within the USA. ■ Despite this and for the sake of completeness, it may be appropriate to 18 mention a few among many who, by 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:31 PM Page 19

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Omicron Kappa Upsilon A Historical and Current Perspective

Jon B Suzuki, DDS, PhD, MBA, FACD micron Kappa Upsilon (OKU) “GV Black,” dean of the Northwestern is the national honor society University Dental School, initiated the Abstract Oin dentistry, symbolizing the first OKU chapter (“Alpha” chapter). Founded by G. V. Black at Northwestern outstanding scholarship and character Black then invited the deans of 51 other Dental School in 1914, Omicron Kappa of graduating senior dental students, as schools to organize and form a national Upsilon is the “Phi Beta Kappa” of determined by dental school faculty. network composed of local honorary dentistry, honoring students, faculty members, and honorary members for The organization is generally referred dental societies, unified with a gold OKU academic excellence and professional to as the “Phi Beta Kappa” of dentistry, insignia (on April 8, 1915), a certificate character. In addition, the honor society with membership restricted to dentists of incorporation (state of Illinois on has a history of granting recognition of recognized in attaining a high grade March 15, 1916), and constitution and schools and individuals who have distin- point average upon graduation from bylaws (1921). guished themselves and show promise dental school. More recently, OKU Several dental schools quickly fol- for advancing dental education. has broadened its sphere of influence lowed and became charter members. beyond scholarship and includes such These include, in order: the University of initiatives as service, mentorship, Pittsburgh (Beta chapter); Washington outreach, and research. University, St. Louis (Gamma chapter); Primary alumni membership in North Pacific Dental College, Seattle OKU is first determined using a two-step (Delta chapter); Creighton University, process: first class rank is considered Omaha, Nebraska (Epsilon chapter); (top 20% of the dental school graduating University of Southern California (Zeta class upon GPA), the faculty vote from chapter); The Ohio State University this pool based on other qualities includ- (Theta chapter), Vanderbilt University, ing character, service, research, etc (top Nashville, Tennessee (Iota chapter), 12% of the dental school graduating University of Pennsylvania (Eta chapter), class). Therefore, in a class of 100 dental and Medical College of Georgia, Augusta students, only 12 students are inducted into the local dental school OKU chapter Dr. Suzuki is Secretary/ as alumni members upon graduation. Treasurer of OKU Supreme Other categories of OKU membership Chapter and Associate Dean for Graduate Education, are faculty and honorary membership. Temple University School These categories also follow specific of Dentistry; Jon.Suzuki@ criteria for induction, such as excellence temple.edu. in teaching, research, and service to the Acknowledgments: component dental school (please see Recognition is extended to Ms. Jan John, Corresponding www.oku.org for further details). Secretary for the Supreme OKU has its origin with the senior Chapter, and Ms. Gayle graduating dental class of 1914 at Schooley, Administrative Specialist to Dr. Suzuki. Northwestern University in Chicago. Dr. Green Vardiman Black, known as

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Table 1: OKU Chapters Chapter Active School Inception Secretary Alpha No Northwestern University 1914 Beta Yes University of Pittsburgh 1916 Dr. Michael A. Dobos Gamma No Washington University at St. Louis 1916 Delta Yes University of Oregon 1916 Dr. Larry Doyle Epsilon Yes Creighton University 1916 Dr. Gary H. Westerman Zeta Yes University of Southern California 1916 Dr. John Sanders Eta Yes University of Pennsylvania 1916 Dr. Arthur I. Steinberg Theta Yes Ohio State University 1916 Dr. John Walters Iota No Vanderbilt University 1916 Kappa Yes Virginia Commonwealth University 1921 Dr. Carol Brooks Lambda No Emory University 1923 Mu Yes University of Iowa 1923 Dr. Heather Heddens Nu Yes University of Louisville 1924 Dr. Gary A. Crim Xi Yes Marquette University 1924 Dr. Thomas Smithy Omicron Yes Baylor College of Dentistry 1925 Dr. Brent Hutson Pi No Loyola University (Chicago) 1925 Rho Yes University of Missouri at Kansas City 1928 Dr. John Rapley Sigma Yes University of Illinois 1928 Dr. James Ricker Tau No Loyola University (New Orleans) 1928 Upsilon Yes Case Western Reserve University 1929 Dr. Madge Potts-Williams Phi Yes University of Maryland 1929 Dr. Elaine Romberg Chi Yes University of Michigan 1929 Dr. Philip Richards Psi Yes University of Tennessee 1929 Dr. Mark Scarbecz Omega Yes New York University 1929 Dr. Michael B. Ferguson Alpha Alpha Yes University of Nebraska 1929 Dr. Paul Hansen Beta Beta Yes University of Minnesota 1929 Dr. Carol Meyer Gamma Gamma Yes Harvard University 1930 Dr. I. Leon Dogon Delta Delta Yes University of the Pacific 1933 Dr. Robert Sarka Epsilon Epsilon Yes Columbia University 1934 Dr. Jason J. Psillakis Zeta Zeta No Georgetown University 1934 Eta Eta No Saint Louis University 1934 Theta Theta Yes Indiana University 1934 Dr. Lisa Willis Kappa Kappa Yes Temple University 1936 Dr. Louis Tarnoff Lambda Lambda Yes State University of N.Y. at Buffalo 1937 Dr. Gerard Wieczkowski Jr. Mu Mu Yes University of Texas Houston 1940 Dr. Lisa Thomas Nu Nu Yes University of Detroit Mercy 1941 Dr. James Winkler Xi Xi Yes Tufts University 1944 Dr. Arthur Weiner Omicron Omicron Yes Meharry Medical College 1945 Dr. William Scales Pi Pi Yes Howard University 1948 Dr. Cecile E. Skinner Rho Rho Yes University of California-San Francisco 1948 Dr. Molly Newlon Sigma Sigma Yes University of Washington 1950 Dr. Douglas Verhoef Tau Tau Yes University of Toronto, Canada 1950 Dr. Julia Rukavani Upsilon Upsilon Yes University of North Carolina 1953 Dr. Allen Samuelson Phi Phi Yes University of Alabama 1954 Dr. Merrie H. Ramp Chi Chi Yes Loma Linda University 1956 Dr. Gregory Mitchell Psi Psi No Fairleigh Dickinson University 1957 Omega Omega Yes UMDNJ-New Jersey Dental School 1957 Dr. James Delahanty Alpha Beta Yes West Virginia University 1961 Dr. Robert Wanker Beta Gamma Yes University of Puerto Rico 1961 Dr. Darrel Hillman Gamma Delta No University of Manitoba, Canada 1961 Delta Epsilon Yes University of Kentucky 1966 Dr. Robert Kovarik Epsilon Zeta Yes UCLA 1967 Dr. Carol A. Bibb Zeta Eta Yes University of South Carolina 1970 Dr. Walter Renne Eta Theta No University of British Colombia 1970 Theta Kappa Yes Louisiana State University 1971 Dr. J. Lee Hochstedler Kappa Lambda Yes Georgia Health Sciences University 1972 Dr. Kevin Frazier Lambda Mu Yes Boston University 1972 Dr. Catherine S. Sarkis Mu Nu Yes University of Texas, San Antonio 1973 Dr. Michaell Huber Nu Xi Yes Southern Illinois University 1973 Dr. Debra Dixon Xi Omicron Yes University of Florida 1974 Dr. Ronald E. Watson Omicron Pi Yes University of Oklahoma 1975 Dr. J. Mark Felton Pi Rho Yes University of Colorado 1976 Dr. John D. McDowell Rho Sigma Yes University of Mississippi 1977 Dr. William T. Buchanan Sigma Tau Yes Stony Brook University 1977 Dr. Denise Trochesset Tau Upsilon No Oral Roberts University 1979 Upsilon Phi No University of Western Ontario, Canada 1984 Phi Chi Yes University of Connecticut 1997 Dr. Steven M. Lepowsky Chi Psi Yes Nova Southeastern University 2000 Dr. Harvey Quinton Psi Omega Yes University of Nevada Las Vegas 2003 Dr. Marcia M Ditmyer Beta Alpha Yes Arizona School of Dentistry & Oral Health 2007 Dr. Mike Lazarski 20 Beta Delta Yes Midwestern University 2010 Dr. Christine Halket 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:31 PM Page 21

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(Kappa chapter). Due to the closure of To electronically scan and archive Northwestern University Dental School each paper document, photograph, and in Chicago several years ago, the memorabilium of the Supreme Chapter University of Pittsburgh, Beta chapter, is library and files (since OKU’s inaugural now the oldest OKU chapter in existence. meeting in 1914). This project is ongoing All current OKU component chapters in and requires characterization of the tens good standing are listed in Table 1. of thousands of OKU documents. This The mission of OKU is reflected in arm of the OKU-IT initiative is supervised the origin of its name, OKU, indicating by the current (since 1990) Supreme “Conservation of Teeth and Health.” Chapter Executive Secretary/Treasurer, Omicron represents “odious,” or teeth, Dr. Jon B. Suzuki, Temple University, Kappa represents the first letter of Kai, Philadelphia. OKU has broadened its the Greek word for “and,” and Upsilon Although OKU has as its origins to sphere of influence beyond represents “health,” since Upsilon is the honor dental students for excellence in closest Greek letter to sound like the scholarship and character, several pro- scholarship and includes letter “h” in English. Sigma (Greek letter grams have enhanced its development in such initiatives as service, for “S”) represents “conservation” and is maturation as a national program. In the predominant Greek letter on the the 1980s, the “American Fund for Dental mentorship, outreach, OKU logo (see top right). Health (AFDH)-Charles Craig Education Further historical information was Fellowship” was financially sponsored and research. published as “historical review of OKU” by OKU. This award provided tuition and by Erling Theon (1958) and, although living expenses for two years for graduate no longer in print, it is available on the students of specialty training with the OKU.org Web site (see tab on “history” obligation to enter academic dentistry www.OKU.org). full-time for a minimum of five years. In 2005, a major electronic archival These recipients have continued their and database project was approved by academic careers and have emerged to the OKU Supreme Chapter board of become deans, associate deans, and directors (officers) and funded in three- leaders within the profession. Although year increments from the general ledger the AFDH-Charles Craig Education account. This project, referred to as the Fellowship Award was recently discon- “OKU-information technology initiative” tinued, other OKU awards emerged upon or “OKU-IT,” has two aims: nomination, development, and approval To develop a dynamic and historic by the board of directors (officers) of database website of all OKU component the Supreme Chapter, the governing chapters and supreme chapter members, authority of the national network of chap- officers, annual meeting minutes, appli- ters. Established in 1997, and awarded cations for certificates, keys, necrology, annually since 1998, the Dr. Stephen H. and contact information (addresses, Leeper Teaching Excellence Award has phone numbers, e-mail addresses and been dedicated to individuals who have officers) of current chapters. Working demonstrated innovative teaching styles with a web master, the current (since and have exhibited consistent excellence 2000) Supreme Chapter Editor, Dr. in dental education. A list of award James Delahanty, University of Medicine recipients can be found in Table 2. and Dentistry of New Jersey, Newark, has been supervising this arm of the OKU-IT initiative. Annual updates and revisions are completed by June 30 of each academic year. 21 Journal of the American College of Dentists 499379:jacd 5/6/11 4:31 PM Page 22

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In 1999 two new awards were the opportunity to initiate a research approved by the Supreme Chapter. The project that can develop into a larger, Omicron Kappa Upsilon-Charles Craig extramurally funded study. It is expected Teaching Award was created to recognize that the recipient will present the results dental educators who have been teaching of his or her research at the annual fewer than five years and have demon- business meeting of the Supreme Chapter strated innovative teaching techniques in of Omicron Kappa Upsilon during the the art and science of dentistry. Faculty American Dental Education Association at the undergraduate, graduate, and or the International-American residency training levels are eligible and Association for Dental Research annual creativity, motivation, and innovation meetings following completion of the [OKU] will continue to are emphasized. Recipients with their funded project. produce leaders who university affiliation are listed in Table 3. In the past decade, OKU has part- The Omicron Kappa Upsilon nered with its “sister” chapter, the motivate dental students “Chapter Award” recognizes an OKU Dental Hygiene Honor Society, Sigma to achieve academic component chapter that has created Phi Alpha. Each alternate year, the two exemplary programs promoting excel- honorary organizations have organized and clinical excellence. lence at the local level. The award and financially sponsored an “OKU- honors a dental school chapter that has Sigma Phi Alpha” joint symposium at created innovative programs fostering the American Dental Education Associa- professional development in the spirit of tion (ADEA) annual meeting. Recent OKU. Component chapters receiving this topics have included “diversity,” “ethics,” prestigious award are listed in Table 4. “mentorship,” and “imaging in dentistry Details on academic service, scholarship, and medicine.” National officers from and research innovations supported by OKU and Sigma Phi Alpha work together local component chapters may be found beginning one year prior to this sympo- on www.OKU.org and includes projects sium event. such as sponsorships of “white coat” In conclusion, OKU remains a ceremonies, tuition scholarships, Haiti premier and highly selective honorary relief programs, and dental care to dental organization which recognizes disadvantaged patients in the scholarship and character. However, the Dominican Republic. sphere of influence of OKU has recently At the 2005 annual meeting of extended beyond academics and now Omicron Kappa Upsilon, the supreme includes service and related activities. chapter established the “New Educator Characteristics such as leadership in Research Grant” with the provision that academic dentistry, organized dentistry, awarding of the first grant be deferred and clinical practice frequently have until the necessary funds (capital) are their origins in OKU membership. The raised to finance the award. Pursuant to organization will continue to produce this motion, the board of directors has leaders who motivate dental students continued the task of soliciting the to achieve academic and clinical financial support to begin funding this excellence. ■ new award. The goals of the OKU new educator research grant are two-fold: first, to enable junior faculty to develop research skills with an established mentor; and, second, to provide junior faculty with

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Table 2: The Omicron Kappa Upsilon—Stephen H. Leeper Award for Teaching Excellence

Year Instructor Chapter Dental School 1998 Dr. Paul Desjardins Omega Omega University of Medicine & Dentistry of New Jersey 1999 Dr. Frank Dowd Epsilon Creighton University 2000 Dr. Herbert Schillingburg Jr. Omicron Pi University of Oklahoma 2001 Dr. Stuart C. White Epsilon Zeta University of California-Los Angeles 2002 Dr. Karen Crews Rho Sigma University of Mississippi 2003 Dr. Thomas D. Marshall Mu Nu University of Texas at San Antonio 2004 Dr. Kenneth I. Knowles Epsilon Creighton University 2005 Dr. Martin F. Land Nu Xi Southern Illinois University 2006 Dr. Michael Glick Omega Omega University of Medicine & Dentistry of New Jersey 2007 Dr. Donald E. Willmann Mu Nu University of Texas Health Science at San Antonio 2008 Dr. Stanton Harn Alpha Alpha University of Nebraska College of Dentistry 2009 Dr. Aldridge D. Wilder Jr. Upsilon Upsilon University of North Carolina 2010 Dr. Allan J. Kucine Sigma Tau State University of New York at Stony Brook 2011 Dr. James Summitt Mu Nu University of Texas at San Antonio

Table 3: Recipients of the Omicron Kappa Upsilon—Charles Craig Teaching Award

Year Graduate Student Dental School 2000 Dr. Thomas Salinas Louisiana State University School of Dentistry 2001 Dr. Carol Murdock Creighton University School of Dentistry 2002 Dr. Michael Ignelzi Jr. University of Michigan School of Dentistry 2003 Dr. R. Scott Shaddy Creighton University School of Dentistry 2004 Dr. Karl Keiser University of Texas, San Antonio 2005 Dr. John W. Shaner Creighton University School of Dentistry 2006 Dr. E. Richardo Schwedhelm University of Washington School of Dentistry 2007 Dr. Benita Sobieraj University of Buffalo, SUNY 2008 Dr. Lucinda J. Lyon University of the Pacific 2009 Dr. Nicole S. Kimmes Creighton University School of Dentistry 2010 Dr. Rocio Quinonez University of North Carolina at Chapel Hill 2011 Dr. Paul Luepke Marquette University

Table 4: Omicron Kappa Upsilon Chapter Award Recipients

Year Chapter Dental School 2001 Omega Omega University of Medicine & Dentistry of New Jersey 2003 Delta Delta University of the Pacific 2004 Xi Marquette University 2005 Omega New York University 2006 Xi Xi Tuft University 2007 Mu Mu University of Texas Dental Branch at Houston 2008 Beta University of Pittsburgh 2009 Pi Pi Howard University 2010 Theta Theta Indiana University 2011 Kappa Kappa Temple University

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Dental Students Choosing Licensure Path Give More Consideration to Career Flexibility Rather than Ethical Dilemmas

Heather J. Conrad, DMD, MS and he traditional clinical licensure (Dugoni, 1992; Pattalochi, 2002). A Eric A. Mills, DMD examination (CLE) for dentistry in number of criticisms have been made Tthe United States involves the use of regarding the ability of CLEs to evaluate Abstract live patients to evaluate clinical abilities performance on patients. First, the scope Although a patient-based clinical licensure and has been used since the early part of of the CLE tends to be rather limited, examination (CLE) has been used in the the twentieth century (Buchanan, 1991; involving a specific set of restorative United States for many decades to evaluate Chambers et al, 2004; Formicola et al, and periodontal procedures, albeit on an individual’s competency to practice dentistry, there continue to be validity, 2002). Although such a high-stakes per- different patients with differing levels reliability, and ethical issues of concern formance assessment continues to raise of disease (Feil et al, 1999). Second, to the profession. As a result of a 2009 validity, reliability, and ethical questions, the typical carious lesions accepted by decision by the Minnesota Board of passing a state or regional CLE is still examiners for assessing an individual’s Dentistry, dental students from the considered by some dental schools to be clinical abilities are considered by some University of Minnesota School of an effective measure of the curriculum to be treatable by more conservative Dentistry, beginning with the Class of 2010, are eligible for initial licensure in and by many state boards to be a way of means (Formicola et al, 2002; Mount, Minnesota by passing the nonpatient- fulfilling a mandate to protect the public 2005; National Institutes of Health based National Dental Examining Board (Buchanan, 1991; Chambers et al, 2004; Consensus Development Conference, of Canada Examination. Surveys were Stewart et al, 2004; Stewart et al, 2005). 2001; Thompson & Kaim, 2005). distributed to 101 senior dental students In 2000, the American Dental Moreover, although the Commission to assess what factors students used to Association (ADA) and the American on Dental Accreditation standards state decide whether or not to register for a patient-based CLE. The response rate to Dental Education Association (ADEA) that the delivery of comprehensive care the survey was 84.2% (85/101). The adopted policies calling for the elimina- should not be compromised for student opportunity to apply for a license in multi- tion of patients from CLEs by the year advancement and graduation, compre- ple states after passing a patient-based 2005 and supporting the development of hensive care is not the focus of CLEs CLE was the primary factor in influencing a national CLE (ADEA, 2004; Formicola (Hasegawa, 2002). Furthermore, the students to register for a patient- et al, 2002; Gerrow et al, 2006; Meskin, considering that patients are used and based CLE. Regarding the use of live patients in a CLE, students were most 2001). Due to the feasibility of the concept, a limited sample of the candidate’s skills concerned with having to operatively unrealistic timetable, and traditional is demonstrated, factors such as calibra- restore teeth that could be treated more beliefs, the CLE process has remained tion, standardization, validity, and conservatively and for other reasons largely unchanged (Gerrow et al, 2006). reliability are difficult to achieve (Berry, outside of their control, such as the The format of the CLE is typically patient failing to show up, patient not devoid of written questions since eval- Dr. Conrad is Assistant being accepted by the examiners, and uation of basic sciences and case-based Professor, Department of procedural issues during the examination. Restorative Sciences; and judgment are covered by the National Dr. Mills is Associate Clinical Board Dental Examination (NBDE) Dental Specialist, Department Parts I and II developed by the Joint of Primary Dental Care, Commission on National Dental both at the University of Minnesota, School of Dentistry; Examinations of the ADA (Ranney et al, [email protected]. 2004). What the CLE does evaluate is an individual’s ability to perform a sample of dental treatments on a patient 24 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:31 PM Page 25

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1995; Buchanan, 1991; Collins, 1985; state licensing authorities are still Dugoni, 1992; Meskin, 1994; 1996; required to provide the final independent Pattalochi, 2002). evaluation of the graduates of that edu- For those registered to take A positive relationship between a cational program (Pattalochi, 2002). a patient-based CLE, the student’s performance in dental school The enormous pressure to pass CLEs and on a CLE would support the validity has put candidates in situations where ethical issue that most of CLEs (Ranney et al, 2003); however, the best interest of the candidate may such correlations have not been demon- be placed ahead of the best interest of concerned them about taking strated. Several studies have shown the patient (Feil et al, 1999; Formicola the examination was having inconsistencies between the performances et al, 2002). Feil and colleagues (1999) and have concluded that factors other surveyed 1000 general dentists across to operatively restore teeth than the student’s clinical abilities influ- the United States and reported that that could be treated more ence the results (Dugoni, 1992; Formicola 59.1% of the respondents knew of at et al, 1998; Gerrow et al, 2006; Meskin, least one instance of an ethical lapse conservatively. 1994; Ranney et al, 2003; Ranney et al, during a patient-based CLE. Reported 2004). Reasons cited for the lack of ethical issues of candidates included validity of CLEs have included ineffective exposure of unnecessary radiographs, calibration of examiners, the use of coercion of patients into inappropriate patients which results in each candidate treatment choices, creation of intentional taking a different examination, and a lesions for the purposes of the examina- one-shot, limited sample of the candidate’s tions, premature treatment, overly knowledge and skills under pressure aggressive treatment, lack of follow-up and time constraints (Buchanan, 1991; care, and attempts to steal other candi- Chambers et al, 2004; Feil at al, 1999). date’s patients (Feil et al, 1999). The Concerns about the reliability of CLEs low number of reported complaints by have also been reported, based on studies patients participating in CLEs has been that document significant fluctuations in attributed to the fact that most of these pass rates from year to year among can- patients have a prior relationship with didates taking the same state or regional the dental school hosting the CLE and CLE (Meskin, 1994; Ranney et al, 2004). have confidence that they can rely on Those in favor of the use of patients the dental school for care following the in CLEs believe that effective evaluation examination (Buchanan, 1991). of a candidate’s clinical skills requires Whereas some policies are in place an opportunity for examiners to observe that recommend the elimination of the candidate’s diagnosis and treatment patients from CLEs, other ideas have been planning skills, patient interaction and proposed to eliminate the CLE altogether management, and technical abilities and to replace it with other methods of in a real situation (Buchanan, 1991; Pattalochi, 2002). They argue that even though accreditation processes measure the quality of an educational program, 25 Journal of the American College of Dentists 499379:jacd 5/6/11 4:31 PM Page 26

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candidate evaluation such as reliance on covers an equally wide range of topics in their final year of dental school at competency-based educational formats, and is designed to test clinical judgment the University of Minnesota School of use of standardized simulation testing, yet in a case-based forma (Gerrow et al, Dentistry; all other students were excluded. requirement of a year of postdoctoral 2003). The validity and reliability of the One hundred and one students training, development of a third compo- NDEB examination was assessed by were sent the survey instrument and nent to the NBDE, and creation of dental evaluating 2,317 students from 1995 to were instructed to read the consent form, portfolios by graduates (Boyd et al, 2000, and positive correlations exist complete the survey if willing, and return 1996; Buchanan, 1991; Chambers, 2004; between the candidates’ examination the survey to their Comprehensive Care Chambers et al, 2004; Feil et al, 1999; scores and their final grades in dental Clinic group leader, who then returned Formicola et al, 2002; Gerrow et al, 2006; school (Gerrow et al, 2003). the surveys to the primary investigator Meskin, 1996). Due to the complexity in In collaboration with the University (HJC). standardizing treatment difficulty on of Minnesota School of Dentistry, the Although the surveys were anony- patients, there has been an increased use Minnesota Board of Dentistry voted mous, basic demographic information of typodonts in CLEs. Although this use unanimously in the summer of 2009 to including age and gender was collected. does standardize the “patient,” there is accept the results of the NDEB of Canada The students were asked to identify the argument that it does not represent a Examination by dental students from state in which they planned to practice real test of competence (Feil et al, 1999). the University of Minnesota School of and their initial plans after graduation. The advantage of requiring a year of Dentistry, beginning with the Class of Students who registered for a patient- postdoctoral training for new graduates 2010, for initial licensure to practice based CLE were asked to indicate which is that it allows for assessment of compe- dentistry in Minnesota. Minnesota is state or regional CLE they intended to tence using a variety of methods over a the first state in the United States to rec- take and why they registered for that period of time (Formicola et al, 2002). ognize a non-patient-based examination examination. An additional method of candidate as a means of evaluating dentists for All students were additionally asked evaluation comes from a study of licen- initial licensure at the end of their to indicate if they agreed or disagreed sure in Canada. The National Dental predoctoral education. with ethical or other general concerns Examining Board (NDEB) of Canada Senior dental students of the regarding patient-based CLEs. The acts on behalf of the provincial licensing University of Minnesota School of response options were derived using a authorities by examining graduates of Dentistry graduating class of 2010 were five-point Likert scale where 1 indicated all accredited dental schools in Canada given the choice of taking a patient- the student strongly disagreed with the and issuing certificates to those candidates based or a nonpatient-based CLE. The statement, 2 indicated they disagreed, who have met the national standard purpose of this survey was to assess 3 indicated they neither agreed nor (Boyd et al, 1996; Gerrow et al, 1997; what factors senior dental students used disagreed, 4 indicated they agreed, and Gerrow et al, 1998; Gerrow et al, 1998; to decide whether or not to register for 5 indicated they strongly agreed. An Gerrow et al, 2003). Since 1995, the a patient-based CLE. opportunity was offered within the current format of the examination devel- survey for the students to suggest other oped by the NDEB of Canada consists of Materials and Methods concerns or make comments. a combination of a written examination Information gleaned from previous with 300 multiple-choice questions investigations associated with patient- Results and an objective structured clinical based CLEs in dentistry (Buchanan, The total response rate to the survey was examination (OSCE) with 50 stations. 1991; Feil et al, 1999; Formicola et al, 84.2% (85/101). The response rate for The written examination covers a wide 2002; Hasegawa, 2002) and from a focus those registered to take a patient-based range of topics and is designed to test group session with six senior dental CLE was 81.6% (62/76) and for those basic-science knowledge and applied students at the University of Minnesota registered to take the non-patient-based clinical-science knowledge and judgment was used to develop a survey instrument. CLE was 88.5% (23/26) (one student in the areas of diagnosis, treatment The survey was sent to senior dental registered for both examinations). Of the planning, prognosis, treatment methods, students after registration for, but before total respondents, 75.3% were in the 25 and clinical decision-making. The OSCE completion of all components of a licen- to 29 age group and with a male-female sure examination. The inclusion criteria ratio nearly 1:1 (Table 1). Two-thirds of were that the student must be registered the respondents indicated 26 for a licensure examination and enrolled 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:31 PM Page 27

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Table 1. Demographic characteristics of participants in the study

Students Registered for Students Registered for All Students Patient-Based CLE (n=62) Non-Patient-Based CLE (n=23) (n=85) Frequency Percent Frequency Percent Frequency Percent Age (years) 20 to 24 2 3.2 1 4.3 3 3.5 25 to 29 49 79.0 15 65.2 64 75.3 30 to 34 7 11.3 7 30.4 14 16.5 Over 35 4 6.5 – 4 4.7

Gender Male 31 50.0 12 52.2 43 50.6 Female 31 50.0 11 47.8 42 49.4

State of Planned Initial Practice Minnesota 35 56.5 21 91.3 56 65.9 North Dakota 3 4.8 – 3 3.5 South Dakota 3 4.8 – 3 3.5 Wisconsin 3 4.8 – 3 3.5 Montana 4 6.5 – 4 4.7 Undecided 5 8.1 – 5 5.9 Other 9 14.5 2 8.7 11 12.9

Plan After Graduation Private Practice Urban 11 17.7 9 39.1 20 23.5 Rural 11 17.7 4 17.4 15 17.6 Undecided 8 12.9 2 8.7 10 11.8 Military or Public 14 22.6 4 17.4 18 21.2 Health Service General Practice Residency 13 21.0 3 13.0 16 18.8 Specialty Residency 5 8.1 1 4.3 6 7.1

Table 2. Reasons students indicated for registering for a patient-based CLE

(n=62) I am going to take a state or regional patient-based CLE because (select all that apply): Responses Percent I want to keep my options open as to where I may practice. 45 72.6 I have already started and paid for a portion of a CLE. 41 66.1 I am not sure where I am going to practice. 31 50.0 I do not want to study material comparable to parts I or II of the National Board Dental 19 30.6 Examinations again. I am not planning on practicing in Minnesota. 17 27.4 I have patients who are eligible for the CLE. 10 16.1 I believe the National Dental Examining Board of Canada Examination is more difficult than a CLE. 6 9.7 I have been accepted into a residency program in a state other than Minnesota. 6 9.7 I am entering the military, and I do not want my license restricted to practicing in Minnesota. 4 6.5 I do not believe I have ethical issues that concern me. 3 4.8 I believe the current format of CLEs should be maintained. 1 1.6 27 Journal of the American College of Dentists 499379:jacd 5/6/11 4:31 PM Page 28

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they were planning on practicing in respondents strongly agreed). The passing a regional CLE provides. To Minnesota, while the remaining ones ethical issue that least influenced their register for the non-patient-based CLE, a were distributed equally between upper decision was asking someone to be an student would have to be certain they Midwest states and more distant locations, examination patient who was currently were going to practice dentistry in the some of which were due to military or being treated by another provider (1/23 state of Minnesota. The decision to regis- public service commitments or accept- respondents strongly agreed) (Table 3, ter needed to be made by mid-January of ances into dental residency programs. Figure 2). their senior year. At that time, many of All 62 students who planned to take The general issue related to the the students were as yet unsure about a patient-based CLE registered for the patient-based CLE that most concerned where they were going to practice and, Central Regional Dental Testing Service those planning to take this examination as such, wanted to keep their options (CRDTS) examination (Table 2). Two of was the potential that a clinical exami- open for practicing in other states. these same students also registered for nation patient would not show up on Upon completion of a rigorous an additional patient-based CLE, one the day of the examination (52/62 dental school curriculum, students desire with the Southern Regional Testing respondents strongly agreed), whereas to achieve lifetime practice privileges in Agency and one with the Western the general issue that least concerned the profession. Traditionally, in order to Regional Examining Board. When asked them was the ability to secure a dental be conferred this privilege, students why they chose to take a patient-based assistant experienced with CLEs (11/62 have been asked to face ethical issues CLE, the most frequent response was respondents strongly agreed) (Table 4, in patient-based CLEs. Interestingly, the that they wanted to keep their options Figure 3). ethical issue that most concerned the open as to where they may practice in the The general issue that most influ- students in this survey was the operative future (72.6%) and half of the students enced the decision of those who planned treatment of teeth that could be treated also indicated that they were not sure to take a non-patient-based CLE was the more conservatively (Formicola et al, where they were going to practice potential difficulty securing an accept- 2002; National Institutes of Health (50%). Many respondents indicated they able clinical examination patient (19/23 Consensus Development Conference, registered for a patient-based examina- respondents strongly agreed), while the 2001). Evidence-based protocols have tion because they had already paid for general issue that least influenced their caused a paradigm shift to occur from and passed the mannequin portion of decision was the concern that the time the reliance on gross mechanical instru- the CRDTS examination (66.1%) during constraints of the examination could mentation of caries to nonsurgical the junior year of dental school. compromise care for the patient (2/23 intervention with an expectation for For those registered to take a patient- strongly agreed) (Table 4, Figure 4). remineralization (Mount, 2005; based CLE, the ethical issue that most When provided the opportunity to Thompson & Kaim, 2005). The restora- concerned them about taking the exami- suggest other concerns or make com- tive procedures required of candidates nation was having to operatively restore ments, 5 students registered for a in patient-based CLEs may not be in teeth that could be treated more conserv- patient-based CLE and 3 students regis- line with contemporary evidenced- atively (39/62 respondents strongly tered for a non-patient-based CLE added based dentistry. agreed). Least concerning to them was written comments that are listed in The dental students in this survey asking someone to be an examination Table 5. also had ethical concerns about asking patient who was under the care of patients to delay their treatment needs, another provider (8/62 respondents Discussion rendering treatment out of sequence, strongly agreed) (Table 3, Figure 1). The results from the survey indicate that and not being available to the patient for For those who registered to take the students considered a variety of factors follow-up care as they would be graduat- non-patient-based CLE, the ethical issue in ultimately leading them to decide ing. Dental students develop personal that most influenced their decision was whether or not to register for a patient- relationships with their patients and operatively restoring teeth that could based CLE. The opportunity to apply for may find themselves in a predicament be treated more conservatively (22/23 a license in multiple states after passing between their need to secure licensure a patient-based CLE was the primary fac- and what is in the best interest of their tor in influencing the students to register patients. Similarly, patients develop a for a patient-based CLE. 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Table 3. Survey statements regarding ethical concerns of patient-based CLEs

To the following extent, these ethical concerns related to a patient-based CLE affected my decision whether or not to register for a patient-based CLE: Concern that asking a person to be my clinical board patient would cause diagnosed treatment needs to be delayed until the date of the examination Concern that asking a person to be my clinical board patient would cause treatment to be rendered out of sequence Concern asking a person to be my clinical board patient while he/she is currently being treated by another provider Concern about compensating my patient financially for participation in the examination Concern that treatment provided to my patient may need to be redone after the examination Concern that I might not be available to my patient for follow-up care Concern over operatively restoring teeth that other dentists may view as teeth which could be treated more conservatively (e.g., with fluoride application, plaque control, and diet modification)

Figure 1. Frequency distribution on ethical concerns of patient-based CLEs for students registered for a patient-based CLE

Figure 2. Frequency distribution on ethical concerns of patient-based CLEs for students registered for a non-patient-based CLE

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Table 4. Survey statements regarding general concerns of patient-based CLEs

To the following extent, these general concerns related to a patient-based CLE affected my decision whether or not to register for a patient-based CLE: Concern about passing the CLE Concern about the need for a CLE when the accredited clinical curriculum is already competency-based Concern about securing acceptable clinical board patients Concern about the clinical board patient failing to show up on the day of the examination Concern about equipment or other technical failure Concern about following correct procedures during the examination Concern about securing a dental assistant experienced with CLEs Concern about patient-management issues that may complicate the examination Concern that the time constraints of the examination could compromise care for patients Concern that the criteria used to evaluate my clinical judgment and performance are different from those used in dental school

Figure 3. Frequency distribution on general concerns of patient-based CLEs for students registered for a patient-based CLE

Figure 4. Frequency distribution on general concerns of patient-based CLEs for students registered for a non-patient-based CLE

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Table 5. Open-ended statements written by students regarding ethical bond with dental students and may and general concerns of patient-based CLEs sacrifice what is in their best interest in order to help their dental students. Students registered for a patient-based CLE: Several students had concerns about Conflict of interest for CRDTS, financially speaking they make money if we fail. passing a patient-based CLE, not because they thought their clinical abilities were Patient selection is key for this exam! inadequate, but rather due to issues Very concerned with the protocol and the confusion between different written instruc- outside of their control, such as securing tion in the book and instruction in the orientation video. The protocol is too strict and a board-quality patient, having a patient confusing. The procedures don’t concern me, but the paperwork and protocol does. fail to show up on the day of the exami- [I am not concerned about being available to my patient for follow-up care] because I nation, or failing to follow correct chose a patient where this wasn’t a concern. I think the clinical exam is not needed as procedures during the examination. we do it as a competency at an accredited dental school. With the conversion to a competency- (Regarding operatively restoring teeth) This issue is very concerning considering I based curriculum, the need for encountered it numerous times this year. I am concerned about patients being accepted patient-based CLEs has been questioned by board examiners with differences in opinions. (Boyd & Gerrow, 1996; Gerrow, Boyd Students registered for a non-patient-based CLE: et al, 1998; Gerrow, Chambers et al, 1998; Meskin, 2001). You have no control of passing, more in control of patient showing up and qualifying. University of Minnesota students I did not want all the mess of finding patients and all the uncontrollable filters. who took the non-patient-based CLE rep- I am concerned that a license is given to a person based solely on one day’s worth of resented a broad diversity academically ‘ideal’ dentistry, when in fact there are never ‘ideal’ situations. within the class and fared as well as students from Canadian schools. Since this was the first group of students to take the exam and they were self-selected, References they may possess qualities that affected ADEA (2004). Policy statements. Journal their performance unrelated to their aca- of Dental Education, 68, 729-741. demic abilities, such as aggressiveness or Berry, T. G. (1995). The board examination: A true test or only a rite of passage? a sense of responsibility to effect change. Operative Dentistry, 20, 85. Conclusions Boyd, M. A., & Gerrow, J. D. (1996). Certification of competence: A national Within the limitations of this study it standard for dentistry in Canada. Journal was found that although students of the Canadian Dental Association, 62, 928-930. considered a variety of factors in deciding whether or not to register for a patient- Boyd, M. A., Gerrow, J. D., Chambers, D. W., & Henderson, B. J. (1996). based CLE, ultimately, it was the Competencies for dental licensure in opportunity to apply for a license in Canada. Journal of Dental Education, 60, multiple states after passing a patient- 842-846. based CLE that most influenced the Buchanan, R. N. (1991). Problems related students to register for a patient-based to the use of human subjects in clinical evaluation/responsibility for follow-up CLE. Students were most concerned with care. Journal of Dental Education, 55, having to operatively restore teeth that 797-801. could be treated more conservatively Chambers, D. W. (2004). Portfolios for and due to issues outside of their con- determining initial licensure competency. trol, such as securing a board-quality Journal of the American Dental Association, 135, 173-184. patient, having a patient fail to show up on the day of the examination, or failing to follow correct procedures during the examination. ■ 31 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 32

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Chambers, D. W., Dugoni, A. A., & Paisley, Meskin, L. H. (1994). Time for a dental I. (2004). The case against one-shot testing board checkup. Journal of the American for initial dental licensure. Journal of the Dental Association, 125, 1418, 1420. California Dental Association, 32, 243-6, Meskin, L. H. (1996). Dental licensure 248-252. revisited. Journal of the American Dental Collins, W. (1985). Conflicting interests of Association, 127, 292, 294. state boards and the public welfare. Meskin, L. H. (2001). “Freshly washed little Journal of Dental Education, 49, 743-745. cherubs.” Journal of the American Dental Dugoni, A. A. (1992). Licensure—entry- Association, 132, 1078, 1080, 1082. level examinations: Strategies for the future. Journal of Dental Education, 56, Mount, G. J. (2005). Defining, classifying, 251-253. and placing incipient caries lesions in per- spective. Dental Clinics of North America, Feil, P., Meeske, J., & Fortman, J. (1999). 49, 701-723. The restorative Knowledge of ethical lapses and other experiences on clinical licensure examina- National Institutes of Health Consensus procedures required of tions. Journal of Dental Education, 63, Development Conference (2001). Diagnosis 453-458. and management of dental caries through- candidates in patient- out life. Journal of Dental Education, 65, Formicola, A. J., Lichtenthal, R., Schmidt, 1162-1168. based CLEs may not be in H. J., & Myers, R. (1998). Elevating clinical licensing examinations to professional Pattalochi, R. E. (2002). Patients on clinical line with contemporary testing standards. The New York State board examinations: An examiner’s per- Dental Journal, 64, 38-44. spective. Journal of Dental Education, 66, 600-604; discussion 610-611. evidenced-based Formicola, A. J., Shub, J. L., & Murphy, F. J. (2002). Banning live patients as test sub- Ranney, R. R., Gunsolley, J. C., & Miller, L. dentistry. jects on licensing examinations. Journal of S. (2004). Comparisons of national board Dental Education, 66, 605-609; discussion part II and NERB’s written examination for 610-611. outcomes and redundancy. Journal of Dental Education, 68, 29-34. Gerrow, J. D., Boyd, M. A., Donaldson, D., Watson, P. A., & Henderson, B. (1998). Ranney, R. R., Gunsolley, J. C., Miller, L. S., Modifications to the national dental exam- & Wood, M. (2004). The relationship ining board of Canada’s certification between performance in a dental school process. Journal of the Canadian Dental and performance on a clinical examination Association, 64, 98-100, 102-3. for licensure: A nine-year study. Journal of Gerrow, J. D., Boyd, M. A., Duquette, P., & the American Dental Association, 135, Bentley, K. C. (1997). Results of the nation- 1146-1153. al dental examining board of Canada Ranney, R. R., Wood, M., & Gunsolley, J. C. written examination and implications for (2003). Works in progress: A comparison of certification. Journal of Dental Education, dental school experiences between pass- 61, 921-927. ing and failing NERB candidates, 2001. Gerrow, J. D., Chambers, D. W., Journal of Dental Education, 67, 311-316. Henderson, B. J., & Boyd, M. A. (1998). Stewart, C. M., Bates, R. E., Jr., & Smith, Competencies for a beginning dental prac- G. E. (2004). Does performance on school- titioner in Canada. Journal of the Canadian administered mock boards predict Dental Association, 64, 94-97. performance on a dental licensure exam? Gerrow, J. D., Murphy, H. J., Boyd, M. A., Journal of Dental Education, 68, 426-432. & Scott, D. A. (2003). Concurrent validity of Stewart, C. M., Bates, R. E., Jr., & Smith, written and OSCE components of the G. E. (2005). Relationship between perform- Canadian dental certification examinations. ance in dental school and performance on Journal of Dental Education, 67, 896-901. a dental licensure examination: An eight- Gerrow, J. D., Murphy, H. J., Boyd, M. A., year study. Journal of Dental Education, & Scott, D. A. (2006). An analysis of the 69, 864-869. contribution of a patient-based component Thompson, V. P., & Kaim, J. M. (2005). to a clinical licensure examination. Journal Nonsurgical treatment of incipient and of the American Dental Association, 137, hidden caries. Dental Clinics of North 1434-1439. America, 49, 905-921. Hasegawa, T. K., Jr. (2002). Ethical issues of performing invasive/irreversible dental treatment for purposes of licensure. Journal of the American College of Dentists, 69, 43-46. 32 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 33

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Issues A Case of Collegial Communication in Dental and a Patient Who Does Not Pay Ethics

American Society for Dental Ethics Bruce Peltier, PhD, MBA, FACD, Case: Dr. Peltier Alvin Rosenblum, DDS, FACD, This article includes the analysis and Muriel J. Bebeau, PhD, FACD, and opinions of three respected ethicists, Anne Koerber, DDS, PhD one a dentist with 50 years of private Associate Editors practice experience, a second who has James T. Rule, DDS, MS Abstract published groundbreaking research David T. Ozar, PhD Four individuals who teach ethics in dental schools comment on a case in on the moral and identity development Editorial Board which negative financial information is of dentists and other health care profes- Muriel J. Bebeau, PhD revealed by one dentist when transferring sionals, and a third who is a dentist and Phyllis L. Beemsterboer, RDH, EdD records of a potential patient to another a psychologist. All three have taught Larry Jenson, DDS dentist. All commentators find varying extensively at dental schools. Anne Koerber, DDS, PhD degrees of ethical problem with disclosing They respond to a rather simple Polly S. Nichols, DDS, MA such information. Professional codes Donald E. Patthoff, Jr., DDS discourage this practice. All commentators and commonplace scenario in dental Bruce N. Peltier, PhD, MBA stress the importance of the potential practice, one that frequently comes up Gary H. Westerman, DDS, MS new dentist developing a relationship in dental school case discussions as well. Gerald R. Winslow, PhD based on professional standards, with Here is the case: the greatest emphasis placed on the A dentist (DDS1) in a small town Correspondence relating to the patient’s health needs. Several of the Issues in Dental Ethics section of the commentators discuss positive ways of receives a request in the mail Journal of the American College of conducting a patient interview, including from a local colleague (DDS2). Dentists should be addressed to: specific useful language. The request is for the records of a James Rule patient that DDS1 has treated. The 8842 High Banks Drive situation is complicated by the fact Easton, MD 21601 Dr. Peltier teaches ethics at that this patient has an outstanding [email protected] the University of the Pacific, Dr. Rosenblum teaches amount on his account with ethics at the University of DDS1 of $2,100—the last treatment Southern California, Dr. being about a year ago. DDS1 Bebeau teaches ethics at has sent several letters requesting Minnesota, and Dr. Koerber teaches ethics at the payment and has even called University of Illinois, Chicago; the patient to try to collect on the [email protected]. outstanding bill to no avail. Despite these complications, DDS1 sends the records to DDS2 and includes information about the patient’s failure to pay. So, what are the right and wrong things to do? What behavior would be good, bad, better, or best for DDS1 and

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DDS2, not only in relation to the patient, Here is what our analysts recommend. However, the financial information but also with each other? Our experts having been received, and human were asked to respond to the case from Response: Dr. Rosenblum nature being what it is, DDS2 will likely an ethical rather than a strictly legal I have dealt with this general issue on be influenced by the information in point of view. The questions of interest different occasions during my almost some way. With this in mind, what are include these: five decades in private practice. Previous the options that he might consider? 1. What should DDS1 do? treating dentists have told me that a If DDS2 reads the information with • What are her responsibilities? patient I was to see was unreliable with concern, he might reject the patient What should she avoid doing? regard to finances. I have also had completely. Or he might make especially patients who did not meet their financial stringent financial arrangements beyond • Should she have sent the financial obligation to me, and I have had to decide what he would normally impose. He records or not? Should she have whether to share that information might confront the patient, in which sent the entire chart or only the when speaking to a subsequent treating case he would inject himself into the actual clinical treatment notes dentist. Because I consider financial relationship of the patient and DDS1. If and records? information confidential, I take the he were to do that, he might exacerbate • Is it acceptable for her to have position that I do not have the right to an already contentious relationship, “warned” (verbally or in writing) share or receive such information unless perhaps even to the point of involving DDS2 about this patient? An specifically requested to do so by the lawyers. The patient might take extreme example would be the inclusion patient. Also, I do not consider such exception to his personal information of a brief note about this patient’s information when it has been provided, being shared. There is even the possibility payment behavior along with and I do not provide it for others. that the sending of the information by the chart. Once care is agreed upon by the DDS1 was inadvertent or that the finan- • Is it acceptable for her to have patient and by the dentist, the provision cial information in the patient’s record withheld the patient records until of that care is a professional responsi- might even be incorrect or unjustified. she receives payment for the bility. Facts and issues related to fees and Professionalism demands trustwor- services she provided long ago? their payment should be kept separate thiness through actions that are in the 2. What should DDS2 do? What are his from facts and issues related to patient best interest of those in our care. If DDS2 responsibilities? care. I hold that the dentist and the agrees to treat this patient he should, to • Should he speak with this patient patient have two distinct domains of the best of his ability, choose to ignore about the allegedly unpaid bill? responsibility, one to provide and receive the financial information provided. care and the other regarding finances. He should deal with this patient as he • Should he try to ignore any I believe those two domains are would with any other, with reasonable financial information that he mutually exclusive. caution and attention to good business gets from DDS1? For treatment records to be shared practices. For example, if he is wary, • Should he treat or decline to treat with a subsequent treating dentist, it is he can institute a credit check and this patient based on financial required that the patient request such make realistic financial arrangement information from DDS1? sharing. In most jurisdictions that consistent with office policy. • If DDS1 were to have sent finan- requires a written request. In the case It is in our patients’ best interests that cial information or a note to as it is presented, a written request was we never discuss nonclinical information “warn” DDS2, should DDS2 made, though by the dentist and not by about any of them. It would be appropri- speak with DDS1 about the the patient. We do not know any of the ate for DDS2 to call that tenet to the appropriateness of this action? circumstances of the patient’s involve- attention of DDS1. A friendly recommen- • Should he take extra precautions ment in the request, but it seems certain dation that clinical and nonclinical with this patient to ensure that that the patient did not intend that the information should be maintained he receives payment for his financial records be shared. For numer- separately would be in order. services in a timely manner? ous reasons, the records regarding financial arrangements and payment record should be kept separate and remain confidential. 34 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 35

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Response: Dr. Bebeau rebuffed efforts to discuss his reasons for If I were DDS1, I would not have shared not paying suggests some deep discom- the financial information when I for- fort with confrontation. Some might warded the records. Why? Because, label this as a rather passive-aggressive fundamentally, I believe it is a breach of personality. Yet, few of us feel comfortable patient confidentiality. In my judgment, challenging an authority. We recognize a patient has a right to expect that, in that we have no knowledge base upon addition to keeping our relationship which to do so, and so feel uncomfort- confidential, I will not make any dis- able with what may seem to us like a paraging remarks about his oral health confrontation that we cannot possibly status, his inability to modify oral health win from our disadvantaged position. habits, or any other personal shortcom- Whether there is an actual problem with I hold that the dentist and ing or flaw—including what appears the care rendered, pushing the issue is the patient have two distinct to be an inability to discuss either his likely to cause the patient to feel he must unhappiness with the care received defend himself. When pressed to defend domains of responsibility, ourselves, most of us are good at working or the possibility that he has fallen one to provide and receive on hard times and is unable to meet out elaborate and internally persuasive financial commitments. argument to justify our actions. care and the other regarding If DDS1 chooses to communicate From the perspective of DDS1, finances. I believe those because this patient has rebuffed my something to DDS2, as she forwards efforts to engage in conversation about the record she might say: “I’m not sure two domains are mutually the care that may have led him to ___ was satisfied with the care he withhold payment, my first thought received, as I notice he is changing exclusive. would be to wonder in what way I had dentists. If, in the course of your inter- failed him. Perhaps I talked him into action with ___, you discover a source care he really did not want—even if it of dissatisfaction that I could remedy, was care that he needed and was in his and that he would permit you to best interest. Certainly there are persons communicate to me, I would be pleased who habitually take advantage of others, to have that information.” but my job is not to retaliate against The ball is now in DDS2’s court. such individuals. Rather, I need to Will he accept the new patient? How does institute policies in my practice that DDS2 go about the interaction? Does he minimize that potential. And, if I failed simply assume that anyone who makes to recognize a personality flaw in the an appointment and has records trans- patient and extended credit when it may ferred will become a patient? Or, does have been unwise to do so, then perhaps he treat an initial visit as an opportunity I need to learn from that experience. for both dentist and potential patient to I may need to reflect on my strategies explore what it might mean to enter a for eliciting factors that interfere with a care-giving partnership. patient’s ability to exercise his or her Does he reveal that negative infor- personal autonomy. mation was forwarded to him? Again, I Whereas I think DDS1 could ask for think not. The fact that DDS1 violated a small fee to duplicate the records for the patient’s confidentiality does not transfer, in the case of a patient who has mean that DDS2 should reveal the not paid, I would not do so. Failure to dentist’s indiscretion to the patient. pay likely reflects some dissatisfaction Of course, if I were DDS2, having been with the care that was rendered. Perhaps warned might be helpful to me. On the it is simply buyer’s remorse; whatever the reason, the fact that the patient 35 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 36

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other hand, it may subtly bias me as I decision maker, and their available interact with the patient—a bias that the financial resources, including how patient may detect that will interfere accustomed the person is to spending with the trust I hope to establish. money on oral health. Further, if I reveal what I have been told, Category II includes things about I merely reinforce what many patients patients that dentists could influence if tend to believe—“that dentists are all in they have the skill to do so, including cahoots with each other.” Many assume their understanding of the causes and a kind of “gang morality” where profes- prevention of disease; their knowledge sionals engage in activities to protect or perception of general health and oral each other. Some patients even assume health status; their healthcare habits, A patient has a right to that a referral to a specialist is simply a expectations, beliefs, and values; and expect that, in addition to dentist passing a patient on for another finally, the extent to which they see to take advantage of, perhaps even for the dental profession as a trustworthy keeping our relationship a kickback. My job is to reinforce the advocate of society’s oral health interests confidential, I will not integrity of the profession and the and the extent to which they see their integrity of my colleagues. particular dentist as someone who is make any disparaging So, how should DDS2 proceed? In committed to giving priority to their oral remarks about his oral my judgment, DDS2 should proceed as health interest rather than his or her he would with any new patient. In fact, own needs and interests. Many of these health status, his inability some practice management consultants characteristics interact with each other to modify oral health suggest that the office staff introduce the and form significant barriers to patient person as someone who is considering acceptance of treatment. habits, or any other becoming a patient in this office. If Therefore, armed with a kind of personal shortcoming the goal of the practice is to promote template of issues to explore, how should individual responsibility for oral health— DDS2 proceed in his interview with the or flaw. and I hope it is—the dentist will want to patient? Obviously, a first question is systematically identify factors that inter- whether the patient has any immediate fere with patient compliance. Dentists issues that require attention. If the spend a great deal of time diagnosing patient in this case has a concern about oral diseases and contemplating treat- the quality of care that was provided, ment alternatives to promote the he will likely voice that concern at this patient’s oral health. Much of that time point. This is the place for “active listen- can be wasted effort if dentists fail to ing”: “So, you are wondering whether identify and address factors that inter- the care you received met the standards fere with patients’ compliance with you should be able to expect?” Or, “You treatment. I have written elsewhere— are wondering whether you actually based upon many conversations with needed that work?” The goal of active professionals—about two categories of listening is to clarify what the patient characteristics that interfere with com- wants to know without offering any pliance (Bebeau, 1996). judgment. Be sure to ask whether the Category I includes characteristics patient wants you to provide a clinical of patients that the dentist must accom- judgment about that. Don’t say: “Well, I modate, such as their medical and wasn’t there so I can’t judge.” Of course dental health status, their native intellec- there may be things that you cannot tual ability which influences their ability judge based on the clinical assessment to learn, their psychological status as a and review of the records, but frame this as a problem the patient can help with: “If there are questions I have that I can’t 36 answer by looking at your record and 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 37

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examining your mouth, would it be okay about a tooth ache?” “How would you patient to achieve goals. Mention how with you if I spoke with DDS1?” At this judge the status of your oral health? Tell the patient’s current habits are facilitating point, the patient may express some me about the oral habits you have been goals, and indicate any habit modifica- reservation about such contact, and may able to establish for yourself. What is tions that could advance the patient’s be reluctant to tell you why. If this hap- your understanding of the relationship goals, if the patient decides to modify pens, you must point out that the patient between seeing the dentist regularly and them. Next, help the patient evaluate has a right to a second opinion. It may achieving your goals? Between cleaning his or her employee compensation. also be an opportunity to express any your teeth and achieving your goals?” Most patients will have little trouble positive impressions you may have about What the dentist is trying to do at this recognizing that benefit packages are DDS1, and if you are unable to do that, point is to expand the diagnostic assess- not necessarily designed with their to express the general oath dentists take ment to systematically identify factors interests in mind. Helping the patient to put patients’ interests first. You can that interfere with patient compliance. understand the motivation behind the also express your own eagerness to By eliciting understanding, beliefs, and benefit plan counters the tendency to know if a patient is unhappy with some- values, and addressing misconceptions see the benefit industry, rather than the thing and your appreciation when other in the process, the dentist begins to dentist, as the protector of the patient’s dentists have helped you understand a empower the patient to take responsi- interest. Finally, help patients see how patient’s dissatisfaction—dissatisfaction bility for his oral health. By getting investment of personal resources will the patient may not be able to articulate. the patient to articulate goals and to help them meet goals and conserve If the patient does not voice a specific prioritize them, by exploring any mis- personal resources in the long run. Point complaint, a first question might be to perceptions or beliefs about the cause out that many people with good oral explore the patient’s goals. Recognizing and prevention of disease, by uncovering health do not find that it is cost-effective that many patients have not thought in any mistrust—including the belief that to invest in a dental benefit plan because terms of long-range goals, the dentist the dentist is simply there to separate the dental disease does not have the charac- may wish to present a list, asking what patient from his or her money so as to teristics of an insurable risk. is most important: Avoiding the dentist? support the dentist’s lifestyle, the dentist If, at the end of the interaction, Avoiding dental expenses? Getting out of is in a position to clarify the dentist’s the patient has not revealed any prior pain? Being able to chew? Having teeth role. I recommend being explicit about dissatisfaction, has decided to become look good? Improving function? Keeping this: “My job is to be sure you have all a patient in DDS2’s practice, and the teeth for the rest of your life? (It may the information you need so you can matter of the unpaid bill has not been help to have an actual list that can be make, what is for you, a good decision.” raised, I do not think DDS2 should added to.) Often a bit of humor is called And, when the patient asks: “But doc, say: “I see from the records that were for as one reflects on these goals. what would you do?” resist the urge to forwarded that you have an outstanding “Avoiding the dentist” and “avoiding give your opinion. Say instead: “What I balance with DDS1.” But I do think expensive dentistry” can be thought of would do has to do with my goals and DDS2 could say: “Patients change den- as really good goals. “Did you know that values. This decision is about you. You tists for a variety of reasons. What are it is possible?” said that… (restate the patient’s goals) important issues for you?” Once goals have been identified, help was most important for you.” I remember a case my daughter, a the patient prioritize those goals. This is Since money was an issue for this practicing dentist, told me about a few really important because you want to patient, be sure to talk about money. months ago. She received a new patient come back to the patient’s goals as you But I would frame it as examining what who had been a patient of someone discuss treatment alternatives and costs resources are available to accomplish she knew and respected. Records were of treatment. Then, before looking in the the patient’s goals. And, do not let the transferred and she did an initial exam, mouth, ask a series of questions: “What patient’s prepayment plan dictate the which reinforced for her that the patient is your understanding of the causes of treatment. Say: “Let’s examine the had received competent care. She said: dental disease?” What diseases are you resources you have to meet your goals.” “Care to tell me why you are switching aware of? Would you call the doctor at Focus on the most important resource dentists?” The patient related that he the first sign of a cold? Why not? What first: the person’s health care habits. Discuss the extent to which the frequency of dental visits or cleaning is helping the 37 Journal of the American College of Dentists 499379_jacd 5/11/11 4:02 PM Page 38

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was really annoyed by a sudden change met the standards you should be able to in policy in the office. One day he came expect from the profession.” for his appointment and learned that he had to pay for services up front. He said: Response: Dr. Koerber “I have always paid my bill on time and A review of the ethical codes pertaining this really irritated me. I just decided I to dentists reveals some ambiguity in would go somewhere else.” My daughter whether DDS1 breached the rules of commented that his previous dentist ethical conduct. There is universal was really a good dentist and began to agreement in the codes that patient explain why the office may have changed information should be shared with other policies based on the recent economics. providers treating the patient in order The Code of Professional She also mentioned that it may be hard to provide good patient care. The Conduct of the American for front desk staff to remember who ambiguity pertains to whether patient should and should not be asked to pay consent is needed to share patient Dental Association and before service is rendered. The dentist records with another treating dentist the Ethics Handbook for may have simply decided it was best to and what information should be shared treat everyone alike. “Well,” he said, beyond the treatment record. Dentists of the American “that may be true, but I have to say that The Code of Professional Conduct College of Dentists I have learned more in the last half hour of the American Dental Association about the status of my oral health, and (ADA Code) and the Ethics Handbook both agree that patient what I need to do to maintain it, than in for Dentists of the American College information should be all the years I went to that office. So, if of Dentists (ACD Handbook) both you don’t mind, I’d like to stay with you.” agree that patient information should shared for the good of To this my daughter said: “Would it be be shared for the good of the patient. the patient. all right with you if I told your previous Neither requires patient consent for such dentist why you left? I think she would sharing. Neither directly discusses shar- appreciate knowing.” ing information about patient payment This case highlights some of the behavior, but both imply that the infor- challenges in maintaining relationships mation to be shared is for the patient’s with colleagues while giving priority to benefit (not for the protection of either the needs and interest of the patient. dentist). The ADA Code of Professional The challenge in dealing with the work Conduct, 1.B. of the Patient Records of a previously treating professional is to Section, states, “Dentists are obliged to truthfully provide a second opinion on safeguard the confidentiality of patient the work and then to assist the patient records…. Upon request of a patient or in addressing a problem. It may be another dental practitioner, dentists tempting to give the patient information shall provide any information in accor- and leave it to him or her to interact dance with applicable law that will be with the previous dentist. Resist this urge. beneficial for the future treatment of The patient will not be able to deliver the that patient.” “Beneficial for the future objective assessment as well as you can. treatment of the patient” indicates that Further, you owe your colleague your the code’s objective is to benefit the professional judgment. Also, support patient, not to facilitate the collection your colleague. If the work is within the of payment by the second dentist. The standard of care, be sure to tell the ACD Handbook states, “The accepted patient that. “You may not have been standard is that every fact revealed to satisfied with the care you received or the way you were treated, but you should know that the care you received 38 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 39

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the dentist by a patient is, in principle, tion is included in “protected health Ozar’s central values, ranked in subject to the requirement of confiden- information” (Wun & Dym, 2008). Both order of importance, are (a) general tiality, so that nothing may be revealed HIPPA and medical ethics therefore are health, (b) oral health, (c) patient to anyone else without the patient’s more concerned than the dental ethics autonomy, (d) esthetics, (e) dentist’s permission…. This standard has several codes with confidentiality for the patient preferred patterns of practice, and (f) accepted exceptions. It is assumed that regarding sharing information with conservation of resources. The central other health professionals may be told another provider. This greater concern is values are based on obligations widely the facts they need to know about a reflected in allowing a patient to restrict discussed in the medical literature, patient to provide effective care.” a provider’s access to medical informa- obligations to do no harm, to put the Similarly to the ADA Code, the ACD tion, and in specifically limiting the patient’s health needs ahead of the Handbook both upholds the principle information provided to only that which provider’s need for a sale, to allow the of confidentiality, but appears to remove is needed for the treatment. patient control over his or her own it when another treating dentist is con- Since the dental codes are not as body and medical information, and cerned. However, they both imply that specific as the medical codes, I conclude obligations to maintain workable sharing of the information is for the that DDS1 may not be breaking an dentist-patient relationships in order to benefit of the patient, not for the benefit ethical rule of dentistry when she gratu- facilitate the patient obtaining good of protecting the other dentist from a itously shared payment information care. Central values provide guidance patient who may not pay her bill. with DDS2. She may even be in compli- to a dentist’s actions when approaching In contrast, medical codes and ance with HIPPA if her office HIPPA a patient. regulations view confidentiality more policy states that she routinely discloses Considering the disclosure to a stringently. The American Medical all patient information (including patient second dentist of payment information Association affirms in Section 10.01 (4) payment behavior) to other treating in light of the central values, we see that of the Code of Medical Ethics that, “The dentists. However, she certainly is in this action does not affect the patient’s patient has the right to confidentiality. violation of at least the spirit of HIPPA, general or oral health, but certainly The physician should not reveal confi- by providing unnecessary payment affects the patient’s autonomy. One dential communications or information information to the second dentist. might even argue that it could ultimately without the consent of the patient, Putting aside rules for the moment, be detrimental to the patient’s oral unless provided for by law or by the how shall we judge whether DDS1 ought health if it hurts the patient’s trust in need to protect the welfare of the indi- to have provided the payment informa- dentists to the extent that it interferes vidual or the public interest.” The Health tion to DDS2? Although we may not with seeking dental treatment. For these Insurance Portability and Accountability choose to evict her from the American reasons, I conclude that the conscien- Act of 1996 (HIPPA) upholds the impor- Dental Association, we might still ask, tious and professional dentist should not tance of patient confidentiality even to “What should a conscientious, profes- disclose information to another dentist other providers, although it does not sional dentist do in this situation?” This about patient payment behavior unless require explicit consent for such sharing. kind of question is often better addressed the patient specifically consents. HIPPA calls for institutions (which by applying the ethical principles of den- Next, let us consider what the second include dentists’ private practices) to (a) tal practice. Although one could address dentist ought to do when receiving this inform patients of how protected health this problem by considering dentist information from the first dentist. The information is shared with others (if obligations or societal expectations, I most important question to be deter- specific patient consent is not obtained), will apply David Ozar’s Central Values of mined is whether a dentist should use (b) inform patients that they may request Dentistry (Ozar & Sokol, 2002, Chapter payment information when deciding restrictions on the provider’s policies 5). I choose the central values because whether to accept the patient into the regarding sharing of information (that in teaching ethics, I find they often focus practice or in deciding how to behave is, they may specifically refuse to allow the conversation most usefully on the toward the patient. The issue of choosing sharing of certain information with cer- most important considerations necessary patients based on information that tain providers), and (c) that disclosure to uphold professionalism. should not have been shared is not of information should include only the specifically dealt with in dental ethics minimum necessary for accomplish- documents. It would not violate the ment of the task. Furthermore, HIPPA specifically notes that payment informa- 39 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 40

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letter of the ADA Code for DDS2 to refuse would be based on whether the dentist the care he needs and desires. This to accept the patient into a practice, and patient shared an understanding should be done without disparaging assuming the dentist has not yet begun of what treatment would be provided, DDS1 and without indicating that she treatment, because Section 4.A. dealing what the cost would be and the parame- did anything wrong. Further, DDS2 with patient selection specifically says ters of payment. should not use the payment history to dentists may exercise discretion in The next question is, would that dis- scold or otherwise be judgmental or self- patient choice except for certain reasons, cussion include revealing to the patient protective when talking to the patient. and past payment behavior is not one of DDS1’s disclosure of payment informa- The payment history should be treated those reasons. The ACD Handbook tion? Both the ADA Code and the ACD like any other part of the history. states that dentists are not obligated to Handbook include veracity as a value in The second ethical approach would treat everyone, but are obligated to avoid dealing with patients. The ADA Code be to simply have the usual conversation discriminatory actions. In contrast to also states, “Patients should be informed with the patient about what he expects the ADA Code which lists reasons the of their present oral health status with- from treatment, what his previous expe- dentist may not discriminate, the ACD out disparaging comment about prior riences have been, how past mistakes Handbook lists reasons why a dentist services,” while the ACD Handbook could be avoided, and how best to provide may refrain from providing treatment; does not directly address how dentists him with the care he needs and desires, payment behavior and ability to pay should talk about other dentists to but ignoring the past payment history. are not among the listed reasons. In patients. Both the ACD Handbook and The advantage of the first approach summary, it is expected that dentists Ozar & Sokol, in Chapter 3, note the is that it is honest, direct, and transparent. charge for services, but ethics documents obligation of the dentist to strive for the If handled correctly by DDS2, for most are silent on the subject of how dentists ideal dentist-patient relationship. Taken patients this would encourage a frank ought to handle patients with histories of together, these sources suggest that talk and a good resolution without DDS2 nonpayment for dental services, except dentists ought to be honest with patients, either protecting or disparaging DDS1. to say the patient cannot be abandoned. that dentists ought to help patients trust However, the risk is that the patient Although DDS2 may not be violating dentists and dentistry; and that dentists would get angry, either at DDS1 for dis- rules to refuse to accept the patient, he ought not to interfere with the relation- closing the information or at DDS2 for would not be acting ideally either. The ship between a patient and another implying that the patient is a poor billing interactive model, described by Ozar and dentist. The purpose of this set of obliga- risk. Ultimately, the risk is to hurt the Sokol in Chapter 4 of their book as most tions is to facilitate the patient being patient’s future relations with dentists. fully promoting patient autonomy within able to trust dentists enough to form The first option requires good the parameters of acceptable treatment, effective working relationships with communication skills and also requires directs that health professionals ought dentists in order to make appropriate a dentist who is capable of handling to do what is reasonable to form a good decisions and to allow themselves to patients who become angry. The best relationship with the patient, under- receive care. way of handling angry patients is to stand their patients’ concerns, help their The problem comes in deciding how hear the patient out and reflect back to patients make informed choices by edu- honest to be with a patient about another the patient in a nondefensive manner cating them, and negotiate a mutually dentist. What behavior would most facili- one’s understanding of why he or she is acceptable treatment plan. Applying the tate a good dentist-patient relationship? angry. When the patient understands model to this case, we conclude that the I think there are two ethical that the dentist has heard her, then the ideal provider would initiate a discussion approaches DDS2 could take, with one dentist can invite the patient to suggest with the patient about what the patient being probably better than the other, a solution, and begin a negotiation wants from dentistry, what his or her depending on the patient’s characteris- process. This kind of discussion is past experiences and expectations are, tics. The first and most ethical approach difficult and requires practice. It also and what he can reasonably expect from would be to lay out the information pro- requires a dedication to professionalism dental care. The decision whether to vided by DDS1, including the payment and to helping patients feel trust in the accept the patient into the practice history, as part of the conversation about oral healthcare system. If DDS2 does not what the patient expects from treatment, feel he has the communication skills to what their previous experiences have handle the conversation, or if he believes been, how past mistakes could be avoided, 40 and how best to provide the patient with 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 41

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the patient has an emotional problem a stance of being morally superior to to the extent that he will not be able to another. By keeping the communication negotiate the conversation, then DDS2 focused on facts (“My policies are…” is entitled to ignore the payment history instead of, “You shouldn’t be doing information and proceed without dis- that.”), DDS2 may avoid the ones- cussing it. upmanship so often risked in ethical However, in so doing he is missing discussions. Since the case description an opportunity to help the patient repair suggests that DDS1 is likely to be in relationships with dentistry and learn violation of HIPPA, she might welcome how to work with a dentist. In addition, it being brought to her attention. he is running the risk that the same situation may repeat itself with him, and Summary and Conclusions: The most important he will be forced to deal with it while Dr. Peltier pretending that he does not have the Three senior dental ethicists agree question to be determined prior history. I think this puts DDS2 in an that disclosure of negative financial is whether a dentist should ethical bind that ultimately jeopardizes information to a dentist who is about to the relationship with the patient. begin treatment of a previous patient use payment information I am not worried about repercussions is a bad idea. when deciding whether to for DDS1 by disclosing the action to the Dr. Rosenblum is the most direct, patient, as long as DDS2 simply men- writing that the clinical and financial accept the patient into his tions the disclosure in the context of the aspects of dentistry represent two mutu- practice or in deciding how other information obtained, without ally exclusive domains. He asserts that labeling it as “unethical.” If DDS2 handles because “financial information is confi- to behave toward the patient. the situation correctly, there will be no dential,” DDS1 has no right to share adverse effects on the patient of DDS1’s this information without explicit patient disclosure (that is, the patient will be permission. His point of view is supported able to negotiate treatment with DDS2 by the American Dental Association’s so there would be no real damages), so document on patient records which the patient would have little reason to states that: “No financial information act against DDS1. should be kept in the dental record. A further issue is whether DDS2 Ledger cards, insurance benefit break- should discuss DDS1’s release of payment downs, insurance claims, and payment information with DDS1. There is an vouchers are not part of the patient’s obligation to discuss ethical concerns clinical record. Keep these financial with a colleague who is not behaving records separate from the dental record” optimally. Admittedly this discussion (ADA, 2010). would be difficult. DDS2 would want to Given such guidance it appears that avoid scolding or shaming DDS1, but the inclusion of financial information in both dentists could conceivably benefit any packet sent to the new dentist would from an open discussion of the most involve the addition of information to ethical way to handle the situation. that patient’s actual dental record. While DDS2 could approach it by sharing with we can fairly assume patient consent to DDS1 what his own policies are with release treatment records in this case, it regard to disclosing patient information, is not safe to assume that this patient and state what his concerns are with disclosing payment information, and leave it to DDS1 to use the information as she sees fit. The communication danger arises when one person is taking 41 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 42

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has consented to the release of the and dental care, as well as a way to negative payment history. Who knows enhance professional relationships what a patient thinks about this matter? between dentists in town. She advocates One must wonder about what active listening and thorough discussions motivates DDS1 to send payment infor- about treatments, choices, and payment mation. Is she seeking retribution from options. She also makes the point that this patient? Does she feel a powerful the sharing of patient financial informa- sense of loyalty to DDS2 or to her tion in the service of doctor well-being colleagues in general? Is she trying to only serves to confirm the impression strengthen her relationship with DDS2 of some patients that dentistry is more There is one potentially or polish her reputation with her like a guild than a profession and that colleagues? It is difficult to imagine that dentists look after each at patient expense. positive way to view she is motivated by an interest in her Dr. Koerber examined several ethics transmission of payment patient’s well-being when she decides codes and formal documents to come to send financial records. to the conclusion that communication information, and that is All three commentators—Rosenblum between doctors is to be done for patient whether this information most directly—make the important point benefit, not for the convenience or well- that nothing is known about the specific being of dentists. She asserts that shared causes a clear and circumstances of the financial situation. information should be limited to the effective discussion Perhaps there was an error in accounting. minimum amount needed for treatment. Maybe this patient’s dental plan has That said, the standard of care implies about the costs of new not upheld its end of the bargain or is that when records are sent those records treatment, possible dithering. It is also possible that there ought to be complete, so it makes no was unclear communication between sense to remove components of a patient financial arrangements, DDS1 and her patient, and now the record before sending it out. This is or expectations for patient refuses to pay for something that certainly true in legal situations. in his view was not agreed upon. Dr. Koerber writes that the act of both parties in advance Dr. Bebeau is also very clear. She views sending financial or payment informa- of treatment. the sharing of financial information as tion is likely to be a HIPAA violation “a breach of patient confidentiality.” or at the least a violation of the spirit of Her view is that patients have a right HIPAA. She also notes that the release of to expect that dentists will not share financial information violates Ozar and disparaging remarks about patients with Sokol’s hierarchy of professional values, each other. Also, while acknowledging and concludes that DDS1 should not the possibility of patient grifting, she do so without explicit patient consent. views the payment delinquency as part She writes that “the conscientious and of a larger treatment problem, a commu- professional dentist should not disclose nication issue, or as an indication of information to another dentist about undisclosed patient dissatisfaction. On patient payment behavior unless the a positive note, she sees the situation as patient specifically consents.” an opportunity to enhance the doctor- While the commenters are unanimous patient relationship and to increase the in their opinion that negative financial patient’s understanding of oral health information should not be forwarded, they did not mention a darker possibility: In small town America the negative opinion of one dentist could effectively make it impossible for a patient with a

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“bad reputation” to find dental care in but only as exceptions to the norm. simply use the term “decide to treat” that town. While unlikely to happen, Weak financial practices and unclear or “agree to treat” or “decline to treat” such an event seems completely at financial communication open the door in its place? Words matter. odds with any reasonable definition of to ethical problems. The question of interests is key in a profession. There is one potentially positive way this case, and the sharing of information The experts are less clear about other to view transmission of payment infor- between dentists is considered unethical questions in this case. As a group they mation to DDS2, and that is whether when the primary motivation is to equivocate as to whether DDS2 should this information causes DDS2 to engage serve the interest of dentists, especially speak with DDS1 about the propriety in a clear and effective discussion with when done without the knowledge of of having sent the financial records. this patient about the costs of new treat- a patient. ■ Dr. Rosenblum suggests a “friendly ment, possible financial arrangements, recommendation from DDS2 to DDS1” or expectations for both parties in References about the matter. Dr. Koerber advocates advance of treatment. Such a discussion American Dental Association, Council on Dental Practice, Division of Legal Affairs a discussion between the two dentists might actually enhance future treatment. (2010). Dental Records. Chicago, IL: The while acknowledging the delicacy of The management of this case Association. the situation. requires careful communication between Bebeau, M. J. (1996). Managed care: They alluded to the impact that dentists and patients. It is important Maintaining professional autonomy. old payment information might have to recognize Koerber’s and Bebeau’s Connecticut State Dental Association Journal, 72, 18-21. on the new treating dentist. It would implicit recognition of how difficult it is be impossible to remove that negative to “do the right thing” during discussions Wun, E., & Dym, H. (2008). How to imple- ment a HIPAA compliance plan into a information from one’s mind once it of thorny issues. Simply knowing what practice. Dental Clinics of North America, registered. Who could blame a dentist to do and having good intentions is 52 (3), 669-682. for taking special care to avoid being often inadequate because it is so uncom- burned by such a patient? fortable to bring up difficult issues. The commentators did not address Sometimes this happens because dentists the issue of withholding all the records just do not know what to say or how to until this patient cleared the bill, perhaps do it. Koerber and especially Bebeau, because such behavior seems so clearly give specific helpful suggestions about wrong and typically illegal. Here is what how to bring up difficult issues along the ADA Code says about this matter: with examples of what to say. “Upon request of a patient or another There is one last issue worthy of dental practitioner, dentists shall provide comment, and that is the use of the any information in accordance with term “accept” when used to mean that a applicable law that will be beneficial for dentist decides to take on the treatment the future treatment of that patient…. of a patient. This term, and its polar This obligation exists whether or not opposite, “reject,” imply that the dentist’s the patient’s account is paid in full.” practice is something like an exclusive One hopes that this case represents or private club and that patients must an isolated incident in DDS1’s practice. submit themselves for acceptance if they Frequent occurrences of this sort would expect the profession to provide dental call the dentist’s financial practices into treatment. This is unseemly and can question. Allowing patients to incur sub- serve to put the public off. Why not stantial debt generally does no one any favors in the long run. Dental practices are not banks, and dentists are not in the business of loaning money to patients. Occasional problems with missed pay- ments or even the necessity to “write off” a debt now and then are expectable, 43 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 44

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Decision Making

David W. Chambers, EdM, MBA, t is late Thursday afternoon in Kansas could be a month or perhaps even six PhD, FACD City. Three dentists are engaged in months to get the model and color he Iweighing important and complex really wanted, so Dr. C went with green. Abstract alternatives. Dr. A is at a board meeting Only one of these dentists made a A decision is a commitment of resources of her component society. A community decision, and right now he is probably under conditions of risk in expectation health project that the society funded drawing admiring glances as he drives of the best future outcome. The smart six months ago is being critiqued. Dr. A with the top down five miles an hour in decision is always the strategy with the best overall expected value—the best notes that she should have been given the evening rush-hour traffic. combination of facts and values. Some more attention when she pointed out of the special circumstances involved in when the program was first reviewed What is a Decision? decision making are discussed, including that, even if successful, the society would A decision is a commitment of resources decisions where there are multiple goals, be criticized because it is sponsored by under conditions of risk in expectation those where more than one person is a group known to be advocating for of the best future outcome. Dentists A involved in making the decision, using trigger points, framing decisions correctly, expanded functions. Now it looks like and B were not making decisions because commitments to lost causes, and expert the project might be a success. There is they committed no resources. They are decision makers. A complex example of also a possibility that the size of the just exploring the nature of a problem. deciding about removal of asymptomatic budget may not be large enough to carry The community project that Dr. A is third molars, with and without an EBD the project through to completion as critical of has already been funded. Dr. search, is discussed. proposed and the group will be back for B is debating the academic merits of a more funds. treatment procedure, but not actually Dr. B is a graduate student in the treating anyone. Only Dr. C committed prosthodontics program at Thursday’s resources to one alternative over another lit review seminar. The debate is hot in hopes of being better in the future. and furious. There are advocates for and Decision making entails risk. Risk is against an experimental procedure. a technical term for a degree of doubt The literature is inconclusive and some somewhere between absolute certainty of it provides a field day for the method- and randomness. Swerving to avoid a ological purists. The term “EBD” flies head-on collision is not so much a around the room. Dr. B managed to decision as an obviously appropriate find a large critical review based on a response under the circumstances. meta-analysis of more than 60 studies Deciding how fast to drive on that road that shows a measure of effect of almost in light of suspected hazards is a decision. .80 for one procedure. The opposite extreme from certainty is Dr. C is inspired. For almost no randomness: the condition where noth- reason in particular he walks into the ing is known that favors one alternative Porsche dealership and purchases a over the other. Picking the winning British racing green Carrera. He might numbers in the lottery is pure chance. have preferred red, but the dealer said it Flipping a coin is not decision making (although choosing to settle an issue by the flip of a coin may be). Decision 44 making takes place in that range of 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 45

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probability between certainty and Christian life is certainly a decision in complete uncertainty. That is what makes the full sense of the concept. So Pascal it a human act. Idiots can be trained to reasoned: either there is an eternity of A decision is a always pick the right course of action bliss that can be won by sacrifice in when there is only one alternative and the present life or there is not. The commitment of resources when all options are equally likely. alternative way of viewing the situation under conditions of risk Half the money market managers involves getting as much as one can in outperform the median every year. The life because there is nothing after that. in expectation of the others go to courses in the Bahamas Theologians to that point in history had best future outcome. on how to explain away chance poor engaged in endless and useless debates performance. Managers make decisions over how to establish the likelihood that —they commit other people’s resources there is an afterlife. Pascal’s insight was under conditions of risk—but success to say that it did not matter what the should not be measured by the outcomes. probability of an afterlife was. This is a common misconception regard- Here is how he reasoned. The expected ing decision making. The standard is value of a selfish worldly life is whatever whether a prudent person would have can be expected hereafter plus what can made the same decision under similar be grabbed right now. Let’s say we are circumstances. Every dentist understands pretty certain there is no afterlife and the difference between bad treatments that we can profit at the expense of and bad outcomes. Sometimes the best those suckers who defer to us now in that can be done, even the best that a hopes of a later reward (as in fact the team of experts can do, turns up with German philosophy Friedrich Nietzsche unwanted outcomes. That is what it claimed). The alternative involves multi- means to commitment resources under plying the probability that there is an conditions of risk. Although there are afterlife by the value of such an afterlife no guarantees in decision making, there should we be right. The probability of a are approaches that are more defensible glorious hereafter might be rather small, than others. but eternity is a long time to enjoy one’s blessings. An infinite eternity of bliss Expected Value multiplied by any small probability is The Frenchman Blaise Pascal (1623-1662) still infinitely large. Pascal’s Wager states wondered about philosophy and mathe- that as long as there is any finitely small matics during the period in European probability of an infinite rich afterlife it history known as the Age of Reason. A exceeds the expected value of a highly devout Catholic, but a critic of dogma, probable small and fixed payout for a he combined his intellectual interests in material existence. what has come to be known as “Pascal’s Wager.” Whether one should lead a

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Personably, Pascal’s logic is unsatis- than the greater risk of not getting the There is also a special kind of flaw fying to me because it crowds out the preferred color. in expected-value calculations where vital role of faith. But his analysis of The next time you find your mind the probabilities and the values are con- decision making has become the standard wondering in a meeting because the founded. Outcomes are often devalued in Western thought. Small chances on conversation is going in circles between because they are thought to be unlikely large rewards are worth taking; so are advocates of one alternative or another, or probabilities are exaggerated, or nearly sure bets on small outcomes. The try this little experiment. Check to see because they are discounted because of best commitments of resources under whether one side is arguing the high the consequences of the outcomes. This conditions of risk involve high probabili- value of this or that outcome and the failure to independently estimate proba- ties and high payouts. Stupid folks fuss other is arguing the high probability of bility and value is called the Aesop effect over long odds on small prizes. something else. Each side is playing with by game theorist Ken Binmore. He has This is called expected value logic. It half a deck and hoping the other side in mind Aesop’s fable of the fox who is very simple. Multiply the value of an does not realize it. tried unsuccessfully to jump up to reach outcome by the probability that it will The expected value formula with its a cluster of grapes. The fox ended by occur. EV = Pr * V. That is just another distinction between probability of an walking away muttering that the “grapes way of saying that the value of what you outcome occurring and the value of the were probably sour anyway.” The are looking for is adjusted proportionally outcome should it occur sheds some bioethicist Robert Pellegrino cautions to reasonable expectations of obtaining light on common mistakes in decision against confounding values and proba- it. This formulation meets the criteria for making. People who have inaccurate bilities in the other direction. He says a decision because it addresses both views of either the probability or the it is unethical to “shave the facts” so future benefits (V) and risk (Pr). All that value of alternatives are called fools. others will be prejudiced toward the is necessary is that resources be commit- That is a technical term. They may make outcome one favors. “It is not right to tee to alternatives. This is accomplished very rational choices between alternatives say that something is probably so just by calculating the expected value of the but they have distorted the way things because you want it to be.” available alternatives, including doing are in the world and they must bear the nothing, and committing to the one penalty for their foolishness. The world Some Issues in Decision Making with the largest expected value. is well stocked with fools. People who Although the basic model for decision To my mind, there is something have the facts of the matter right, who making is surprisingly simple, there inherently wonderful about this. The have pretty accurate estimates of both are more than enough complications expected value formulation insists that the probabilities and the values, but to confuse us. Some of these, such as we cannot make good decisions without are incapable of performing the logical single-issue thinking, incomplete fram- paying attention to both facts and values. calculations needed to fairly weight the ing, and sunk costs, are poor strategies Dr. A was concentrating on value alternatives are called irrational. The on the part of the decision maker. Multi- outcomes associated with the community technical term for a person who acts objectivity, multiple decision-makers, project. She compared several alterna- contrary to his or her rational calcula- and trigger points are inherent in the tives as if they were actually certain to tions is akrasia. It is not as common as nature of some types of decisions. occur or had already occurred. Dr. B foolishness, but people do say things was concentrating on probabilities. like, “I have seen the evidence that Multiobjectivity Techniques were compared only on the treatment X is not effective, but I still find Picking a restorative material for a basis of statistically significant probability it a useful procedure in my practice.” If particular patient’s situation is not auto- without consideration of the cost or you want to check for irrationality in a matically easy, despite what evidence- benefit to the patient and the practitioner meeting, try paying particular attention based information one has at hand. But of following that line of treatment. Only when an expert presents the results these benefits do not naturally cluster Dr. C weighed the full expected value of a survey. When the numbers strongly together. The restoration should be of his choice. He went with the high suggest a course of action that is uncom- aesthetically acceptable, long-lasting, probability second choice of color rather fortable, you can expect to hear all sorts and low cost. The evidence might exist of excuses such as “the sample size could to pretty precisely indicate the probability have been larger, we can’t trust those of satisfying each of these criteria and folks, or that doesn’t square with my 46 impression or the experience of my three best friends.” 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 47

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the value of each is known to be high. ance patients to no patients, we would But breaking the problem into three be irrational to prefer no patients to separate decisions does not look to be a fee-for-service patients. And that is why realistic alternative. This is the multi- some dentists take insurance. The only objectivity problem in decision making. way to escape this type of logical order- Often, we are seeking a single action ing in multiobjectivity is to invent special designed to satisfy more than one goal, circumstances that differ across the and often the actions that maximize one alternatives. Some people are experts at goal compromise another. such creative stage-setting. “Honesty is Multiobjectvity problems are the best policy, except when…” addressed by focusing on the values, not Multiobjectivity is sometimes impli- the probabilities. Better science is not the cated in a maddening game called “avoid It is human nature to answer in this case. What is required is all loss.” Here is how the game works. make faux decisions; finding some way of comparing apples The patient says, “I really value the bene- and oranges. The values must be weighted fits you describe for the new crown. But they are safer than the on a common dimension. We need the I also do not want to spend more than real kind. equivalent of a method for comparing $750. If you could find some way so that this fruit salad with the other. I did not have to take a hit on the cost, Multiobjectivity is a central problem this would be an easy decision.” This in economics and several methods have patient is refusing to make a realistic been developed for managing the prob- and required value trade-off. He or she is lem. All of them involve asking potential looking for a decision that has no down decision makers to make a series of two- side. Lest we mistakenly believe that alternative choices and then assembling only others do this, listen carefully in the these choices into a pattern. Economists next meeting you attend. There is bound call these patterns utility curves, and to be an individual, and often it is the they might result in value profiles such same individual across meetings, who as the following: Mr. X would be indiffer- blocks progress toward a common solu- ent between closing his diastema and tion by coming back repeatedly to the being given $800 and he would be indif- down side of a decision where overall ferent between having a flat-screen TV the best alternative is clear. These folks and being given $1,200. So Mr. X should are not decision makers; they are worry be indifferent between a lottery where warts, often assuming a probability near he has a two-thirds chance of winning a 1.0 for all possible down side outcomes. TV and having a dental procedure with a Decision making is about finding the best; 100% probability of closing the diastema it is not about holding out for the perfect. (1200 * .67 = 800 * 1.0). Naturally, we do not go around Multi-person Decision Making performing such calculations on our When there are multiple goals involved spreadsheets and working things out to in a decision, it is often possible to work the third decimal place. But there is out the best alternative by considering abundant evidence that all of us are trade-offs. When there are more than intuitively fairly consistent in making two people involved in making the deci- the kinds of choices implied by multi- sion, the way forward is not so obvious. objective value trade-offs. The economist Kenneth Arrow has As long as the circumstances remain actually proven that there is no method stable, rational individuals retain consis- tent ordering among their preferences. If we prefer fee-for-service patients to insurance patients and we prefer insur- 47 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 48

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that will always work. (By contrast, circumstances, we will…” or “You can with any two people trying to make a count on me to do this…” Decisions mutual decision among two strategies, involve action, not just judgment. We it is always possible to find an optimal could save ourselves time and be a lot way forward.) less annoying to others if all exercises in So here are some suggestions that decision making began with a frank usually help. Make certain that issues of assessment of whether this is really our probability and values are kept distinct. problem, whether an action must be Probabilities are the kinds of things that taken now, and whether we are prepared lend themselves to averaging. After full to take any actions. Only the actions we disclosure of evidence and discussion, are warranted for and willing to take “It is not right to say have those participating write down should be allowed to enter the discussion. their independent estimates of the prob- All the rest is grinding our teeth about that something is abilities involved. Take the average. It how we feel or showing off our academic probably so just because will almost always be better than even insights. (Of course, we need chances to the best guess of the best expert. Do vent and to strut and it is so hard to get you want it to be.” not attempt to reach consensus (also these venues on the agenda.) known as coercion by the most confi- I like the image of the trigger point. dent), and make sure you are averaging This is not about waving a gun around the probabilities and not the outcomes or even taking aim; it is about pulling (probabilities multiplied by values). the trigger. There is a zone of emotion Values are harder to manage in these that leads up to the trigger point. We settings because people do not like to express concern, we weigh emerging admit that they are revealing their consequences, we build coalitions, and personal preferences. This takes we take positions. But until we actually patience, a non-judgmental environment, commit resources, we are not in the and gentle questions to draw out the zone of action. implications and possible overlaps Often the best decisions are those among what people want. Often, in the that clearly articulate a trigger point process of estimating probabilities and before the pressures of the situation clarifying values, the dominant commit- either allow passion to provoke an over- ment of resources under conditions of reaction or allow fear to cover the case risk emerges spontaneously. If not, vote with indecision. A pre-defined action on the top two alternatives. Do not let is a good kind of decision. Oral surgeons someone make a motion for yes or no have many such decisions covering on a single strategy they think is the patient heart rate, color, and breathing. will of the group! Periodontists and orthodontists have such trigger points defined as pocket Trigger Points in Decision Making depths or landmark angles that automat- It is human nature to make faux decisions; ically initiate treatment. they are safer than the real kind. A faux Of course, there are second-order decision sounds something like this: decisions about whether to execute “the right thing to do under the circum- previously made decisions; there are also stances would be…” or “someone really decisions about the extent to which we ought to do something about…” A real should follow through on any decision. decision has this form: “Because of the There are even cases where merely expressing a position can amount to a commitment of resources. In some countries around the world, posting an 48 e-mail message with an opinion about 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 49

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the government may have serious conse- screenings such as PSA are discussed table—what do they add to what has quences. Voicing certain opinions about rather than the total consequences of already been decided? dental policy in some groups may also their use or disuse. America did the Good money after bad or escalating be tantamount to shortening one’s same thing after 9/11. Air miles were off commitment to lost causes is a regret- career in organized dentistry. Social by 18% during the three months follow- tably common effect. Candidates who events in conjunction with meetings are ing the tragedy. No one died flying and have no chance of winning, plans that useful for snooping out which resources that was celebrated. The increase in car looked good before circumstances are safe to commit. traffic fatalities during this period (since changed, programs that should not have driving is intrinsically more dangerous) been funded in the first place but are Partial Framing from “playing it safe” by not flying was back for that last dollar needed to push Group decisions are hard to make and 5,000, with 45,000 serious injuries. All things over the top, and all manner of personal decisions tend to come unrav- of the consequences of action and alter- remedial activities should be viewed as eled over time because of the way they are natives must be considered in framing new endeavors when each decision is framed. The frame is how the decision a decision. made. The primary reason for escalating is conceived. Alternative framings of the commitment to lost causes actually is same problem or different ways of Commitment to Lost Causes wound up in decision making. As long breaking it into component parts can Decision making is about the future. as resources are still being spent on lead to different outcomes. A common mistake is to count the total strategies that would not be chosen Consider the case of deciding cost of alternative strategies, when only under present circumstances, the original whether to restore a tooth that appears the marginal cost matters. This is known decision makers do not have to admit to be carious or restoring the same tooth as the sunk-cost problem or the problem that they made the wrong choice. following caries risk assessment. These of escalating commitment. certainly are not the same decision, Take the case of a broken down Expert Decision Makers even if we assume that the dentist and molar. It started as a nice filling that Decisions tend to repeat themselves, or patient share common values about the was ruined by recurrent decay. A large parts of them do, and they can spin out desirability of treating infected teeth. restoration and a build-up were per- into sequences where one part of the Practitioners who agree on the wisdom formed, perhaps a crown. The tooth decision depends on what has happened of caries risk assessment may still dis- continues to decline, and a decision is before. Our experience of encountering agree on the threshold for restorations. due. Endo and a crown are a possibility, fragments of decisions that we master Those who have a common threshold and so are extraction and an implant. and then apply in novel situations is a may disagree on whether testing is The correct decision is between the likely blessing. That is why master clinicians worthwhile in a particular case. There future cost and probability of success of know that the presentation of a case are three components to the decision in the two alternatives, without considera- may be slightly different from textbook this situation, depending on whether the tion whatsoever for the previous work descriptions and that patients who say decision is framed as treatment, testing, done. Some might be tempted to say that that want one thing sometimes end by or a combination of testing and treat- so much has already been invested in wanting another. Chess experts beat ment. When smart and well-meaning the tooth that it would be a shame to novices more because they have seen professionals disagree on a decision, abandon it. That is wrong: the previous patterns of moves before rather than the most likely reason is that there is a effort is sunk. It will make exactly the because they “think more moves in framing problem. They are not actually same contribution to the present decision advance.” Decision making is a learnable making the same decision. regardless of which alternative is selected. skill. But the learning is largely situation- Manipulating the frame is the This is a new way to think about margins specific. We cannot make better decisions essence of propaganda. Antifluorida- (in the economic or decision-making by taking drugs or having our brain tionists and antiamalgamists point to the sense). The only relevant considerations cells pump iron, but with years of experi- devastating consequences when things in decision making are the marginal ence we can improve the accuracy in go terribly wrong, but do not consider contributions of the alternatives on the estimating probabilities and deepen our the entire situation. That is the way understanding of what is valuable to malpractice lawyers make a living. Only ourselves and others. More experienced the upside of drugs such as Vioxx and individuals make better decisions. 49 Journal of the American College of Dentists 499379:jacd 5/6/11 4:32 PM Page 50

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Decision Tree

An Example gery. We will even agree on a cost for the Let’s first consider the basic decision The expected value formula has the surgery and a future cost should eventual appearing in the shaded area. This is advantage of being precise rather than problems arise. Just to make the case a the decision whether to remove the fuzzy. It also provides a means for bit more interesting, we will let the asymptomatic molars based on what the addressing complex problems. It can practitioner decide whether to engage in dentist already believes about the case. even reveal assumptions that make a search of EBD literature to confirm or These beliefs include that, under ideal the true problem obscure. The follow- disconfirm a supposition that this type circumstances, there will be no future ing example, diagramed above, is of patient has special circumstances that complications and that the patient will complex, but instructive. This is called alter the probability of future complica- incur no costs (loss of value). But there a decision tree. tions. The probabilities are all given in is a 5% chance of complications even if A clinician must advise a patient precise decimal form. The costs are in the molars are removed. The probability who has asymptomatic third molars, but arbitrary units, but they are intended to be of complications without surgery is with some potential for future complica- proportional to each other. If the values three and a half times greater (Pr = .175). tions, whether to have the teeth removed are multiplies by $100, the example The cost of the complications is ten times prophylactically. To make the decision seems to make sense to most readers. as great as the cost of the surgery (-1 easier, we will set in advance the proba- (This matter of scale has no effect on and -10, respectively in arbitrary units). bilities of future complications and the decision.) All costs are expressed as Thus, there are four possible assume that there are none in the sur- negative numbers; the goal is to pick the sequences of events: (a) no prior infor- commitment of resources under these mation (the dentist is working with conditions of risk that minimizes cost. 50 2011 Volume 78, Number 1 499379:jacd 5/6/11 4:32 PM Page 51

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estimations of averages from experience the EV of the future condition given no To evaluate the decision regarding and chance reports), surgery, but future surgery (-1.75). The patient can see in search or no search, the probabilities of complications anyway; (b) no prior this complete framing of the decision finding hoped-for results and costs of the information, surgery, and no complica- that the cost is greater than just the search must be added in. The chances tions; (c) no prior information, no cost of the surgery, but all costs and of the no surgery (-1.25) outcome are .2, surgery, and future complications; and probabilities considered surgery is the and the changes of the survey (-1.50) (d) no prior information, no surgery, wise decision. outcome are .8, and the certain cost of and no complications. The best outcome Notice that in working this example, the search is -.1 (the weighted average). is the last one: if it turns out that way, we move from right to left, combining So the EV of the decision to search, there is zero cost. The worst outcome is probabilities and values as we get closer under the assumptions the dentist makes complications despite the surgery. But to the actual decisions that can in this example, is -1.50. That is the we cannot pick the outcome we want; we be controlled. same expected cost as calculated for the can only select the strategy most likely Now let’s make the example more no search case. But the extra cost of -.1 to lead to the best outcome. realistic. All patients are not the same, for the search must be added back in, The circles, by convention in such perhaps there is information that would making the search just a bit less attractive tree diagrams, represent events in permit the dentist to customize the than going with the given information. nature, to which probabilities must be estimate that the patient will suffer the The decision tree for the value of assigned. The EV for each circle is the condition in future. For the purposes of a search is illustrative. Looking for weighted average of the product of the this example, think of the dentist delay- information is not costless, nor is it probability and the cost for what nature ing matters a bit and conducting an guaranteed to produce useful results. deals out under the circumstances (-10 * EBD literature search in hopes of getting These parameters must be estimated in .050 + 0 * .950 for the case of surgery better estimates of the probabilities advance to determine whether the and -10 * .175 + 0 * .825 for no surgery). involved. Information searches are not search is prudent. Low-cost searches on Preparing for the future condition by naïve shots in the dark; a prudent practi- high-likelihood and highly impactful means of surgery looks very attractive tioner would not go off looking just on outcomes are wise. Just looking to see because its EV is small (less anticipated the off chance that something useful what can be found is not. This example cost) than the no-surgery approach. might turn up. So we will make some is written for a single search, and, The squares, by convention in such assumptions to aid the decisions: the presumably, the search cost could be tree diagrams, represent events over new information cuts the probability of skipped when treating future patients, which we make decisions. Just as complications without surgery from .175 making the search a slightly favored probabilities are assigned to all circles to .125 (from three and a half times as strategy. On the other hand, the example (nature), costs are assigned to all likely as with surgery to two and a half is useful as a template for recurring squares (decisions). In this case, the cost times as likely), there is a two-in-ten diagnostic costs such as biopsies. of the surgery is -1 unit, and this must chance that such studies will be found, Having a worked basic decision tree be added to the expected outcome of the and the cost of the search is -.1. such as this is also a valuable general pair of alternatives on the top of the This branch of the decision tree is decision tool. One can substitute various shaded area—situations when surgery is shown on the top of the diagram. The plausible values in the decision tree to performed, but not to the two alterna- lower part, where the search turns up see to what degree the assumptions tives on the bottom because the patients no new information, is the same as the would have to change in order to justify skips the surgery. All in and all done, shaded area, where no additional infor- making a different decision. Decisions surgery is a slightly better decision mation was assumed, except that an that remain the same, despite large because it has a lower expected cost. extra -.1 in cost has been added because variations in some of the parameters The EV of the surgery (-1) plus the EV of the fruitless search. But if the infor- (probabilities or costs), are said to be of the future condition given the surgery mation is found as hoped, as shown by “robust” decisions. ■ (-.5), combined expected cost of -1.5, is the top four paths, the best strategy for less than the EV of no surgery (-0) plus the patient is no surgery, taking chances on the better odds of being free of future complications (-1.25).

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Binmore, Ken (2009) individuals and when there is risk Rational Decisions* involved in the outcomes of their choices”. Princeton, NJ: Princeton University Press. Games are situations where individuals ISBN 978-0-691-13074-3; 200 pages; seek to maximize their utility by initiating about $30. strategy in the face of a generally known structure with uncertainty introduced by Straightforward language: devilishly others’ strategies or by unknown states difficult concepts. A nice introduction of natures. The book describes games to the role of personal preferences, risk, under increasingly complex sets of probability, and decisions that are based assumptions: zero-sum, non-cooperative, on other decisions. Filled with examples cooperative, n-person games with possi- of what appear to be easy choices that bilities for coalition, and group decision turn out to be common blunders. making or the impossibility of a com- pletely satisfactory welfare distribution. Selected Leadership Essays in Although written in the 1960s by a UC The literature on decision making this journal. These are available online. Irvine and a Harvard professor, it tends to be technical. There is a American College of Dentists→ remains the classic reference in the field. large literature on how individuals Home/General →Publications→ actually make decisions. This leader- → JACD Previous Issues: Keeney, Ralph L., & Raiffa, Howard ship column, and consequently the (1993) references mentioned below, are Chambers, D. W. The mumpsimus about how individuals should make [leadership essay]. Journal of the Decisions with Multiple Objectives: decisions. Each is about three pages American College of Dentists, 2003, Preferences and Value Tradeoffs* long and conveys both the tone and 70 (1), 31-36. Cambridge, UK: Cambridge University content of the original source through Chambers, D. W. The value of information Press. ISBN 0-521-43883-7, 570 pages; extensive quotations. These summaries [leadership essay]. Journal of the about $15. American College of Dentists, 2003, 70 are designed for busy readers who The classic work in the theory of (3), 50-55. want the essence of these references in values as part of decision making. The twenty minutes rather than five hours. Chambers, D. W. Behavioral economics theory of trade-offs to combine multiple Summaries are available from the [leadership essay]. Journal of the objectives is developed in detail and is ACD Executive Offices in Gaithersburg. American College of Dentists, 2009, applied to cases where there is certainty A donation to the ACD Foundation of 76 (4), 55-64. (no risk) and where there is risk. $15 is suggested for the set of summaries Chambers, D. W. Risk management Rather technical, but filled with detailed on decision making; a donation of [leadership essay]. Journal of the case examples. $50 will bring summaries for all the American College of Dentists, 2010, 2011 leadership topics. 77 (3), 35-46.

Luce, R. Duncan, & Raiffa, Howard (1957) Games and Decisions: Introduction and Critical Survey.* New York, NY: Dover. ISBN 0-486-65943- 7; 509 pages; about $12. “Our primary topic can be viewed as the problem of individuals reaching decisions when they are in conflict with other

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