Gawande’s rules

by Barry F. Polansky, DMD

A glance at the top of the page reveals the category of my column in Dental Economics^®: High Trust, High Performance. That is the topic my editors felt confident giving me to write about since I wrote a book on the very mundane subject of “the art of the examination.” You don’t see very many books written for dentists that do not discuss some kind of treatment. Treatment is generally commensurate with production in dental practice, and production is one thing most dentists have on their minds when they go to work every day. I always felt that the examination was the gateway to comprehensive dentistry, and the more masterful I became at the examination, the more capable I would be at doing highly productive, meaningful comprehensive dentistry. Productive and meaningful could lead to a more fulfilling career.

Dentistry is an art. I don’t necessarily mean art in terms of how good one is with one’s hands, but rather art as an expression or application of human creative skill and imagination. Art by this definition requires more than just good hands. It requires a good mind and heart as well ... some might call it the art of clinical judgment. Another way to express this art would be to practice at the highest levels of trust and performance. Many of the articles I have written for this magazine have been related to high trust and high performance. Sometimes I feel like a lone voice in a world where so many are concerned with bottom-line dentistry.

High trust can only be accomplished through the development of strong relationships with patients. You don’t get to do very meaningful dentistry on a consistent basis without high trust. I have always said that trust is the highest form of human motivation. You don’t get to do very productive dentistry without a good track record, and that means high performance. In most industries, high performance is measurable. Many, many years ago, improving their levels of trust and performance rewarded dentists. Over the last 20 years in both medicine and dentistry, there has been a fundamental change in the approach professionals have taken. Bottom-line dentistry and evidence-based dentistry have undermined the human factor in health care and hurt the art of clinical judgment.

But I see a light at the end of the tunnel.

Voices of opposition are rising up to criticize our current health-care situation. Many of my mentors through the years told me to be patient with our system. America is a self-righting system, and in time, through freedom of expression, things change. This past summer saw the release of Michael Moore’s documentary, Sicko, which takes on our health-care system. I was never a fan of Moore, but this movie does a nice job (not completely accurate) of exposing some of the problems we have with the system. Even more importantly was the release of two books by physicians that became bestsellers. Dentists will enjoy both How Doctors Think by Jerome Groopman, MD, and Better - A Surgeon’s Notes on Performance by Atul Gawande.

In the latter book, surgeon Gawande, writing about the field of medicine, tells us, “The social dimension turns out to be as essential as the scientific.” Both authors discuss the value of the softer skill sets that separate the very best doctors from the mediocre. Many parallels can be drawn to dentistry. Both books have chapters devoted to an examination process that helps to create better diagnoses, and both emphasize very subtle human communication skills. I enjoyed both books, but then I would, as someone who has been writing about these things for years. Hopefully these voices will lead us into the future of health-care reform as the voices of the professions.

Gawande sums up his book by asking health-care professionals to become positive deviants. As a lifelong deviant, I am certainly in favor of that. What he means by a positive deviant is that so many of us fall into a mode of work that we can’t get out of ... we become like everyone else. In the end, he claims, we all ask ourselves if our work really matters. As an answer, he likes to give medical students five suggestions for how to make a worthy difference, or what he calls a positive deviant. I was so impressed with these suggestions that I now call them Gawande’s Rules. Let’s explore them and see how they can work in dentistry.

Rule No. 1 - Ask an unscripted question. Many dentists come to my practice to observe my examination technique. Many of them leave telling me that they do it exactly as I do it. But they don’t. This seems quite easy, but it’s not when your mind is on the mouth, your next patient, and the task at hand. For many, it’s medical history, dental history, and chief complaint, but there’s so much more to the examination than that. Some consider this “small talk.” Some dentists aren’t interested in making this type of connection. They just want to look in the patient’s mouth and get on with it.

I ask unscripted questions all the time. Just this morning I had a new patient who seemed distant and in a hurry. During my initial approach I noticed how well developed his shoulders looked. I asked him how often he went to the gym. Once that horse got out of the gate, the exam flowed like butter. When he left, he grabbed my hand like he knew me forever. Ah, the power of human connection. The first time Sherlock Holmes met his lifelong friend, Dr. Watson, he opened the conversation by exclaiming, “So it seems you’ve been in Afghanistan?” Totally unscripted. Gawande tells us, “If you ask an unscripted question, the machine begins to feel less like a machine.”

Rule No. 2 - Don’t complain. We all know how trying dentistry can be. Most of us work alone, with no one to complain to, and we certainly know there is a lot to complain about: difficult patients, staff members, and the war in Iraq. It’s so easy to fall into this trap. Most of us don’t have coaches who can help us get back on track when we start to complain. Stealing a page from Dr. Groopman’s book, he tells us that how much we “like” our patients actually affects our ability to diagnose. He sites statistics revealing that many misdiagnoses come when the doctor doesn’t like his or her patient.

Rule No. 3 - Count something. In other words, become a real scientist, not just an economist. Most dentists count what I call the big three: production, collection, and new patients. I understand these numbers are important to the business of dentistry, but if you want your performance to get better, it may be a good idea to measure something more meaningful. Gawande tells us, “It doesn’t really matter what you count. You don’t need a research grant. The only thing is that what you count should be interesting to you.” Obviously when you count something that’s interesting to you, you will learn something interesting. How many teeth do you restore that come back sensitive? What’s the track record of a certain cement? How many patients say “yes” to comprehensive treatment? How many times do you use an endo instrument before it breaks? Imagination is the key here.

Rule No. 4 - Write something. Never underestimate the power of writing. I carry index cards with me wherever I go. I am constantly taking notes. I transfer my notes into a journal that I keep. Writing allows you to get all of your feelings on paper. It also lets you chronicle the way each day goes and helps you to stand back from your practice and make necessary changes. The Pankey Institute’s new curriculum includes journal writing, so students can record all of their goals and progress. Who knows, maybe you could start a patient newsletter with your writing.

Rule No. 5 - Change. Dentistry has changed through the years. Gawande advises us to become early adopters of change. You don’t have to jump onto every new thing that comes along, but have an open mind. Don’t resist positive changes. How many of us are still not accepting implants? Or veneers? Look for opportunities to embrace change. Sure, mistakes will be made, but we can learn and grow from our mistakes. His final words are: “Find something new to try, something to change. Count how often you succeed and how often you fail. Ask people what they think. See if you can keep the conversation going.”

Barry F. Polansky, DMD, practices in Cherry Hill, N.J. Author of the book, The Art of the Examination, and publisher of “Dental Life,” he is on the visiting faculty of the Pankey Institute. E-mail him at [email protected].