KDA Today

KDA Today

For Immediate Release

Date: Aug 14th, 2015
Contact: Dr. Beverly Largent
Phone: 800-292-1855
Email: info@kyda.org

First, Do No Harm?

A few months ago, I spent four days wearing a saucer-sized contact in my left eye to protect the cornea following a self-inflicted, sizeable corneal abrasion. One does feel foolish admitting to the ophthalmologist, that while placing mascara, my hand slipped. I did not admit that I was using a new-fangled mascara wand that vibrates! For over 40 years, for most days of my life, I have attempted to enhance my modest lash endowment with various brands and colors of “goop”. Only this year have I had a problem, or at least one that caused me to cancel patients, call in favors and make a trip to the physician’s office. Such an incident causes one to self-evaluate, and while I was assured that this is a common problem, it did cause me to question my eye-hand coordination. Was I losing it? Was this a freak accident? Am I competent?

Questioning competency in a dentist can arouse an emotional response. I recall a conversation with a colleague a few years ago discussing what we planned to do when we were too old to adequately perform dentistry. He expressed to me that he wanted to stop using his hands when he was at the top of his game and then start to share the knowledge he had gained in his years of practice. He was a much loved former educator and planned to return to his first love, teaching pediatric dental residents. He recommended that I make similar plans. Sadly, his health took an unexpected decline, he was forced to leave his practice without warning and he was not capable of pursuing another career in education. He did spend some time at the very end of his career with his hygienist, basically in a supervisory position. We never discussed the definition of “old” or the definition of clinical competency, or their relationship, if any. I often wonder if he recalls that conversation and if he believed he was a good dentist during his last months of practice.

State boards license new dentists who have passed examinations to prove their knowledge and clinical skills. Most dentists in Kentucky have been examined by the Southern Regional Testing Agency, whose mission is to “provide valid, reliable, legally defensible examinations and results while striving to implement new testing methodologies in a candidate friendly environment for the next generation of dental professionals.” (srta.org) The duty of state boards is to regulate the profession of dentistry and protect the public. This involves “licensing and registering qualified practitioners, (and) setting standards for the issuance and renewal of licenses and registrations.” (dentistry.ky.gov/board/) The state board enforces the laws of the Commonwealth, and in general, attempts to ensure competency by requiring and tracking continuing education of the dentist. Rarely does continuing education require any clinical training and most of us have NEVER had our clinical abilities evaluated after our board experience. Is this a problem? Are we capable of self-evaluation and self-improvement? Can we critically look at what we do and strive for better, or are we stuck in the swamp of complacency? Does our clinical performance improve the oral health of our patients and our communities?

These questions have haunted our profession. Of the nine dental specialties, all but one require recertification. Diplomate status is generally awarded after specific testing and qualifications have been met. During the 1990s, most of the specialties began issuing time limited certificates, requiring a recertification process. This is an effort to maintain high quality board certification and keep certified members on the cutting edge. Diplomates with a lifetime certificate are usually grandfathered and are not required to complete a recertification exam. Obviously, the recertification process does not address the older Diplomate or a specialist who does not choose to participate in the board certification process. The Academy of General Dentistry is a major provider of continuing education for the general dentist. Each member’s continuing education is tracked and status levels awarded, accordingly.

In an effort to ensure quality and respond to the Institute of Medicine for quality measures in dentistry, the ADA established the Dental Quality Alliance. The mission of the DQA is to advance performance measures as a means to improve oral health, patient care and safety through a consensus building process. (ada.org) Membership of the DQA is broad, including specialty organizations, AGD, numerous councils of the ADA and public health. The greatest challenge of the DQA is that there are very few evidence-based guidelines, limited knowledge of outcomes, limited diagnostic data to establish oral health benchmarks and limited access to claims data. (DQA Guidebook)

So, in summary, the Institute of Medicine has called for quality measures in Dentistry. The profession is attempting to answer this call on many levels, but the fact is we cannot measure quality until we can define quality, and there is very little science to support definitions of all treatments. Just when I think I have a handle on competency in dentistry, the AMA discusses the need to test their senior physicians. One in four practicing physicians in the US is over the age of 65. They, too, have licensing requirements and continuing education requirements, but this discussion centers on mental and physical competency, as well as treatment outcomes. The AMA admits that outcomes may require such testing on all members. The latest ADA report which gives complete data for 2013, indicates the number of practicing dentists in the US over the age of 65 is 14%. That seems like an advantage until the physical requirements of dentistry are considered. Physicians with poor vision or poor manual dexterity could likely be competent physicians. No so with dentists.

So, as I reflect on my self-assessment, I realize that competency is not age dependent. Certainly, age is a factor; it is well known that, in general, our skills diminish with increased age. Without a doubt, dentists are judged by their clinical skills. As a profession and as individuals we will be judged by how well we follow guidelines, especially evidenced-based guidelines. We will be judged by patient satisfaction and how we improve the oral health of those persons in our care. As a newly minted dentist or a seasoned practitioner we must be prepared for these evaluations. The days of “Primum non nocere” (first, do no harm) have long passed.

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