Business science and evidence-based decision making
2021; Elsevier BV; Volume: 160; Issue: 2 Linguagem: Inglês
10.1016/j.ajodo.2021.03.011
ISSN1097-6752
Autores Tópico(s)Meta-analysis and systematic reviews
ResumoI read with interest 2 excellent articles in the December issue of the American Journal of Orthodontics and Dentofacial Orthopedics; that is, a Guest Editorial by Dr Ernst M. Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar ("An argument for healthy skepticism in orthodontics") and a Letter to the Editor by Dr David W. Chambers2Chambers D.W. Shifts in the continuing education model.Am J Orthod Dentofacial Orthop. 2020; 158: 777Abstract Full Text Full Text PDF Scopus (1) Google Scholar ("Shift in continuing education model"). Both authors argued for increased attention to evidence-based science in continuing education and residency training programs. Despite the evidence-based science, the authors believe there is a focus on anecdotes and weak clinical studies used to promote the marketing and selling of orthodontic products. Both are condemnatory of the emphasis on business science. Chambers2Chambers D.W. Shifts in the continuing education model.Am J Orthod Dentofacial Orthop. 2020; 158: 777Abstract Full Text Full Text PDF Scopus (1) Google Scholar writes, "Clinical studies based on bits of evidence, often out of context, are now being added to continuing education programs… there is more to be made from selling products than understanding orthodontic outcomes." Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar adds, "Has business science clouded all of our ability to be perceptive evidence-based clinicians?" Furthermore, Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar believes that healthy skepticism of the "fake news" involves clinicians and orthodontic residents developing and exercising the skill of discernment, which relies on the ability to think critically. Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar said that discernment is "… the quality of being able to grasp and comprehend what is often obscure, even the ability to decide between fact and error." He adds, "… lack of discernment will lead to a multitude of sins, the consequences of which will, ultimately, come to haunt us." In addition, Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar claims that some orthodontists "…have long forgotten, or have never been taught, the time-tested fundamental principles of orthodontics, of which the most frequently ignored are the limitations of the denture." Let us now consider Drs Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar and Chambers'2Chambers D.W. Shifts in the continuing education model.Am J Orthod Dentofacial Orthop. 2020; 158: 777Abstract Full Text Full Text PDF Scopus (1) Google Scholar points further, as they relate to the contextual environment of orthodontics, sociability in orthodontics, evidence-based decision making, dental and resident education, and foundational principles. There is an alarming concern that orthodontists are losing claim to their specialty. The landscape of orthodontics has certainly changed and continues to evolve. There is much competition for orthodontic patients that is driven by the participation of corporate practices, do-it-yourself orthodontics, entrepreneurial orthodontists with multiple offices, nonorthodontists doing orthodontics and in particular using clear aligners, an influx of new orthodontic graduates, use of 3-dimensional printing to manufacture appliances, marketing and direct mailing of appliances to customers, and so on. Much has been written about these encroachments on the so-called traditional orthodontic practice. Parenthetically, if one looks at the above-cited competitive environment of orthodontics, with few exceptions, it is orthodontist competing against orthodontist. Even in corporate orthodontic practices, are not "real" orthodontists providing the treatments? "We have met the enemy and he is us."3Kelly W. "We have met the enemy and he is us".https://improvegovernment.org/wp-content/uploads/2016/07/Position-Paper-AIG-April-2016.pdfGoogle Scholar This point has to be considered when setting up the American Association of Orthodontists marketing advocacy programs that inform the public of the benefits of receiving orthodontic care from a certified orthodontist. These contextual forces, as well as the significant indebtedness of recent orthodontic graduates, have led orthodontists to consider the business and economic side of orthodontics over the professional and service side. Whether orthodontists work on their own, for others as independent contractors, as associates, or in a corporate practice, all have a heightened desire to make money. This could lead to over treatments and attention to products, treatments, and procedures that bring in the most money, albeit at the expense of considerations for science and evidence. There is the human need for fellowship and camaraderie, which is often displayed by belonging to a group. This is true for orthodontists as well. Among other things, belonging to a group gives a sense of worth. In some instances, however, group loyalty can suppress the thinking and reasoning of the individual. By this I mean, there are certain tenets and principles that groups espouse, and the followers accept. Whether it be a study group or more formal venues such as professional organizations, associations, and societies, all those in the group pledged allegiance to that group's precepts. Those who most uphold the doctrines of the group are the ones who are most respected. Indeed, an orthodontist's practice and treatments clearly reflect the ideas of the group, and this is irrespective of clinical science and evidence. Is there a gullibility pandemic going on in orthodontics? If we rightfully demanded science and evidence from our infectious disease experts during the coronavirus disease 2019 pandemic, why will we not demand the very same standards for orthodontic clinical decisions? The nebulous, intangible notion of evidence-based science is pitted against the visible, hyped-up, sensationalized convictions heralded by the orthodontic vendors, key opinion leaders (KOLs), and their journal magazines. These intuitively appealing notions and pseudoscience are spun into a web of deceit by the charlatans of orthodontics. Victims are typically mesmerized by an item of fact intertwined with a sense of reasonability. Once captivated, apocryphal notions are then espoused about a product, regimen, theory, or teaching. The spurious claims marketed by the pretenders for "the biggest and the best" are without evidentiary support and focus their assertions on "cherry picked" case reports and anecdotal evidence. This has fostered a following devoted to fabricated falsehoods. Let me be clear, not all companies and KOL's are guilty of advancing unproven claims to sell products, and I would like to believe that this is the exception rather than the rule. Furthermore, it would be foolish to think that all orthodontists and graduate orthodontic residents will follow the evidence-based decision-making teachings, even when well delivered (ie, "I know what I like and I like what I know!"). As Dr Johnston facetiously said, "When everything 'works' and nobody dies, evidence-based practice is for many an unnecessary elaboration that serves only to interfere with the orderly flow of commerce."4Johnston L.E. 21st century orthodontics: when everything works, can anything matter?.Semin Orthod. 2019; 25: 307-308Abstract Full Text Full Text PDF Scopus (2) Google Scholar Similarly, it has been professed that the success of orthodontic treatment is not proof of the correctness of treatment. That is, most orthodontic treatments are successful to the extent that the outcomes of treatment are an improvement over the pretreatment conditions. However, was the treatment "correct" from the perspective of efficiency, effectiveness, and risk-reward? Related to risk-reward, did the treatment cause any harm (ie, decay, decalcification, periodontal disease, root resorption, worsening of the face, dehiscence, fenestration, etc). On the reward side, did the treatment provide a benefit in regard to stability, function, dental esthetics, facial balance, health-related quality of life, and so forth? It should be pointed out that not all orthodontic clinical decisions can be "evidence-based." For some gray areas of orthodontic clinical practice, there is little to no evidence in which to base judgments. Some examples of these muddled areas are early treatment, direct vs indirect bonding, 2-step retraction vs en masse retraction, what constitutes good orthodontics, open bite treatments, and so on. In these incidences, orthodontic clinicians have the freedom to choose a course of treatment on the basis of low-level evidence, experience, or logic. Animus and vitriol exchanges should not ensue among orthodontic brethren over who has the best remedy for clinical decisions in a murky area of orthodontic practice. It is discomforting when practitioners express a sense of superiority in presuming that their way is the preeminent and only way in these uncertain areas of orthodontic practice (ie, "whoever does not practice the way I do, is not as good an orthodontist as I am"). I close this section with a quote from St Augustine related to differing religious views, but his words are applicable to our discussion: "In essentials unity, in non-essentials liberty, and in all things love."5Saint Augustine of HippoThe Confessions of Saint Augustine. Project Gutenberg, Salt Lake City2002Google Scholar The views promulgated in the repositories of Drs Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar and Chambers2Chambers D.W. Shifts in the continuing education model.Am J Orthod Dentofacial Orthop. 2020; 158: 777Abstract Full Text Full Text PDF Scopus (1) Google Scholar are certainly not new. The cry for science and evidence-based decision making dates back to at least the 1920s. In his 1926 report on the condition of dental education in the United States and Canada, William Gies6Gies W.J. Dental Education in the United States and Canada. Carnegie Foundation, New York1926Google Scholar petitioned for university-based education over the existing forms consisting of preceptorships and proprietary schools. He called for university-based dental schools to foster the principles of science and evidence. It was hoped that the introduction of problem-based learning (PBL) and case-based learning in the mid to late 1980s would help to promote critical thinking in the predoctoral dental school curricula.7Rinchuse D.J. Zullo T. The cognitive level demands of a dental school's predoctoral, didactic examinations.J Dent Educ. 1986; 50: 167-171Crossref PubMed Google Scholar,8Rinchuse D.J. Zullo T. Rinchuse D.J. The cognitive level demands of the National Board Dental Examination.J Dent Educ. 1987; 51: 543-545Crossref PubMed Google Scholar Critical thinking skills developed in the predoctoral dental school curricula would then be meliorated in the postdoctoral dental school curricula. In theory, this was a good initiative, but based on the way it was approached, it fell short of expectations. To explain, dental schools' plan for the delivery of PBL was to merely add several courses to the existing curricula that had literature reviews and group-type interactions and titled them PBL. To truly develop critical thinking skills in dental students, evidence-based learning needed to be expansive and more than adding a few PBL sessions. Dental educators needed to possess the pedagogic skills to provide higher-level cognitive learning in every aspect of their teaching, such as learning objectives, teaching sessions, and evaluations (examinations), according to Bloom's Taxonomy of Education Objectives.9Bloom B.S. Taxonomy of Educational Objectives. Longman, New York1956Google Scholar It is not good enough to teach for knowledge and understanding. Dental educators must develop critical thinking skills in students so they can apply knowledge as well as analyzing, synthesizing, and evaluating information.9Bloom B.S. Taxonomy of Educational Objectives. Longman, New York1956Google Scholar Knowledge that cannot be applied is useless. Einstein has been quoted as saying, "Education is that which remains after one has forgotten what one has learned in school." It is the concepts that remain and an attitude that allows receptivity to new ideas. Obviously, orthodontic graduate programs have to teach some aspect of evidence-based science and decision making as required by accreditation standards (American Dental Association Commission on Dental Accreditation). However, do educators teach enough of this, and is this aspect of an orthodontist's clinical decision making evaluated and rewarded (eg, ABO Board Certification)? In the teaching of research and evidence-based decision making, there needs to be a teaching of epistemology (how knowledge is acquired), as supported by eclectic, heuristic, and PBL. These steps may better prepare graduates to possess the skills of discernment and critical thinking as advocated by Dr Taeger.1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar Parenthetically, discernment can be considered by some as a gift that some have, and others do not have. In this regard, educators may only be able to impact some learner's ability to discern and to a limited extent. In addition and contrast, it would be foolish to think that educators can teach gullibility "out of" any student. Common sense is not so common. There will always be those in a society who believe alternative facts, but this should not be the rule as it applies to a specialty. Aristotle has said, "It is the mark of an educated mind to be able to entertain a thought without accepting it." As mentioned earlier, orthodontic residents, along with existing practitioners, need the knowledge and skill to identify spurious claims of charlatans, product manufacturers, those KOL's with conflicts of interest, product and treatment-oriented study groups, op-eds, and hyped-up propaganda-type magazines. There needs to be a focus on how knowledge is acquired which pits science against the unscientific ways knowledge can be acquired, such as tenacity, rationalism, authority, intuition, and empiricism.10Helmstadter G.C. Research Concepts in Human Behavior: Education, Psychology, Sociology. Appleton-Century-Crofts, New York1970Google Scholar,11Rinchuse D.J. Rinchuse D.J. Kandasamy S. Evidence-based versus experience-based views on occlusion and TMD.Am J Orthod Dentofacial Orthop. 2005; 127: 249-254Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Of course, the scientific method uses the above listed unscientific ways in various manners in its protocol(s) but not as the determining factor. Dr Alex Ditmarov12Ditmarov A. How to win orthodontic patients and cash in on ignorance?.orthodonticgrammar.comGoogle Scholar listed 10 "tongue and cheek" ways to build wealth in orthodontic practice at the expense of truth and professionalism. His list includes: advertising as a nonextraction orthodontist, using a superior or magical appliance, becoming a discipline of some pseudoscience school, becoming a friend with airway, and so on. An example of a tactic used by the charlatan is the Galileo ploy (ie, people of Galileo's day mocked and laughed at him, as well as Columbus and Copernicus). We wrote an answer to this thinking in one of our articles, "They also laugh at clowns in the circus."13Rinchuse D.J. Sweitzer E.M. Rinchuse D.J. Rinchuse D.L. Understanding science and evidence-based decision making in orthodontics.Am J Orthod Dentofacial Orthop. 2005; 127: 618-624Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Be reminded, the burden of proof for claims of miracle products, treatments, and cures are in the hands of those making the claims, not the critics! Perhaps the American Association of Orthodontists, among other considerations, could gather a team of prominent orthodontic clinical scientists to develop an evidence-based program that all graduate orthodontic programs could use. This program should discuss ways to recognize deceptive claims of orthodontic hucksters. Dr Taeger1Taeger E.M. An argument for healthy skepticism in orthodontics.Am J Orthod Dentofacial Orthop. 2020; 158: 775-776Abstract Full Text Full Text PDF Scopus (1) Google Scholar suggests that orthodontists get back to the basics and look to the foundational principles of clinical orthodontics, the least of which is the strict limits of the denture. As an orthodontic resident in the mid-1970s under the tutorage of the late esteemed orthodontic professor, Dr Viken Sassouni (Chair and Program Director at the University of Pittsburgh), I was taught the need to extract teeth to not violate the arch perimeters as nature established for each patient; the immutability of the arch width of the mandibular canines. We residents needed to have study models present at the chairside for each patient. We then had to form each patient's archwires to correspond to the patient's original archforms. This was done out of a straight wire, not starting with a generic preformed archwire. The only resilient wire we had back then for initial leveling and aligning was Twist-a-Flex wire (not nickel-titanium wires) made from bundled small steel strains woven into a single wire. Even these wires had to be individually shaped. All this in an effort to preserve each patient's pretreatment archforms. When examining a new patient with crowded teeth, an often-asked question is, "Can I squeeze all the teeth in with a little IPR (interproximal reduction) and some expansion?" The answer to this question was, most often, yes. But the more important question is, should I? To wit, will I cause more harm than benefits as it relates to stability, facial and dental esthetics, and dental and periodontal health? After 45 years in orthodontic practice, I can honestly say I have lamented the extraction of teeth for only a few patients. In contrast, I have regretted not removing teeth for many, many patients. Orthodontic educators and students alike should reflect on the teachings of our eminent nonexpansion orthodontic pioneers such as Drs Alan Brodie, Charlie Tweed, Hayes Nance, Alton Moore, and Dick Riedel, to mention a few. Although the outlook for orthodontics and especially private practice may appear bleak, there is the anticipation that we have seen our darkest moments. It has been said, "The night is darkest just before the dawn" (Batman-The Dark Knight, 2008). As the onset of a new day comes forth, we have the opportunity to determine if the day will bring sun or storm. We look toward a rainbow of hope that will guide our future. However, we are at an inflection point of choice. On the one hand, we can let the competing, contextual, and economic forces of the marketplace of orthodontics play out, unhindered, and accept the consequences as they may be. Or, on the other hand, we can take a preemptive stand and discover ways and strategies to tip the odds in our favor. When the specialty is ready, orthodontic heroes will appear. Let those in our specialty with the profiles in courage necessary to change the direction of our specialty step forth, and let the journey begin!
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