Honesty is such a lonely word – Billy Joel
Bias and integrity are strange bedfellows. They are two qualities that we speak of in absolute terms although there is no absolute measure for them. Both qualities force us to look at ourselves critically, an exercise often avoided because all too often we end up not liking what we see. In the end they are opposing forces; the more you have of one, the less you have of the other.
Last year in these pages, a terrific article about the effect of cognitive biases on decision-making in dentistry by Dr. Mark Douglas appeared. He wrote about four different biases, but Confirmation Bias is the one most applicable to this discussion. Also last year in these pages, I wrote an editorial about fairness in the scrutiny of sedation/anaesthesia for dentistry. Specifically, I was concerned about the fate of dental practitioners who as part of a team, oversee sedation/anaesthesia and perform dentistry. Both pieces challenge biases; both pieces challenge us to have more integrity.
There are at least three provinces (Alberta, Saskatchewan and Ontario) that are currently revising their guidelines for the practice of dentistry with sedation/anaesthesia. Ideally, these guidelines, would be about three pages long. My ideal document would have just three statements (wrapped in lots of trust): 1. choose your patients carefully; 2. stick to what you know; 3. do it properly.
In the province of Alberta, the Alberta Dental Association & College (ADA&C) has decided to effectively take deep sedation and general anaesthesia out of dentistry. Separate, medical anaesthesiologists could do it. Why the change? Ostensibly to provide patients with safer services. I’m all for improved safety in sedation/anaesthesia for dentistry. I applaud the integrity of that ideal. However, a closer look at this decision and the process that led to it reveals many biases.
Last Fall, I was contacted by the Chair of the ADA&C’s Sedation Omnibus Committee (SOC) for my view on some parts of the practice of sedation/anaesthesia for dentistry. The discussion started off on best practices to ensure patient safety, then it zeroed in on the procedure of endotracheal intubation. The lead-in was whether or not I thought that intubation was an essential skill for the practice of deep sedation/general anaesthesia (DS/GA). My response was that I thought that it was a default skill that anyone trained in deep sedation and general anaesthesia would acquire through their training program; I didn’t like the word “essential”. There is a minimum number of intubated cases required in training programs, and that criterion is easily met during the normal course of participation in all accredited postgraduate programs. After a few hundred intubations, the skill becomes like riding a bike; over time without practice your skill level may decrease but you’ll never go back to not knowing how to do it.
I’ll condense the rest of my hours-long conversations: I didn’t agree to the idea of using the singular skill of intubation (or any other singular skill) as a qualifying measure to maintain the privilege of providing DS/GA; the committee’s medical anaesthesiologist focused on how many intubations should be done in order to continue to qualify as a DS/GA provider. The stated fact that intubation is not required even in Advanced Cardiac Life Support protocols was ignored. The stated fact that intubation, as a procedure has an adverse-effect probability, which means that it should be done only when indicated was ignored. The stated fact that the safety record for procedural team anaesthesia in dentistry is better than the safety record for medical anaesthesia was ignored. The stated fact that sedation/anaesthesia for dentistry is different than sedation/anaesthesia for medicine was ignored. The beat went on; a practitioner’s ability to continue to deliver DS/GA was to be tethered to performing a certain number of intubations over a set period of time.
At the end of these discussions I was frustrated and confused. Why in the name of Hippocrates were so many of my points being ignored? Why rest the burden of DS/GA qualification solely on a procedure that often is not indicated for the safe delivery of deep sedation/general anaesthesia? Who stood to gain from this suggested change? Not practicing in Alberta and unable to get direct answers from the SOC Chair, the ADA&C or the province’s Minister of Health, I had to do some research and follow the information path to the best of my abilities. I found out that Alberta has twenty-seven oral and maxillofacial surgeons1 and four dental anaesthesiologists; they would be the dentists allowed to provide deep sedation/general anaesthesia to their patients under the former set of rules. The majority of the oral surgeons who offered DS/GA services already employed medical anaesthesiologists in their practices. This meant that to most of the qualified practitioners the change would not actually represent a change at all. On the other hand, the practices of Alberta’s dental anaesthesiologists, who did not employ physician anaesthesiologists, could be devastated. Still, for the ADA&C, the optics of the change were good since they could announce a tangible change in the name of better patient safety. It is of note that this change would not have prevented the injury sustained by young Amber Athwal (the focal point for change in Alberta).
This move is in the opposite direction to the American Society of Anesthesiologists’ quest to improve the safety and delivery of sedation and anaesthesia in dental offices.2 This move, to my knowledge, is not consistent with the practices of most other oral and maxillofacial surgeons in the country. This move ignores the new, good research on patient safety by Dr. Alia El-Mowafy in Ontario. The requirement for a minimum number of intubations, required or not, ignores the equivalency for learning or maintaining complex procedural skills using high-fidelity simulation. Cricothyrotomies are more complicated than intubation. Simulation training works there, and high-fidelity simulation is available for intubation, so why not spare a quota patient’s nose and throat?3
The answer may lie in the realm of bias. Let’s say I’m the Chair of the SOC. Let’s also say that I’ve had a medical anaesthesiologist working in my office for years, and that I’ve been happy with the service. Let’s also say that medical anaesthesiologists approached me with an interest in expanding into dentistry. Okay, how could we make that happen? Well, I could create a set of qualifying criteria that only medical practitioners could meet, like a minimum number of intubations per year(s). Intended or not, there is a lot of bias here. Ignoring other points of view from my committee cohorts, ignoring information that does not confirm my predilection, and/or never sharing information for peer-review (even on request) does not show a lot of integrity from my supposed-to-be objective position of Chair. It also renders the naysaying members of my committee moot, which is highly problematic (i.e. confirmation bias). Is this what actually happened in Alberta? Maybe, maybe not, but unfortunately the explanation fits.
Changes within organized dentistry shouldn’t negatively affect dentists unless it can be shown to be in the public’s best interest. Everyone operates with some level of bias in every task they undertake, I understand that. However, positions of responsibility demand that premiums be placed on objectivity, integrity and honesty. To the other provinces’ committee members that are revising their guidelines to govern their colleagues: remember your roles as representatives. To quote the end of Honesty, “Honesty is hardly ever heard/And mostly what I need from you”.
- Alberta Society of Dental Specialists. Specialist Directory for Oral and Maxillofacial Surgery. Referenced from the Alberta Society of Dental Specialists website: https://www.asds.ca/find_oral_and_maxillofacial_surgery_specialist.php. Accessed December 28, 2017.
- American Society of Anesthesiologists. ASA Statement on Sedation & Anesthesia Administration in Dental Office-Based Settings. Referenced from https://www.csahq.org/docs/default-source/default-document-library/asa-statement-on-sedation-anesthesia-administration-in-dental-officebased-settings-(1).pdf?sfvrsn=0. Accessed on December 28, 2017.
- S Boet, BCR Borges, VN Naik, LW Siu, N Riem, D Chandra, MD Bould, HS Joo. Complex procedural skills are retained for a minimum of 1 yr after a single high-fidelity simulation training session. British Journal of Anaesthesia, 107(4): 533–9 (2011).
Dr. Peter Nkansah is a Dental Anaesthetist with a private practice in Toronto. He is a member of the editorial boad for Oral Health and is an Assistant Professor at the University of Toronto’s Faculty of Dentistry.