Case Selection: The Zen of Practice Life

by Iain Nish, DDS, BSc, MSc, FRCDC

It is fair to say that we all start with the best of intentions when we initiate treatment for our patients, and we strive to achieve optimal outcomes. As the marketing ads indicate, we want to be “the dentist to ease the pain”, or the person “providing the optimum surgical solution”. From each successful case completion, the patient benefits and we receive among other rewards, a great sense of satisfaction. However, patient-related or treatment-related factors occasionally arise to negatively influence the satisfaction we would otherwise experience. We should recognize that some of these factors are within our circle of influence, and with purposeful case selection we may limit the occurrence of such events.

Many of the treatment-related problems begin with poor case selection or misdiagnosis. New graduates, empowered with fresh knowledge, eager to please and build their practices, may feel that they should be able to treat every patient with every condition. Unfortunately, this can lead some to accept technically difficult cases and to initiate treatment beyond their present clinical ability or experience. Even established clinicians may on occasion embark on treatment that they would otherwise not perform, either in an effort to assist a distraught patient or to maintain a busy practice. While seemingly obvious, some poor outcomes result from providing the wrong treatment through misdiagnosis of a difficult condition. A clear indicator of this case type is when you ask yourself on completion, “What was I thinking when I said yes to that?”

A thorough clinical examination, and selected ancillary tests and their interpretation, will in most cases, allow you to correctly diagnose a condition, and advise a patient of all possible treatment options, and potential associated risks and complications. With the aim in mind to ease the stress of practice life, clinicians need to purposefully select and advise the patient of those treatments that they are willing (and able) to provide. There will always be procedures that we are technically more proficient at performing, and generally these will often be those aspects of our practice life that we enjoy the most. Through careful case selection and appropriate referral of those that are beyond our scope or interest, the patient’s best interests can be served, and we will enhance our availability to perform more of the procedures that we enjoy the most.

When a difficult or unknown condition is encountered, referral to a general or specialist colleague for additional insight can be invaluable. There will be occasions when a definitive diagnosis cannot be made, but you may still be in a position to advise patients of what the problem is not by ruling out odontogenic causes. Old and new graduates alike should be confident in their patient assessment and management, and not be tempted to initiate treatment in the absence of a definitive diagnosis. Negative assessment outcomes can still be meaningful, as some systemic conditions are only ever identified as diagnoses of exclusion.

Patient-related occurrences that may lead to treatment difficulties can often be identified by a patient’s manner at the initial consult appointment (although this is all too often realized in hindsight). When a patient attempts to define for you their required care or the manner in which care will be provided, we are faced with a layperson’s concept of what constitutes proper care. Some may present seeking a third or fourth opinion on a matter, and continue to seek alternate opinions until they hear what they want to hear, or find someone willing to perform the treatment that they feel is required. There are many sources for their beliefs, including third-hand accounts, to information gathered from the Internet. The Internet, while useful can be a source of misinformation, due to the lack of regulation of information, and the ease with which a patient’s search can be diverted to tangential and unrelated topics. Others still may appear highly critical of previous practitioners, or adopt a suspicious position with respect to the information being provided to them. These patients create an “air of mistrust” which can be difficult to alleviate. The best approach, before any treatment is contemplated, is open dialogue regarding the patient’s apparent mistrust of your assessment, and their confrontational manner. Generally, the patient will either adopt a more receptive position, or will go elsewhere for their care, both of which are acceptable outcomes.

Mindful case and patient selection go a long way in helping to avoid many situations that can otherwise leave you feeling stressed and unhappy. This is accomplished by electing to carry out those procedures that you are trained and qualified to perform, and more importantly those that you find enjoyable.

By maintaining your knowledge as an expert in oral health care, you will ensure that intelligence, clinical ability and sound treatment principles guide your treatment. Knowledge is power, and the more that you know, the more likely you will be in a position to assist your patients. Finally, we should understand that we do not have to treat every patient or every presenting condition. On occassion ‘knowing when not to do something’ will be the best clinical choice and both you and the patient will benefit from recognizing that fact.

Dr. Nish is on staff for pediatric oral and maxillofacial surgery, The Hospital for Sick Children, Toronto, and is staff oral and maxillofacial surgeon at Lakeridge Medical Centre in Oshawa. He maintains a private practice in Whitby, ON.