February 1, 2014
by Peter Nkansah, DDS, Dip. Anaes., Specialist in Dental Anaes. (Ont.)
Through 2013, I was fortunate enough to be a student in a year-long mini-residency in implant dentistry instructed by Dr. Jim Lai and Dr. Joe Fava through the University of Toronto. It was a wonderful course that I recommend wholeheartedly to anyone wanting to introduce the discipline of implantology into their practice. Along with the terrific instruction that I received on the many aspects of implants, I began to recognize the largely unrealized value of checklists in my practice.
As a person who used to pride himself on his memory, my world shifted slightly during some introspection. In the face of incorporating implant placement into my practice, other questions came up about the existing state of things in my professional world. How could my dentistry become better or at least more efficient? Was the range of services that I was offering broad enough? Where could I improve in my teaching commitments? Setting my aforementioned pride aside (one of the seven deadly sins), I became a little dissatisfied with how often I referred to technology for information that was no longer (or maybe was never) readily available in my memory. Using ePocrates or the eCPS or PubMed or any other of any number of apps felt like cheating. Then I forgot my smartphone at home for a day which led to a (seemingly) disastrous day. Later, a tech glitch with a PowerPoint presentation raised anxieties about my teaching abilities; what would people think if I lectured without a computer?! I was functioning but not as well as I thought I could. My practice was fine, but I thought it could be better. My teaching sessions were receiving good feedback, but as Dr. Scott Woodside said in a lecture that I attended, “If power corrupts, PowerPoint corrupts absolutely.” Some answers to these questions, especially with regard to improving my clinical dentistry, started to present themselves back at the implant course with a book suggestion from Dr. Fava for
The Checklist Manifesto by Atul Gawande. While I thought it was a well-written, engaging and (in my opinion) important book, I’m not sure that it said anything particularly new. That is, that using checklists doesn’t constitute cheating; checklists are simple, highly effective tools to get things done properly. Similar ideas about checklists are espoused by Malcolm Gladwell in Outliers and by Daniel Kahneman in Thinking Fast and Slow, as well as other books. But as the adage says, “timing is everything”, and Manifesto caught me at a receptive time. The tipping point was reached when I received my periodic newsletter from the Anesthesia Patient Safety Foundation. The main headline read: “Emergency Manuals: The Time Has Come”. And with that, I unfurled my white flag. Look, I’m as stubborn as the next dentist, but when you hear the same thing so many times from different sources…well, Elvis Presley had an album called 50,000,000 Elvis Fans Can’t Be Wrong. Point taken.
Dentistry already has 10 specialties plus the disciplines of implantology and aesthetics, which certainly have specialized knowledge. Add in all of the theories, the material advances and the specific and sensitive techniques in all of these fields, and the average practitioner (like me) could run into some trouble keeping things straight. Furthermore, clinical dentistry is a team sport; your support team is invaluable. A team operates better with everyone on the same page. And the better your team operates, the better care you will provide, which is the ultimate goal.
So when is it OK for professionals to use checklists? To answer a question with a question: when isn’t it? Call them algorithms if you want; heck, call them BillyBob if you want to, but use them. Not all the time since you shouldn’t paint by numbers. There is still some art to the practice of dentistry and to teaching. Expertise and creativity allow the artist in you to thrive; embrace the artist in you, just don’t be crazy and cut off your ear or something.
Don’t challenge your memory in unfamiliar surroundings. Mess procedures up, and the results could range from less-than-desirable to downright dangerous. No one wants that. Personally, I’d rather stay out of trouble than stare it down. I’d also like to make sure that my team is on the same page as me. I hold no secrets. I have checklists for medical history taking, for Advanced Cardiac Life Support procedures, for using luting cement for porcelain veneers, and of course for implant dentistry. There are more checklists for lots of other procedures and circumstances in my office too. I even have a checklist for the treatment of malignant hyperthermia, which thankfully I’ve never seen, but I know could happen given the anaesthetic part of my practice. Again, I’ll take preparation over panic or apologies.
Can checklists and my pride co-exist? Sure. I still have some pride, but not at the sinner’s level. As for my office team, it works pretty well, better now with the checklists but there are always things that we can and will do better in the future. As for my teaching, I’ll be looking to defend my University of Toronto teaching award this year. Check please! OH