Discretion, please.

Abstract

Jimmy is an only child, the sensitive 12-year-old son of a prominent periodontist and a prosthodontist. Although the family lives a considerable distance from your office, their level of trust surpasses the effort they must expend to commute to your office. An anterior open bite and aberrant tongue posture are evident. The patient is periodontally susceptible. One mandibular incisor is absent, which contributes to the excessive overjet. Although his profile is balanced, the appearance of Jimmy's dentition concerns his parents greatly. Correction of their child's malocclusion is a high priority. You decide to treat Jimmy with reproximation of the maxillary anterior teeth combined with mild proclination of the mandibular incisors. You explain that an ideal overjet will be unattainable owing to the interarch tooth size discrepancy. Jimmy's mother will contribute to continued surveillance and maintenance through her periodontal office, including the levels of keratinized tissue. She is aware that future soft tissue grafting might be needed. After a year of therapy, all seems to be going well. Then the crisis begins. The child's dentist is a fine clinician but reputed to be outspoken and occasionally not at all discreet. She takes one look at Jimmy at his most recent recall visit and blurts out, “What's with this overjet? How long as he been in treatment? This kid will never be able to even bite an apple!” Jimmy bursts into tears, and his mom becomes visibly shaken. This had been a consuming experience for them, and because they are a family of dental professionals, the issue is further amplified. Maleficence in the health care arena can include subjecting the patient to undue risk or the commission of a harmful act. Commonly cited examples in orthodontics are failure to diagnose periodontal disease before initiating orthodontic treatment or damage that occurs when a separator fractures during placement, gouging the patient with the separating plier. Failure to maintain professional competence is another example. But can maleficence be committed by verbal communication? Patients judge the quality of care by our communication abilities or our level of empathy. They assume that requisite professional education among orthodontists is sufficiently uniform to provide the skill set necessary to deliver equal and adequate levels of care. Yet poor communication can be a major reason for reluctance to commit to treatment or can undermine patient confidence once treatment begins. An investigation into the communication skills of 59 general practice physicians and 65 surgeons revealed that the frequency of malpractice claims that occurred among the general practice physicians was correlated with their communication abilities. Those general practitioners who discussed treatment expectations before therapy, used humor in patient dialog, and attempted to solicit the patient's feedback during treatment had fewer malpractice claims than those who did not.1Levinson W. Roter D.L. Mullooly J.P. Dull V.T. Frankel R.M. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.JAMA. 1997; 277: 553-559Crossref PubMed Google Scholar Our communication skills are integral in responses to patient inquiries and in conveying our level of empathy. Empathy levels appear to vary among medical specialties. Psychiatrists, considered to represent a patient-oriented specialty, demonstrated the highest levels of empathy. In contrast, technology-oriented specialties, such as anesthesiologists, neurosurgeons, orthopedists, and radiologists, were found to have the lowest levels of empathy.2Hojat M. Gonnella J.S. Nasca T.J. Mangione S. Veloski J. Magee M. Assessing practitioners: the Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level.Acad Med. 2002; 77: S58-S60Crossref PubMed Scopus (282) Google Scholar Society and the courts assign the responsibility of empathetic communication to the professional. Inappropriate, hurried, or inadequate communication can catalyze an unfortunate escalation of anger between the patient and the doctor. Patients of primary care physicians who feel rushed during appointments have been reported to be more prone to sue their doctors. And the brevity of the visit appears to be correlated with increased frequency of lawsuits within this patient group.1Levinson W. Roter D.L. Mullooly J.P. Dull V.T. Frankel R.M. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.JAMA. 1997; 277: 553-559Crossref PubMed Google Scholar The indiscretion that Jimmy's dentist demonstrated not only caused unnecessary angst within a highly sensitive patient and family, it also violated the ethical principle of nonmaleficence via her spoken word. In this case at least, discretion might indeed have been the better part of valor.