Your brother's gatekeeper.

Abstract

You have accepted the request to provide an independent medical examination for a patient from another state. The attorney who sought your assessment of 17-year-old James has told you little except that James had already undergone comprehensive orthodontic correction and a previous independent medical examination. James' prolonged adolescent treatment was intended to resolve his borderline Class III malocclusion. He had recently gone to a second orthodontist to seek esthetic aligner therapy to realign his relapsed maxillary incisors. When the panoramic film revealed 3 mm of root resorption at the incisors, this orthodontist encouraged legal action against James' original orthodontist for creating the resorption. As you review the film, James blurts out, “I know my roots are short—will I lose my teeth or will I…?” Before you can respond, James' mother interrupts by telling you that a previous examiner had claimed that the root resorption could jeopardize James' teeth in the future. Your role as a second examiner is to determine the prognosis of his dentition in relation to the amount of root loss and the relationship of the first orthodontic therapy to James' presentation. It's a potentially volatile endeavor because your opinion might affect the legal proceedings—and James' and his mother's high levels of anxiety. Honoring a request to provide an opinion regarding another orthodontist's treatment outcome can place one in a difficult predicament. Your intent to provide beneficence (do good) for the vulnerable patient is tempered by the call for veracity (truth) about the case outcome. You also might feel professional allegiance to the previous orthodontist, even though you are unaware of his or her identity. Perhaps the discussion boils down to whether you are “your brother's keeper.”1Edge R. Groves J. Professional gatekeeping as a function of role fidelity.in: The ethics of health care: a guide for clinical practice. Delmar, Albany, NY1994: 184-185Google Scholar Do you have the right to comment on the work of one of your colleagues? Unlike a typical commercial transaction, the patient is at your mercy since he has insufficient knowledge to discern what is excessive in terms of harm or benefit. The term gatekeeping in journalism is the process by which the media assign selectivity to which news should and should not be publicized. Given the vast amount of information to which journalists are exposed, it would be impossible for them to disseminate it all for public benefit if it were not for gatekeeping. Gatekeeping is the process by which journalists cull the important from the inconsequential; the profound from the trivial. Gatekeeping affects the audience's perception of reality, because facts that are pertinent are spared, and those that are banal are relegated to obscurity.2Shoemaker P. Vos T. Reese S. Journalists as gatekeepers.in: Wahl-Jorgensen K. Hanitzsch T. The handbook of journalism studies. Routledge, New York2009: 73Google Scholar Consider the analogy in orthodontic practice. Whether the discussion is in treatment planning consultation, disclosure of informed consent, updating a parent at a routine visit, or final assessment of a treatment result, gatekeeping is essential. Too little information violates the principle of veracity and deprives the patient of autonomy, but deletion of a pertinent finding can be just as harmful as lying. Too much information can spin a parent into a state of confusion. Gatekeeping associated with an independent medical examination requires a keen level of discretion between providing sufficient information and creating an environment of alarm for the parent and patient. Most would agree that root resorption occurs routinely, and most root remodeling typically does not affect the longevity of a dentition. And if James and his mother were not apprised of the possibility of root resorption in the informed consent discussion, this shortcoming might contribute to their breach of trust and subsequent legal inquiry. Your documentation of James' status for the independent medical examination should represent only his history and your assessment of his clinical and radiographic findings. It will be impossible to determine his future prognosis. But anything you say or write should be weighed very carefully. And remember: when it comes to root resorption and other minor treatment sequelae, let he who is without guilt cast the first stone.