A message to the graduating orthodontic residents of 2021
This week’s post is an excellent discussion by Rob Kazmierski, who has been a specialist orthodontist in New Jersey, USA, for 32 years. He provides relevant advice to new orthodontic graduates on some of the current pitfalls in our speciality. I think that he makes very valid points in his message.
Congratulations! You are embarking on what can be one of the most rewarding careers in which someone can engage.
First, let’s cover the tough stuff. You are also starting out in one of the most challenging and turbulent times in the history of our profession. As a result, there is the desire to fully warn you of some of the perhaps unanticipated challenges that you definitely will face. Towards that end, I would like to share three old and new challenges that I wish that I knew 32 years ago.
Following the Gurus
The first challenge is that in orthodontics, there is no safety in numbers. Occasionally, it seems like every orthodontist you encounter, every orthodontist who is in a particular Facebook group, or every orthodontist who is at a specific meeting does what a Guru teaches. They appear to subscribe to a specific philosophy or uses a particular appliance. This does not make it safe to use that technique, philosophy, or appliance. This problem is nothing new in orthodontics. Orthodontists have followed Gurus right over the cliff, to the detriment of their patients, since the very beginning of modern orthodontics.
The founder of modern orthodontics, Edward Angle, thought it was malpractice to extract teeth under any circumstances. We can all envision possibilities where that would be harmful. At the other extreme, far too many overzealous followers of Charles Tweed thought it was correct to extract teeth merely to achieve a certain measured number on a cephalometric radiograph. You can easily imagine the harm that can come from this philosophy.
The point here is not whether extraction, non-extraction, Angle, or Tweed philosophies are correct. To the bane of our profession, the point is that the tendency to follow Gurus blindly, a philosophy, or what everyone seems to be doing has not gone away. The fact that some Guru is promoting it, everyone else is doing it, or some company sells it will not protect us. Importantly, when a Guru, philosophy, or company’s recommendation goes wrong, it will not be the Guru, group, or appliance company standing there by our side for our defence. Unfortunately, we are alone with our decision and its consequences. Currently, orthodontists are doing things merely because a Guru, group or company advocates it. Disappointingly, this is showing no signs of abating.
Doing the wrong thing by a patient is a very individual and personal matter. We are expected to, and should, do the very best for that patient. Our decisions must be based upon a thorough consideration of our education, experience, and interpretation of research. There is no justification in the Guru says this, the group does this, or the appliance manufacture says this, and there never will be. We owe the patient the best of our complete personal and unique consideration.
On line Orthodontic “education”.
The second challenge is that online orthodontic education currently represents the very best and worst of our profession. It can be the very best as information can be quickly and sometimes near-instantly obtained. I have benefitted in any number of ways from online education and interaction. There are excellent orthodontic online and Facebook leaders such as Neal Kravitz and Mo Almuzian, to name two. They and many others give selflessly and seemingly tirelessly to better our profession.
However, IMO, there are also wolves in disguise amongst the sheep. It can sometimes be tough to tell the best from the worst. This issue did not exist to this extent in prior generations. This problem is one of your unique challenges.
In days gone by, for any lecturer to be considered seriously and have their lectures attended, they would need the backing of an accredited orthodontic department of a university. If they were given time and published enough publications, they could eventually earn themselves names that entitled them to complete respect of their own accord. Bill Proffit, Vince Kokich, Charlie Burstone, Lysle Johnston, and many other very respected names in orthodontics were birthed from this system.
Unfortunately, the filter of an accredited orthodontic program of a university has now ceased to marginalize the unworthy in online and “Facebook” continuing education. Many whose only talents are timing, charisma, and the ability to attract followers to their Facebook groups have succeeded in profiting from promoting techniques, philosophies, and appliances that at best do not help patients and sometimes may hurt them. Importantly, if the individual members consistently help one another, and 19 of 20 messages from the administrators are of the nature “let’s help and support one another”, wouldn’t we all think that we are in a helpful and great group?
However, it is a sufficient warning that we are not in a healthy group if we see that one in 20 messages from a Facebook group administrator asks us to pay to take a particular course that is unethical. For example, some have supported courses that violate the AAO white paper’s recommendations on sleep-disordered breathing (SDB) or to use 3D radiographs for a purpose they are not diagnostic for, or using a particular appliance that research does not support. In my opinion (IMO), we are being asked to swallow a poison pill.
One of the benefits of being an orthodontist is that, when appropriately practised, we neither save nor cost people their lives. The rules on SDB are pretty straightforward. We should refer patients with known or suspected SDB to those most qualified to diagnose and treat them, physician’s board-certified in sleep medicine or groups who contain a physician with this certification. Doing otherwise needlessly places the patient’s life at risk. Unfortunately, the charlatans are willing to take the risk with others’ lives for their profit.
It can be hard to tell the bad Facebook groups and administrators from the good. Some have even created faux universities. They use their names to provide the illusion of accredited orthodontic program backing. To make it even more complicated, the charlatans themselves are all charismatic. The noticeable jerks get filtered out quickly. Jim Jones was very liked by his congregation and had a beneficial and supportive message. It was only once that he asked them to drink Kool-Aid. My advice, if you see an administrator doing these things, booting anyone from the group who disagrees with their promotions, or attacking anyone who disagrees with them while they claim to be attacked, be aware of where you are. Someone asking you to do something unethical just once is enough warning. This pearl is, don’t drink the Kool-Aid.
The companies and the Key Opinion Leaders
Third, and then I will leave you alone. Starting about 20 years ago, it became common in orthodontics for corporations to make a claim that sounded logical, had no basis in research, had compelling key opinion leaders (KOLs) backing it, and then make hundreds of millions of dollars off of this claim. Many, if not most, of the products they sold in that way have since been proved ineffectual and sometimes harmful. Other companies have now learned from the prior companies’ success at this technique. Unfortunately, it has become commonplace for claims to be made without any research justification. They will make money, regardless, and if, 20 years from now, the product has been proven ineffectual or harmful, they will argue about the research while they start promoting the next greatest thing. The use of charismatic KOLs is commonplace here, and big money changes hands, both directly and indirectly.
This situation is not normal, and orthodontic products should not be brought to market in orthodontics in this way. This pearl is to question everything that a company tells you and question the information from KOLs of that company, no matter how likeable they are. That being said, not all companies and KOLs are bad. There are an incredible number of honest and reputable companies and KOLs out there. We all have much that we can learn from them. We need to be very active in separating the wheat from the chafe.
In anticipation of specific arguments against this, requiring research before making claims does not stifle innovation. There are many new orthodontic products from reputable companies developed and brought to market without making false and unproven claims. We all know what they hope these products will do. It is just proper to wait until research proves that they do it before a company or KOL claims that they do it.
Despite the difficulties listed above, there is much in your favour. Most of our fellow practitioners strive very hard to provide the best ethical treatment for our patients, aid our fellow practitioners, and positively influence our profession. It is hard to attend an AAO and not feel collegiality. With this collegiality, many of us who have been in the profession longer wish you who are just starting to be fully protected with as much information that we can provide to you.
I hope that my message is useful to you. My sincerest best wishes to you, the future of our wonderful profession!
Emeritus Professor of Orthodontics, University of Manchester, UK.