March 26, 2018

A great personal view about being an orthodontic Key Opinion Leader

This is a guest post by Jason B. Cope. He is a highly respected orthodontist from the USA. He provides a great personal viewpoint on the tricky issue of being a Key Opinion Leader. I spotted the original version of this post on the excellent Orthodontic Pearls Facebook page and I asked him if he could write it for my blog.

I have published two posts on KOLs before. My first post was an overall comment. This, the second, was, in retrospect, a little disparaging.

Anyway over to Jason…

I’ve watched the discussions about products and Key Opinion Leaders’s for a while. I have been hesitant to say much because I have a very real bias. I am currently and have been a Key Opinion Leader for various companies for the past 15 years. However, I suspect my thoughts will be quite different than would be expected from a Key Opinion Leader. As I watch this continued downward spiral of vitriol and name-calling, I have to consider whether I should continue to sit idly by or try to effect change. I choose the latter.

My standard declaration of potential conflict of interest

First, let me do as I have done within the first 15 minutes of every lecture or presentation I have given for the past 15 years. After explaining my background and history, my last bullet point states that I am actively involved in product development and testing. That is my cue to state the following –

“I say that so you are aware of my biases. We all have biases based on our experiences, our interests, and our desires. They are neither good nor bad. They simply are. The only things I can truly talk about with expertise are my experiences and beliefs. They are mine; I own them and can’t change them, although sometimes I wish I could. Some of what I will discuss with you has good scientific evidence, some will merely be my opinion. I will try to point out the difference as we go along. If you are uncertain, please ask. You deserve to know.

I am a KOL for several companies. I also developed the IMTEC Ortho Implant System that was later acquired by 3M and sold as the Unitek TAD System and I receive royalties on that. Furthermore, I believe that clinicians being involved with product development is a good thing; it helps advance the specialty. But, there is a potential for bias so I want you to understand that. I suggest that you take everything I say with a grain of salt. You should question everything I say, as we all should do for each and every speaker when we are members of an audience.”

Some basic facts

I would also like to outline some basic premises from which I operate:

I am a lab tech (I started at age 13), I am a clinician (I started assisting at age 15), I am a researcher, a scientist, an academic, and multiple other unimportant things.

Importantly, I am not one of these things to the exclusion of the rest. I am all of them, all of the time. Some people are ethical and tell the truth. Some people are unethical and do not tell the truth, or stretch the truth, or tell half-truths. Unfortunately, we don’t walk around with these notices on our foreheads, so we have to use situations, circumstances, and experiences to discern the difference.

We need to remember that orthodontics is a field of basic and clinical science and art – it is both, to the exclusion of neither. Anyone who says it is all art, is not correct. Likewise, anyone who says it is all known science is also incorrect. The difference being that art is simply the subjective interpretation of an object, whereas science is the attempt at objective interpretation of the same object. There are certain basic scientific tenets with which we (should) base treatment. Importantly, there are many things that are known and there are many others that are not.

My perspective on KOLs

I would like to propose a different perspective on KOLs and product discussions/presentations and the questioning of KOLs. These are general statements and not directed to any one or more individuals. I have friends on both sides of this discussion today; I hope I can say the same tomorrow. This is really concerned with the situation in general, as it has unfolded over several months. Nevertheless, a particular post prompted me to say something.

Recently, a friend and colleague of mine responded to a discussion post with the following statement

“We are NOT in the field of questioning. Unless you are a philosopher, an academic or a researcher.”

Respectfully, I disagree with him and believe nothing could be further from the truth. If we do not question, then tacit acceptance of dubious comments becomes the norm.

Many young, impressionable eyes are watching and some are easily influenced and may readily accept these comments as fact. This is because it was posted by someone with stature “who should be believed”, or who had a louder voice. Others use bullying and sarcasm in an attempt to force their opinions on others. This necessitates the need for healthy, but respectful questioning.

A questioning approach

Personally and professionally, I respectfully question everyone and everything.. For example, how did you do that? Why did you do that? Did you base it on a hunch or an article, or were you just bailing out the only way you knew how at the time? If you don’t know, then just say it. No one has all of the answers, so stop any posturing that you do. To admit we don’t have the answer makes us believable and trustworthy. If you claim that it works 100% of the time, you just made yourself woefully unbelievable. Nothing works all of the time.

It is important to remember that those who don’t ask questions, should become acquainted with the phrase “buyer beware”, as they will most likely be haunted by it from this day forward. I also question my own treatment. Did it work? Did it not work? If not, why? Did I incorrectly apply the mechanics? Did I miss the diagnosis? How do I correct it? How could I have done it differently and better and faster?

The intentions of KOLs

I have been in this game for way too long to believe everyone has altruistic intentions. Although some do, they are few and far between. Others want a soapbox. Others want notoriety. Still others do it to feed their ego. Others do it for money. And usually, it’s a combination thereof.

Hopefully, I’m a better version of myself than I was 10 years ago, 5 years ago, and even 5 days ago. But to not question someone because we should first assume everyone has integrity is a fool’s errand. Trust but verify! And for those whose skin is too thin to be called to task, and asked the tough questions regarding proof, then you might consider staying out of the arena.

A way forward

We should be able to professionally and respectfully disagree without the name-calling, which is all too easy to do, particularly when safely tucked behind a keyboard. And this applies to both sides of the discussion. I have witnessed people posing questions that were completely unwarranted and unprofessional. Consequently, some of the responses to those questions have been equally distasteful.

I frequently try to remind myself of a story, the moral of which is that people who resort to name-calling are usually those that are not intelligent enough to win an argument. My higher self, the one that appears all too infrequently, has saved me a few times, albeit not enough, by forcing me to hit the Delete key instead of the Enter key.

The burden of proof

The burden of proof always lies with the person making the claims. This does not apply only to KOLs. It applies to anyone who makes a claim without evidence. If a person makes a statement that is hard to believe, then the burden of proof is theirs alone. If someone stands on a stage and makes claims, they should expect to be questioned. When they post something on Facebook, they should expect to be questioned and asked for proof. Although, the absence of proof is not proof of absence – it is lack of proof.. We should not make claims that we cannot support. Instead, a better approach might be,

“I tried this and it appeared to work. Although I have no proof, here is what I think is happening and why. I’ve tried to base it on scientific principles, but admittedly, some of it is trial and error.”

At least that is the approach I have taken with my clinical techniques and presentations.

Orthodontic magic

Unfortunately, various people are proclaiming “magical” techniques and products with little proof. This, of course, is nothing new – we’ve all seen the magic brackets that reportedly grew bone. By all accounts, the products appear to offer benefits, but that does not make them “magical”. It simply makes them an alternative, and perhaps an even better appliance than what we currently use, but still, at this point, just an alternative. The scientific proof is lacking. Period. Time will tell. But for now, it’s so much easier to simply acknowledge those facts already in evidence instead of applying circular logic, or deflection, or redirection to avoid acknowledging the simple fact that the product is too new to have real proof. It appears to me that this, above all else, is what is being met with such resistance. I think that people are just tired of this approach.

Solutions?

We should come together as professional and respectful colleagues. We need honest conversation about important issues. But, it can’t happen without the honesty, the respect, and the ability to disagree with professionalism. Hopefully, that will happen sooner rather than later. We could desperately use some unification.

The people in the audience, at least the discerning ones, are already suspicious that they are being sold based on these auspicious claims. The speakers can save their credibility by acknowledging the facts publicly. Otherwise, they run the risk of being labeled a company spokesperson instead of a person who speaks for a company. It takes years to build a reputation, and but seconds to destroy it.

Final thoughts

Lastly, I take the statement that “WE on Facebook are not the guardians of our profession” quite seriously and personally.

I freely acknowledge my bias here. I come at this from the position of the son of an orthodontist. My Dad felt like he received the single golden ticket when he was accepted to orthodontic school. Everything I have is inextricably tied to my Dad’s choice to join the orthodontic specialty. Education, knowledge, speaking, travel, patents, friendships, my wife, our baby – the list is far too long to post here, but is all due to orthodontics, both the tangible and intangible blessings that it provided, and my Dad’s passion for it.

I decided long ago, that if I did not give back as much as I had received from orthodontics, then I had failed miserably. As most will no doubt understand, that’s an utterly impossible goal set by a naïve guy many years ago, but a driving force nonetheless. It’s not a job or a profession; it is a love, a mission, a passion that cannot be quenched. So to be involuntarily lumped into the collective “WE” whose responsibility it is not, I opt out. I hereby self-select out of the WE group.

If I have to choose between a bracket and the specialty, then I choose the specialty. If I have to choose between a company and the specialty, then I choose the specialty. Finally, if I have to choose between someone or something in the specialty and the specialty, then I choose the specialty. There will be other brackets and other companies, but there will not be another orthodontic specialty. Instead, I prefer the If not me, then who? group.

Sorry for the heaviness, but someone needed to say this. And I figure if not me, then who?

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Have your say!

  1. Avatar

    Thank you for taking the time to share your perspective and thoughts on KOLs and more importantly on our wonderful specialty. You have been a leader since I met you in dental school 24 years ago and appreciate your perspective and contributions to Orthodontics.

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    I know Dr Cope and appreciate his passion for orthodontics. I have been fortunate to take some of his CE courses and they never disappoint.

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    Great Jason

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    You said it all Jason . . . on behalf of the many KOLs who are just doing it, mainly to put something back.

    Fine words my friend.

    Jonathan

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    You said it all Jason . . . on behalf of the many KOLs who are just doing it, mainly to put something back.

    Fine words my friend

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    Jason – great post.. and your honesty. I fully agree too many in the profession and specialty do not ask “WHY?”
    My father was also an orthodontist and when i ‘went off to university’ he told me to remember one thing “always ask why?” : and as an academic who has jumped ship into ‘real word orthodontics’ who still teaches, i would add a corollary to the “why?” question…. and it is “there is no such thing as a stupid question, but there are many stupid answers”

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    Like your father, we orthodontists have all received the golden ticket. You also received the gift of humility.
    This trait does not make for a better orthodontist but serves to stoke the fire of one who aspires to be.
    That in itself is enough.

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    Well stated my friend!

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    Well said Jason, I share your thoughts but lack the skills to be so eloquent in expressing them. On the day of my first encounter with my University residents I ask them what they think is the most important aspect of orthodontics that I can teach them over the next 30 months. As expected most answers have something to do with moving teeth. It gives them a bit of a jolt when I respond “no it is critical thinking” for without critic thinking you will most likely fall victim to one of the many “rascals” offering a better way to “bake the cake”. For 50 plus years I have attempted to carry the torch for my University of Michigan training and your thoughts give justification for the journey.

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    I have shared this profound post to my doctor husband and veterinary daughter. The philosophy is transferable: a succinct and profound article.

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    Well said Dr. Cope. I did an Air Force GPR out of dental school and one of the most important things our program director taught us was to know why we were doing what we were doing.
    I wear a “Be Humble and Kind” bracelet, not because I’m a huge Tim McGraw fan but because I think it’s a good way to conduct myself from day to day. I call it my “Don’t be an A**hole bracelet”.
    We have the best jobs in the world.

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    Thanks for this and a very refreshing approach to what being a Professional person is – for Dentistry then always being a ‘thinking Dentist’ and always asking WHY at least 3 times for anything we do or consider progress – yes for current approaches as well as relatively ‘new’ ones !!!

    As regards Science vs Art, it is always painful to have to admit having done many years University training undergraduately and then postgraduate courses/training too, that the majority of what we do is mainly ‘Art’ and very little indisputable ‘Science’, indeed most of what has been published scientifically in the last 20 years, has been found to be ‘invalid’ and the majority of Cochrane ‘reviews’ of the scientific literature, often says it found 1000s of papers, only 9 were considered ‘robust’ and if you are lucky, you might have ‘moderate’ or low confidence in their conclusion, but very very rarely do they state ‘high’ confidence scientifically, for anything 😮

    So let’s acknowledge that – even for Class 2 div 2 Ortho, Cochrane says there simply is NO credible evidence for ANY approach Orthodontically and even NO treatment may be just as good outcomes-wise, because……… the evidence-base is SO poor.

    Again difficult for many to admit.

    Last but not least, orthodontics is dentistry and it should NOT be separated from GDPs learning and doing more – it is no more ‘extra-special’ than any other speciality in Dentistry and by trying to become exclusive/excluding GDPs (unlike all other dental specialities like Oral Surgery or Restorative etc.) it would do well for ‘Orthodontic’ KOLs in high positions of power to also ask WHY do we too often ‘disempower’ rather than ’empower’ GDPs about the wonderful benefits of doing Orthodontics (especially for simpler or more routine cases), when Oral Surgeons want us to get better at Extractions and do more, Endodontists want us to get better at RCTs and do more, Prosthodontists want…….. well you get the idea.

    Sadly the perception is too many in power in Orthodontics are behaving more monopolistic than empowering and supporting their general dentist colleagues to do more Ortho, constructively, which is in very STARK contrast to all other dental Specialities and thus, do other Specialities have more trust & respect by GDPs – is this WHY many look for alternatives to this traditional “If you are not a Specialist in Orthodontics you are not worthy” perception out there ?!?

    Orthodontics is Dentistry and are MORE Art than Science………. some seem to have great difficulty in acknowledging that status today.

    Patients also seem to prefer their ‘own’ dentist does as much as possible and these days, combined Treatment Planning is often optimal.

    Yours Teamworkingly,

    Tony Kilcoyne
    Specialist in Prosthodontics (UK)
    & General Dentist who likes to move teeth into more favourable positions than drill them down!

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    A purportedly poor-evidence base is no license to endorse pseudo-science. GPs who are able to diagnose and treat to the standards of a specialist, as well as critically evaluate the science are always a compliment to the profession. However, that doesn’t seem to be the case in the vast majority of situations. The tendency seems to be to disparage the scientific foundations of the specialty with zero basis, and bad quality science. Obviously such interloping attempts will be met with well-deserved derision. Those who want to provide ortho services need to eschew the snake-oil salesmen first before expecting the profession to embrace their empowerment. Orthodontics is more art than science only to those whose agenda is enriched by making such specious and ill-founded statements. Is it any wonder that there is resistance to these attempts?

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      Sorry Phil Kemp, but I have to both disagree with you and simultaneously thank you, for making my point so clearly, when you state “GPs who are able to diagnose and treat to the standards of a specialist, as well as critically evaluate the science are always a compliment to the profession.”

      How unrealistic is it that all GDPs to ‘Diagnose and treat’ to the same standards of a Specialist, always ???

      Oral Surgeons do NOT require these extra hurdles for GDPs to extract teeth routinely, Endodontists do NOT require these to root canal teeth, Prosthodontists do NOT require these for Crowns and Bridges, Paedodontists do not require these to treat children etc, etc, because by definition, GDPs are NOT Specialists. Yes GDPs should recognise the complex from the less complex cases and which to treat or refer appropriately, but that is not what you said or implied.

      Of course Specialists are important for both Training and Empowerment of Undergraduates & qualified GDPs to do more and continually improve, maybe one day reaching the dizzy heights of a fully experienced Specialist in some respects, but not doing so STILL makes a GDP an important contributor to society in Orthodontics when NOT at the same standards as a Specialist, but still Reasonable and safe and able to depend upon good support from Specialists for the more difficult cases too!

      However increasing numbers feel Orthodontics is ‘non-supportive’ for GDPs and about 20 years behind most other UK Dentistry Specialist disciplines – with some notable individual Orthodontist exceptions of course.

      Sadly unless this improves through demonstrable actions (rather than fine sounding words alone), I fear many GDPs will increasingly just look away from those who SHOULD be helping/leading Orthodontics progress for all, especially if viewed as acting Monopolistic or even over-critically of their Practitioner colleagues, in stark contrast to the other Dentistry Specialist disciplines whom are far more progressive and supportive by comparison, wouldn’t you agree?

      Again (and apologies for stating the obvious) Orthodontics is Dentistry and GDPs do the majority of Dentistry.

      Yours diagnostically,

      Tony Kilcoyne.

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    You can disagree all you want…doesn’t change the facts. Perhaps this persistence could be applied toward learning the science instead of railing against the immutable. So, the decision is simple – Either embrace the standards, discard junk science and bridge the knowledge gap, or refrain from providing orthodontic care. Our patients deserve no less.

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    Just read this beautifully written thought provoking editorial by Jay Bowman in the recent Angle Orthodontics. Worth the time: http://www.angle.org/doi/pdf/10.2319/0003-3219-88.3.370. Well done Jay!

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