Clueless in Chicago?

Part III

(The third and final editorial about the state of our specialty as this editor sees it. The opinions stated in this article are solely those of the editor and do not necessarily reflect those of the New Jersey Association of Endodontists Board of Directors or its membership. To view Parts I & II please link to NJAE’s website at www.njae.org/ )

  

‘Government without popular information, or the means of acquiring it, is but a Prologue to a Farce or a Tragedy, or perhaps both. Knowledge will forever govern ignorance: And a people who mean to be their own Governors, must arm themselves with the power which knowledge gives.’ – (James) Madison, 1751 – 1836                                          

Does the membership of the AAE have the right to know how their money is being spent?  Do our Executive Committee, the Board of Directors and the Executive Director of our association have an obligation to their stakeholders, to provide meaningful information on staff salaries, budgets, contracts and their governance decisions and make it accessible to you? Does the term” rhetorical” come to mind? Would any rational individual think that their association leadership and executive director should be anything but transparent and accountable? Creating and sustaining a culture of trust requires our leaders to be willing to entertain consequential dialogue with its members even when that exchange of ideas does not evoke unfettered praise for their programs, judgments and philosophies. The “Us and Them” mentality was abundantly in evidence after my second editorial/blog. “Take me off this email list” was the call of the day for several of the leaders of our organization. Some of my fellow past-presidents requested the same status. Their requests have been noted as well as honored. Confidence in leadership is based on open access to critical information and the willingness to have mutually respectful dialogue with your membership. Sadly, some of the email responses from our leadership, past and present, belie that premise. If I was a recent graduate from PG endodontics or was an endodontists under 40 years of age I might now have some concerns about how “bright the future” of my specialty is!

 

Colleagues, my sole reason in writing these editorials/blogs is to ask questions that apparently no one else will. It is definitely not my intention to denigrate those who serve our association whether they are acting in the capacity as a volunteer member of the governing body or as a paid staff member at 211 E. Chicago Avenue. As a past-president of this association I both appreciate and applaud all those who have made significant sacrifices to help govern and guide our organization. However, anyone who is a dues paying member of the AAE has the right to voice their opinions or concerns about how this organization is administered and governed, even members of the Board of Directors.                                      

                                      

 

Do you know how many dental schools in the United States and Canada teach their undergraduate dental students to employ a surgical operating microscope when providing endodontic care for their patients? More significantly, how many endodontic educators are actually qualified to instruct post graduate endodontic students on how to use the endodontic operating microscope and realize its full potential as a cornerstone to careful and thorough endodontic treatment? Utilizing a microscope as an endodontist requires proper training and understanding of how this invaluable armamentarium expands our capabilities to provide “specialty care” for our patients. Shouldn’t a specialist provide something special for his/her patients? To me and many of my colleagues involved in clinical endodontics it is patently clear that a surgical operating microscope draws the proverbial line in the sand that separates serious endodontic clinicians from dentists and other specialist clinicians who dabble in “root canal”.

 

Dr. Gary Carr, my choice as the foremost advocate and early adaptor in endodontic microscopy has been saying for years that ‘endodontists should have made the microscope the standard of care and understood that it actually defines this specialty, instead of just seeing it as another “tool”.’  Don’t misinterpret what I am saying. Installing a surgical operating microscope in your office doesn’t confer competency nor can it impart special abilities or expertise. However, what it does provide, for those that accept the principle that “you can’t treat what you can’t see”, is the deus ex machina to creating the proper clinical environment needed in endodontics. This tenet, when properly encouraged and taught, fosters a meticulous treatment protocol through the application of disciplined and comprehensive microscopy. When it is coupled with a thorough understanding of dental anatomy, pulp biology and pathology you have four of the most essential elements to foundational clinical endodontics.

 

How many of our endodontic faculty know how to par focal a scope; adjust the interpupillary distance; understand why correct operator position is an essential element of endodontic microscopy; be able to teach proper patient alignment as well as the essentials of the assistant’s positioning during an endodontic procedure; and impart on their students a full understanding of the vital elements and skill sets needed to function ergonomically when employing a scope? Is it not time to create and codify a universal microscope syllabus and a teaching standard for our endodontic post graduate students? Have we given our PG’s the proper guidance and direction to integrate the surgical operating microscope into their daily clinical routine? I know the answer to the last question and it is regrettably and unequivocally ….no! The AAE has been pretty sanguine about the use of the operating microscope for a long time. They don’t disagree that it is conceptually important. They do pay tacit lip service to the scope after all they have pictures on their annual roster books showing endodontists using microscopes and have you looked at your membership card lately? They are also publicity savvy on the website with graphics showing microscopes being employed by various practitioners.

 

What you may not know is the AAE leadership and staff had numerous opportunities to put some real traction into the accreditation standards for advanced specialty training in endodontics with regards to the microscope. I tried very hard to change the existing microscope standard we now have when I was president of the AAE from 2005 to 2006. I was shot down by the majority of my colleagues on the Executive Committee and also by a majority of those serving on the Board of Directors that year. I even asked for a survey to be sent out to all the endodontic chair people and program directors around the country only to be informed by a staff member from the AAE that the survey was not sent out so people could take them privately to express their individual views on the microscope standard. What transpired was an open educator forum, a chat room if you will that actually had a future leader of the AAE change their mind from pro to con during the flurry of opinions expressed on line about the 4-9j standard. Knowledge based governance does not work when the informational survey you use to make informed decisions is biased.

 

 By way of explanation The ADA’s Commission on Dental Accreditation (CODA) is the governing body that defines dental specialty educational standards for all the dental specialties. The ADA’s website has a PDF file on the “Standards for Advanced Specialty Education Programs”. Standard 4 in the endodontics program addresses ‘Curriculum and Program Duration’. According to this standard, curriculum is approached via an evidenced based endodontics (EBE) model. The endodontic-specific Standards are based upon EBE,” the integration of the best research evidence, clinician expertise and patient values”. Now going down to the “Clinical Science” curriculum you will see in section 4-9 ‘The educational program must provide in-depth instruction and clinical training to achieve proficiency in the following areas:’ It goes on to list several clinical areas and the last section is j...Use of Magnification Technologies. It does seem pretty innocuous up to this point. But wait, it gets pretty dubious immediately after that. Just below section j is an intent statement used to interpret and define what specifically is meant by section j’s …’Use of Magnification Technologies’. It reads as follows:

Intent: The intent is to ensure that students/residents are trained in the use of instruments that provide magnification and illumination of the operative field beyond that of magnifying eyewear. In addition to the operating microscope, these instruments may include, but are not limited to, the endoscope, orascope or other developing magnification.

 

Many of us supportive of a stricter interpretation of 4-9j realized that the intent statement essentially provided a mandate for every program in the USA and Canada that adhered to CODA’s curriculum dictates to get a free pass on the operating microscope. If you were the chair or program director of an ADA approved endodontic program you could have a microscope collecting dust in some distant corner of your clinic or better still claim that an endoscope or an orascope were suitable alternatives to employing or teaching your PG’s about endodontic clinical microscopy. The fact is, without a definitive intent statement there was never a need to create a departmental teaching syllabus that would concentrate attention on the operating microscope. Let’s review the genesis of this apparent leadership driven attitude that worked to marginalize the importance of the operating microscope in endodontics?

 

A 1999 article in the JOE by Mines, P., Loushine, R.J., et al, Use of the Microscope in Endodontics: A Report Based on a Questionnaire. J Endodontics 1999; 25: 755-758. The authors surveyed 3356 active members of the AAE and received responses from 2061 of them that indicated 52% of the respondents have access to and utilize an operating microscope (OM). The survey also revealed that ‘the frequency of use appeared to be a function of the years since completing endodontic training. The statistics were as follows: < 5yr, 71%; 6 – 10 yrs., 51%; and > 10yrs, 44%.  For those who answered the survey 36% said they did not use the OM as often as anticipated because of the following issues:

 

•   Restricted field

•   Positional difficulties with the microscope

•   Inconvenience

•   Increased treatment time

•   Lack of auxiliary support

 

‘The results of the survey suggest that increased training results in an increased frequency of OM usage for all procedures.’ In addition this article states that ‘There also seemed to be little standardization in the method of training. Some of the methods included self-training, formal courses or seminars and experience garnered from a residency program or research’. Even the casual observer can comprehend what is missing here… formal training given to every endodontic PG, endodontic resident and endodontic educator to insure that the OM is the standard of care in endodontics. Just about all general dentists in this country have drawers and shelves stocked with endodontic supplies and equipment. How many of them have or employ OM’s when they do endodontic treatment? The microscope has a broad range of tasks that can be completed using it….thus…it’s a fundamental skill set that should be afforded to every endodontic PG or resident while they are in their endo programs. For those of us that use the OM from the start to the finish of our endodontic treatment sequence (especially those under 40 years of age that have some formal training) it is not inconvenient to use and whatever time it takes to treat a case properly is time well spent. Every one of the issues enumerated by that article disappears with proper training. One can only ask why in 2011 is 4-9j still in a watered down state left to the interpretation of individual department chairs or program directors.

 

What has the AAE hierarchy and the Executive Director done about this issue since 2005? At every possible opportunity they have acted in concert to be an impediment to realizing a change in the 4-9j standard. Let us look back at the record as it unfolded over the past few years. After doing several crash and burns in an effort to change 4-9j through standard governance procedures I realized that an end around procedure was needed to get past individuals who steadfastly refused to even consider a change in the magnification/microscope standard let alone permit meaningful debate. I can assure you changing the magnification standard would never have seen the light of day by a “Knowledge Based Governance” committee. So my friend and colleague, Joseph Dovgan, an ardent supporter of strengthening 4-9j, with a little editing from yours truly, put together a petition that was signed by over 200 clinicians and a few educators. Included in that petition was a newly formatted intent statement. It read as follows:

 

Revised Standard:

 

          4-9 j Use of magnification technologies:

          Intent: The intent is to ensure that students/residents are trained in the use of the operating microscope in all phases of non-surgical and surgical endodontic treatment. It is necessary to provide magnification and illumination of the operative field beyond that of dental magnifying eyewear to maintain the endodontic standard of treatment. In addition to comprehensive training with the operating microscope, instruments such as the endoscope and orascope as well as other developing magnification technologies may also be included in the curricula.

 

It was our intention to present this petition to CODA which holds a public forum at every annual ADA meeting. That year’s meeting was held in San Francisco. I was not in attendance at this meeting but I have reconstructed events that transpired thanks to the collective memories of Joe Dovgan, Fred Tsutsui (present member of board of directors from District VII) and Mitchell Davich (former treasurer of the AAE 2007-2009), all of whom were present. Mitchell recalls that during the San Francisco Interim Board Meeting (prior to the ADA Annual Session) the Dovgan petition was glanced over and presented as informational to the AAE Board of Directors and the Executive Committee.  Dr. Louis Rossman, the AAE president, objected to it, saying that many members signed it “not really knowing what they signed,” and therefore the petition should be invalidated. The BOD was advised that Dr. Gerald N. Glickman was to prepare a response and testify before CODA. Dr. Glickman apparently could not make that meeting but Dr. Clara Spatafore substituted in his absence with talking points provided by James M. Drinan, J.D.,  the AAE’s Executive Director and an AAE staff member. Fred Tsutsui presented the petition to the CODA committee members and then stood before the committee  and offered the petitioners request for reconsideration on the intent statement of the 4-9j standard. He relayed to me that after his presentation Dr. Spatafore presented the “AAE’s” talking points and stating that 4-9j had just recently been approved (2005) by CODA and the AAE saw no reason to revisit any modifications. What is so completely disingenuous to me is the executive director of our specialty, our administrator, facilitating an agenda in an area he should not be involved in. Article VIII, Section 2 of the Constitution of the American Association of Endodontists clearly delineates the scope and authority of the salaried head of staff. ‘The executive director shall be the chief administrative officer of Association and responsible only for  management functions. This petition was about issues of clinical significance, not about organizational concerns.

 

How about the AAE leadership, what was their throwaway on this issue? What were some of the quotes attributable to our leaders past and present. ‘Long standing endodontic clinicians can’t be expected to incorporate this new technology’; ‘The microscope is a tool not necessary for endodontic procedures’;  ‘He didn’t like the scope because it obstructed his touch and vision of patients while he was working and that it depersonalized the procedure’;  … admitted to not having the necessary advanced skill set and… thought the scope was too hard to use and too expensive to purchase.’; …  said that program directors already had too many requirements, i.e., too many standards and paperwork to comply with. These additional requirements would be too much of a burden on them. For the benefit of these program directors microscope training and proficiency was a red tape hindrance and should therefore not be mandated’. , When an officer of the AGD was at a joint meeting with the AAE hierarchy he asked ‘What’s the story with this microscope petition?’ Obviously there was a buzz going around prior to CODA meeting.  He was answered by a now past-president of the AAE, who assured him…’Oh, the microscope manufacturers are behind it’. These statements are both telling and incomprehensible to me. 

 

A full CODA board met in Chicago for a hearing in January of 2008. Based on the petition tendered to them in San Francisco they referred consideration to change 4-9j to the Endodontic Review Committee (ERC). The ERC is composed of a Chairman, an endodontic educator plus two other endodontic educators as well as a public sector appointee from CODA and a general dentist also appointed by CODA. Dr. Jeffrey M. Hutter, the present Dean of the Henry M Goldman School of Dental Medicine, was the chair of the ERC and kind enough to invite Joe Dovgan and myself to Chicago for that meeting. We came to Chicago on our own dime to have Joe present the argument for a change in 4-9j. Mr. Drinan was at that meeting along with a member of his staff. Was there a reason that the Executive Director of our organization couldn’t even extend some kind of greeting to a past-president of the organization he worked with for 4 years? Apparently, “Us and Them” is very much part of his administrative culture too. Once again our executive director failed to remain at arms- length when issues pertaining to our association came to the fore? Perhaps it might have been better for all concerned if Mr. Drinan demonstrated his neutrality by not supporting a particular side on a clinical issue. Maybe it might be to his and our mutual advantage to create a new culture of transparency and accountability in his administration of our association.     

 

Returning to the microscope it is the conclusion of a sizeable number of clinicians and some educators  that PG’s and residents that do not obtain this operating microscope skill set during their programs are at a significant disadvantage when diagnosing and  treating today’s more demanding referrals from general practitioners. Do you agree with some or all of these statements then perhaps it is time for you to hold our leadership accountable for what some believe is an egregious lack of insight into what defines us as endodontic clinicians.

 

If what I have written about in this 3 part series has no relevance or concern for you then the AAE and its leadership have met your needs for an organization with clarity of thought and a viable governance model. However, if some of what I have penned might be disturbing to you then now is the time for you to question your leadership and our Executive Director and hold them answerable for their actions and agenda. I pass the baton to ‘you’. As Dr. Stephen Schwartz said ‘If there is resonance to the concerns stated, then actions should be taken, if not, the moment will pass.’ Colleagues, the rest is up to you!

 

 

…made weak by time and fate, but strong in will to strive, to seek, to find, and not to yield. Tennyson; ULYSSES

 

Respectfully submitted,

Marc Balson

Editor, New Jersey Association of Endodontists

(Part III of an editorial/ blog published in www.njendo.org/)

At the past president’s breakfast held in Orlando this past April, then president, Dr. Louis E. Rossman, and the Board shared some good news about ending our contractual relationship with Edelman, the Chicago advertising firm that the AAE hired in 2005 to run our Public Awareness Campaign. As some of you may recall, I wrote an editorial in February of 2009 questioning the metrics of this campaign and its effectiveness in raising public awareness in regards to our specialty (Please go to the website to see this editorial.…www.njendo.org/). Now even though we are no longer committed to a professional public relations firm at the moment, we are still paying an additional $125 to Chicago for a future public awareness campaign (the RFP ((request for proposal)) is due sometime in 2010). The first and foremost question I have for our present leadership is ….How does the AAE justify this supplemental charge when they raised our dues last year and continually raise annual session fees during a time of significant economic hardship to all endodontists? The recovery may well be a few years in the making. Secondly, what type of program does the Public and Professional Affairs Committee (PPAC) and the AAE Board of Directors plan to implement that would produce the impact and traction necessary to be successful in light of the past 4 years? Edelman, in my opinion, failed to show any metrics that could justify giving them over $2,000,000 dollars of your hard earned money? Most of you don’t realize that the American Association of Oral and Maxillofacial Surgeons and the American Association of Orthodontists separately funded over $10,000,000 collectively in public relations campaigns of their own. What lessons should we have learned from them? Perhaps our Executive Director, Mr. James M. Drinan, could enlighten us. He worked for the AAOMS and the AAO before he came to the AAE in 2001.

The $125 we are required to give the AAE as a supplement to this year’s dues begs the question….should not the collection of this assessment involve accountability and transparency too? Do we have the right to know if this mandatory assessment is dedicated to a viable and carefully organized public awareness campaign or are these monies quietly earmarked as “TARP” funds for shortfalls in the AAE’s 2008 & 2009 budget? Do we really have a budget surplus or the illusion of one created with an accountant’s version of smoking mirrors. Why won’t or can’t the AAE’s Board of Directors and our staff give the membership a full and un-sanitized account of these monies? One only has to take a look at the current meltdown of the ADA and almost every one of its divisions that is being caused by the failure in transparency not only to the members at large but to those responsible for the governance of the organization. The ADA’s audit committee has now hired its own independent auditor to act as a checks and balance for the membership. Their foundation is currently under audit and it is well known what happened to ADABEI and the millions of dollars spent and lost by the Association due to the failure of systems and the lack of transparency.

It is now January 2010 and 6 months have passed since the collection of this mandatory supplement. On the AAE’s website (AAE.org) in the Members Section the yearly Annual Reports are provided going back to 1995-1996. Look into the 2008-2009 Annual Report and go to page 10. It gives a less than comprehensive budget report showing cursory revenue and expenditure lists. The fiscal year (2008/2009) shows a surplus of $303,626. As of June 30, 2009 the Membership Demographics census shows there are 4,165 active members (page 9). If my calculations are correct those members paid $520,625 to the AAE for a dormant program.

If you look at the line item designated PA Campaign (Public Awareness Campaign) in the chart below you will see the column marked YTD (Year to Date) Actual (9/30/2009) with $38,270 in expenses in contrast to the column marked YTD in Prior Year with expenses of $40,425. That explains the expenses based on the quarter ending 9/30/2009 and 9/30/2008. Now don’t forget this is an Annual Report. Yet the AAE Board of Directors, the executive committee and our executive director for reasons known only to them haven’t given you any information about the other three quarters in 2008 or 2009. Something puzzles me with their financial calculations. Conservatively, they have probably taken in close to a $1,000,000 over the last two years (2008 & 2009). Yet according to their own annual report they spent about $800,000 for the campaign in the last two years. That leaves the AAE with an estimated $200,000 surplus collectively for the past two years. Again, please remember, the Public Awareness Campaign ended in April of 2009. Admittedly, this is an estimate at best but since the AAE does not provide detailed financial reports to its members I have no way of providing you with comprehensive line item revenue and expense spread sheet for the PA Campaign assessment.

I believe the operative question we should ask the AAE’s Executive Director and our Board of Directors is…..”Why haven’t you provided us with a comprehensive line item spread sheet for the PA Campaign? What was done with the other approximately $200,000 collected in the past 2 years? Isn’t it time the membership had a full accounting of this project with Edelman from beginning to end?” Should the BOD’s fiduciary responsibility to its members be veiled in unfathomable accounting jargon like a credit card disclosure statement or can we finally have a clear and unambiguous explanation of the AAE’s annual budget? Before anyone jumps to any conclusions on my queries please unequivocally understand I am not accusing anyone of financial malfeasance or impropriety.

However, I respectfully ask, and so should you, for more accountability and transparency. How did the Board of Directors and our executive director spend this extra revenue over the last two years and what are their future plans for the campaign monies generated this fiscal year? Were these monies placed in our General Operating Expenses/Revenues to bolster our bottom line or are they clearly earmarked as dedicated funds to be spent only by the PPAC for the Public Awareness Campaign. I believe these are legitimate questions that deserve to be answered by those who have the “real” information to assuage the concerns voiced by many.

Is this continuing mandatory dues assessment providing a meaningful “bang for the buck” for our membership or is this a convenient windfall used to shore up depleted financial resources? I don’t know what the answers are to the questions I have posed. At this point the only thing I know is the AAE is short on disclosure and accountability. If the AAE were not a 501c 3/Non-Profit organization and had to submit to more stringent government disclosure requirements they would never be allowed give a public financial statement that was so scantily clad. However, should the AAE leadership and the executive director wish to respond to this editorial and give us their side of the ledger, so to speak, I will be happy to publish their response on our website. As members of the AAE we have the right to a comprehensive and full financial disclosure. It is time for the leadership and staff of our organization to give us a detailed accounting of the financial position of the AAE. Looking at the present format of our annual financial report is like reading the Monarch or Cliff Notes” to Chaucer’s Canterbury Tales. Transparency is a much abused term but in this instance I believe it to be an appropriate and accurate expression to employ. The top of the financial position report suggests that if you have any questions about the financial position of the AAE you should call our Treasurer, Dr. Robert S. Roda, the AAE Budget & Finance Committee (who are its members?), the Executive Director James M. Drinan or the Chief Financial Officer Jerry McDonald at headquarters for further explanation. That offer doesn’t really do it for me. How about you? Has the leadership ever thought that anything less than full financial disclosure to our membership just might engender some legitimate distrust in the way our organization runs our business? Perhaps it is one of the markers that have precipitated the fractionalization of our membership. This concern has been voiced by me and many of my colleagues across the country including past presidents and current members of our Board. It’s time for the AAE to acknowledge meaningful and constructive dissent and not treat everyone with a dichotomous opinion on an issue as a threat to the leadership and staff of the AAE. The Board of Directors should be reminded occasionally that the privilege and honor of leading this organization also carries the responsibility of transparency and accountability. The JOE should be a conduit for members to express themselves and voice their opinions. Scientific exploration and political dissent or agreement can and should coexist in our journal.

“It does not require a majority to prevail, but rather an irate, tireless minority keen to set brush fires in people’s minds.” Samuel Adams