Clueless in Chicago?
(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
- 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:
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
Editor, New Jersey Association of Endodontists