At one time or another, I have joined four professional groups that required the submission of patient records for peer review. Of course, like everyone else, I displayed my best and most complete treatments and thereby gained entrance. Looking back on it now, I believe I might have become a much better orthodontist had the groups requested me to display the absolute worst treatments I had ever completed. My colleagues could then have offered possible solutions, and I might have learned much earlier how to avoid mistakes that seemed to recur with amazing regularity.
Rather than requiring applicants and members to display their best work, peer groups would be better served by asking for consecutively treated patients. The highly regarded Utah Tweed Study Club, composed of Holdaway, Rampton, Crockett, Miller, Van Dyke, Anderson, Curtis, and Knell, used this method to help develop some of the world's best orthodontists. The member whose turn it was to host the monthly meeting would display the records of the last 10 consecutively treated patients, which the other members would then closely evaluate and openly discuss. This arrangement is not for the supersensitive or the emotionally insecure, but I can hardly imagine a better way of continually improving orthodontic skills and knowledge.
Similar articles from the archive:
- THE EDITOR'S CORNER Who Knows What the Outcomes May Be? March 1995
- THE EDITOR'S CORNER A Good Word about Failure January 1994
- THE EDITOR'S CORNER February 1979
Orthodontic study groups were originally organized to promote excellence in therapy, but many evolved into cliques that embraced particular philosophies or techniques. Treatments or presentations that did not adhere to the groups' rigid codes were considered grounds for denial of membership. Such an approach discourages the innovation that requires trial, error, and failure as the tuition for improvement. A little more thought would help these professional congregations see that the key to organizational and individual learning is to grasp the value of failure.
Truth be told, not many of us have the courage, self-esteem, and willpower to examine our own defects. We live in a society and an era that is interested only in success. "Benchmarking" now preoccupies many large corporations as they seek to emulate those who are best at lowering costs, increasing profitability, and maximizing growth. Likewise, orthodontists eagerly seek out gurus who somehow have convinced them that they hold special secrets of successful mechanics, practice building, occlusal therapy, or TMD treatment.
Unfortunately, when a system is working well, its success depends on a long chain of subtle interactions, and it is not easy to determine which links in the chain are crucial. Even if the critical links were identifiable, their relative importance would shift as the universe around the system changed. That is why orthodontists can probably learn more by studying their own failures than by emulating success.
Aside from our preoccupation with success and the psychological and cultural threats posed by the study of failure, however, there is another reason we are not eager to undertake such self-examination: It is just plain hard to do. We can't always pinpoint exactly when during the past 24 to 30 months we began to lose the maxillary anchorage, or why the maxillary incisor intrusion was inadequate, or what caused the extension of treatment.
Gottlieb proposed a self-assessment of treatment results many years ago (Grading your orthodontic treatment results, J. Clin. Orthod. 9:155-161, 1975), and another version of the same idea is presented this month in an article by Starnes. Some variant of this system can be used to good effect by those without a group affiliation. Self-review is not as useful as peer review, but it is certainly better than no review.
Frederick Reichheld, a director of Bain and Company, suggests that asking why questions helps to discover the root cause of a failure. For example:
Why did the treatment turn out badly?
The patient would not cooperate with treatment.
Why would he not cooperate with treatment?
He constantly broke his Herbst appliance.
Why did he break the Herbst appliance so much?
It restricted his mandibular movement.
Why could he not tolerate restricted mandibular movement?
He has a low tolerance for discomfort.
Why does he have a low tolerance?
It is a genetic quality.
Why did we not recognize this and plan an alternative treatment?
Why indeed?
After five or six whys, it is easier to see what needs fixing, when, where, and how. It may take a few more questions to figure out the solution, but a series of why questions can put us on the road to understanding our failures.
The study of failure may challenge our self-esteem, threaten us psychologically, and intimidate us emotionally, but nothing holds more promise for improving our professional skills. As Vilfredo Pareto said more than 70 years ago, "Give me a fruitful error any time, full of seeds, bursting with its own corrections."
LWW