By Christine Goertz, DC, PhD, and Michele Maiers, DC, MPH, PhD
Recently we had the rare opportunity to meet socially over coffee. After the requisite admiring of each other’s kid pictures, we started talking about doctor/patient interactions. Only in this case, the chiropractor was the patient instead of the physician. Each of us had recently been to the dentist. Both dentists were professional, friendly, conducted a thorough patient history, and performed an appropriate examination. Then both dentists wanted to take intraoral X-rays as part of the examination process. Armed with the evidence and knowledge about current American Dental Association (ADA) guidelines, we each declined X-rays , based primarily upon concerns about unnecessary exposure to radiation and cost. From that point on, our experiences became very different.
The dentist minimized my concerns, stating that X-rays were a standard part of the clinic’s protocol for care, and would be covered by her insurance. He was not able to provide a sound clinical rationale for taking X-rays, and even made up statistics for how frequently they resulted in a finding of clinical significance in an asymptomatic, low-risk patient. I declined the X-rays and began looking for another dentist for myself and my family. Why? Because the dentist seemed to be focused entirely on his own clinical judgement--namely that all patients should receive an X-ray regardless of the underlying condition. He seemed unaware or uninterested in evidence-based ADA guidelines that were contrary to his recommendation and did not give appropriate consideration to my preferences.
The dentist listened carefully to what I had to say, asked good questions about my concerns and then explained why he thought X-rays were clinically indicated in this particular situation. He was knowledgeable about ADA guidance regarding taking intraoral X-rays and told me that he does not routinely order them on every patient. He explained that I had a cavity that appeared to go below the gumline and that he needed an X-ray to guide him in making a treatment recommendation. I agreed to the X-rays and made an appointment for my six-month check-up before leaving the office.
Our conversation then turned to the lessons learned here that can be applied to ACA’s Choosing Wisely recommendations. Choosing Wisely exists to provide information to foster a meaningful dialogue between clinicians and their patients, a dialogue that should be informed by the current state of the evidence, clinician judgement and patient preference. It does not establish coverage decisions, or blanketly deny access to specific treatment or tests.
Choosing Wisely recommendations are not the last word on treatment decisions – the doctor and the patient are -- but they do provide a starting point for the kind of productive discussions we had with our dentists. We encourage everyone to be open to this type of dialogue; after all, which dentist would you prefer?
Dr. Goertz is the chair of ACA's Committee on Quality Assurance. She is also ACA’s senior scientific advisor and CEO of the Spine Institute for Quality (Spine IQ).
Dr. Maiers is a member of the ACA Board of Governors as well as Associate Dean of Research and Knowledge Transfer, and a principal in the Center for Healthcare Innovation and Policy, both at Northwestern Health Sciences University.