July 19, 2008
Members of the class of 2010, welcome to the White Coat Ceremony. You have good reason to feel proud and afraid, both at the same time today. You all have worked so hard to get here, and done so well!
This is the first year that we have worn white coats on the stage at this ceremony, and I have to tell you about an unexpected benefit. As students know, I virtually never wear a white coat, as the white coat symbolizes something quite different in the world of psychology. Nonetheless, I've noticed that the coat conveniently conceals any number of fashion errors and appearance problems. I may have to start wearing this thing at school from now on!
When the dean originally asked me to speak to you this morning, I let him know that I would need about an hour up here to get the job done properly. I also told him that I could make do with just 45 minutes, if time were tight. His response was that I could have ten minutes only, and I was lucky to get that, so we had to engage in some pretty intense negotiations. I knew that what I have to say here could make a big difference in your lives and careers. So, I'm going to use the remaining nine minutes of my time to urge you to think of yourselves as doctors for the rest of your days — not just tooth technicians or tooth detectives or small-business people or entrepreneurs.
This is a big moment, because you are about to enter the world of the doctor. As a doctor you will have the privilege to listen to the concerns and the pains that other human beings experience, and then you will put your talented and well-trained hands on them to help them. You will alleviate pain, resolve occlusion, and remove disease and infection. These are the same hands that have labored so long and hard in preclinical laboratories for oh-these-many-months to prepare for this moment. Now, all that hard work and stress and strain will be put to good use on behalf of others — not just plastic teeth.
To prepare for this talk I sat down and tallied the number of student ethics papers I have read over the past 14 years, each describing a real life dental ethics problem. That number turns out to be 2,240 papers - They represent 2,240 ethically challenging situations, so I have a pretty good idea about the scope and dimensions of the dilemmas that you will face in the clinic. Hopefully, you won't encounter 2,240 ethical challenges, but believe me, there will be many.
In order to be brief I've condensed my findings into ten short recommendations. None of this is likely to be new. You've heard it all before, but a little review never hurts, especially on an occasion such as this.
Patients are not a means to an end. They are not a way for you to get what you want or need. In school you will regularly be tempted to put your "requirements" or thresholds or test cases or grades ahead of what is best for your patients. They typically have no clue about this background plot, and are counting on you to do the right thing for them. Here's a tip: sometimes, if you let them in on the situation, if you let them know what's going on, they will offer to cooperate with you and your educational needs. Our patients can be wonderful if you give them a chance. You might even discover a win-win situation.
Older, successful dentists will tell you that dentistry is really a people business. Without the people, you don't have any teeth or gums to work on. No endo, no perio, no implants, no fixed, no removable, and no graduation. If people don't trust you, if they don't like you, if they are uncomfortable around you, or if you are intimidating, they will avoid you even if you are really smart and well-trained. It's human nature. So, it's essential that you form solid relationships and then strengthen them as you go along. That's really what makes it all work.
Good rapport is magical because it is an elixir and a fixer. If you make an error and have good rapport, the matter can often be easy to resolve. People will forgive you. If you make a mistake and have weak or negative rapport, you've got a problem. If there is ambivalence or uncertainty in the treatment situation, good rapport will allow you the benefit of the doubt--something of great value in our clinic, to be sure. If you have bad rapport, a moment of uncertainty can open the door for payback or even a little round of "gotcha," and that makes everything more difficult.
A prominent researcher in the couples therapy field has shown that relationships are much more likely to succeed when partners are open to the influence of the other. The same thing is probably true in the doctor-patient relationship. This means that you have to take time and mental energy to really listen to your patients and hear what they are trying to get across. This may not always be easy, and they may not communicate directly or clearly or positively, but it will always be worth the effort. You won't have to tell them that that you care or that you understand. They will recognize that. Plus, you might just save yourself a lot of time and trouble if you have an accurate feel for what's on their mind. Hand skills are essential, but you will not succeed as a doctor without empathy.
Recall that the title "doctor" derives from the Latin word for teacher. You can do much more for a patient by helping them take charge of their own oral health than you can by making a beautiful crown. This means really teaching and checking and giving feedback and demonstrating — and then going back over it again next time you see them. This sends the message that hygiene and home care really matter. It involves problem-solving and figuring out what's getting in the way. Simply telling patients that they need to brush and floss more will not help. In fact, it might even make things worse. Patients withdraw from perceived criticism and condescension. Few of us like to be criticized and we don't like the people who offer the criticism. Teach your patients instead. Work with them, and through your actions and interest, demonstrate hygiene's real importance.
Most people hate conflict. Nevertheless, conflict is inevitable. If you avoid it compulsively or if you cannot set limits and say "NO" appropriately, you're dead. You are certainly headed for big problems — I guarantee this. You must enforce your boundaries. Stop avoiding conflict, and teach yourself to have challenging conversations with patients, with teachers, with partners and with family. I'm not urging you to pick fights; but positive confrontation can be the best form of communication if you can figure out how to do it effectively.
Find something good and comment on it regularly. None of us gets enough positive reinforcement. Do you? Think about it: how tough is it to say "Thank you. That was really great what you did." Force yourself to do this until it becomes a habit. This habit will pay great dividends.
Along those lines, remember to behave positively and look happy in the clinic. It's easy to get so focused on the technical aspects that you appear grim and worried to patients and teachers. Your patients need comfort and you need to show them a confident face. This is an important part of doctoring. Train yourself to look positive even when you don't feel that way, especially around patients.
It is normal to fear a visit to the doctor. Dental fear is so common as to be a stereotype. Even dentists are afraid to go to the dentist. But people don't always act like the stereotype. Frightened people act angry or rude, some make jokes, some get silent, some question everything you suggest, some forget appointments, some show up late, and others drink or smoke before their visit. Consider the possibility that fear might be behind any of these behaviors.
There has been a long and arrogant history, a tradition even, that doctors don't admit mistakes. In fact, medical schools used to teach students that doctors don't even make mistakes. Imagine that. It should come as no surprise that this attitude causes problems. Thankfully, things are changing. Lawyers have even begun to recommend that we appropriately apologize to patients from time to time.
It will be impossible for you to make it through the next two years without making an error. This means that you will certainly face a hard decision: Do I own up to my mistake or try to finesse my way out of it? Guess which path works the best in the long run? Guess which one is more professional.
Make a commitment to tell the truth for the rest of your career. This will create some difficult moments to be sure, probably some embarrassing ones, but you will never regret this stance. People will be impressed, and your credibility will grow. You will become special. The most direct route to mediocrity is to take the easy path and say whatever needs to be said to smooth things over. Nobody respects that, and patients will eventually figure you out. When you tell patients and teachers a difficult truth, that sends the larger message that you are trustworthy, and that everything you say is true.
Obviously, most of this good advice is pretty hard to do. I certainly don't have it all down, myself. But these core ideas will work if you will just keep them in mind and practice them. Grow yourself in these areas. If you can learn multi-rooted endo, you can certainly learn the things I'm advocating today.
But, those were only nine principles. Here's the last one:
You can start this in just a few minutes. Take time to appreciate what you have accomplished, and do this continuously throughout your career. You've gotten through the first year of dental school at the University of the Pacific, a world-class accomplishment. You've made it into the clinic and you've put yourself into a very good spot in life. Congratulations.