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Sir,- I should like the opportunity to respond to your thought-provoking leader, 'A matter of taste' (BDJ 2003, 195: 293) concerning the implications of consumerism for dentistry.

In thirty years of dentistry, I have always been keenly aware of the need to address the psychological needs of patients.

This can take many forms, but relevant to the subject under discussion here is the need to inform, explain, discuss, answer queries and advise in relation to a patient's care, and to give that patient the benefit of whatever choice exists.

My experience of relating to patients in this way over the years has taught me that these necessary aspects of my work can meet with varying levels of success. We live in an age of readily available information, and we hunger for information in order to make appropriate choices.

It can therefore be easy, via popular press or Internet, for example, for patients to acquire a little learning, time-honoured as possibly being a dangerous thing.

If information is to be of any value, it must first be understood by the recipient, and then processed along with other items of information in fully appraising a situation, and then making a decision about it. Full understanding comes from the combined exercise of knowledge and intelligence.

Decision making involves an extension of this, but in the case of patients making healthcare decisions, there will nearly always be significant emotional factors in addition, which, rightly or wrongly, may influence their decision.

Without wishing to sound unkind or patronising, it is an inescapable fact of life that we all have a different mix of talents, and it must be common experience that some of our patients are not, and never will be, capable of fully understanding the subtleties, nuances, technicalities and complexities of dentistry, even if we were to try and give them a 'crash course' in their particular dental problem.

Even very intelligent patients often lack sufficient dental knowledge to allow them readily to understand the finer points relevant to their treatment.

It does, after all take five years to train a dentist, even to basic qualification level. Whilst one might have a good chance of success explaining the technicalities of bridgework if one's patient is a civil engineer, the same might not be expected of a doctor of theology.

And I am sure we will all have encountered patients for whom all regions distal to the canines are as familiar as the far side of the moon! If one adds to the shortfall in knowledge or ability to understand, the amount of prejudice, myth, misinformation, mistrust and suspicion which many patients hold about dentists and dentistry, it is easy to appreciate how complex and difficult it can be for us to relate meaningfully to our 'consumers', and vice versa.

Patients sometimes approach us with preconceived ideas, and request inappropriate solutions to what they see as their needs. Telling us what they want is fine, and desirable. But having patients telling us how they want us to achieve what they want is not good news. Some patients can be very insistent, and are unwilling to be advised otherwise.

I sometimes wonder whether such patients, if asked whether they would like their treatment plan to be drawn up by an unqualified person, would give an affirmative answer! But I am not, here, promoting the dictatorial, paternalistic approach of yesteryear, as I believe in self-determination for patients, in agreement with your editorial.

Self-determination is a basic human right, but like all the other rights and freedoms we hold dear, it comes inextricably linked to personal responsibility. Consequently, consumerism in healthcare is a double-edged sword. For patients to be involved in decision making about their dental care is good, but patients cannot expect to be absolved from the responsibilities which go with those decisions, and which belong fairly and squarely in their court. Dentistry, like the rest of human activity, is not risk-free. If a patient has treatment explained, accepts it, has it carried out to a good standard, and then becomes disappointed with the outcome because they did not understand the explanation, or had undisclosed unrealistic expectations, but 'went ahead anyway with fingers crossed,' whose fault is it?

The dentist's fault for not painting a black enough picture? Or the patient's for failing to understand? Similarly, should we always tell patients what we think they need to know, and risk blinding them with science in the process, or should we wait for them to ask questions, hoping and praying that they ask the right ones to keep us out of court? Or to cover all eventualities, perhaps we should do both?

Either way, it can become very complicated, takes time and patience on the part of all concerned, sometimes needs to be repeated, and often, one feels, would be prudently put in writing! Not so long ago, a well-known consultant psychiatrist, popular in the media, pointed out that even when people are given well-constructed, rational arguments illustrating clearly that some aspects of their behaviour are unhealthy or undesirable for them, and despite those people understanding the arguments and agreeing with the conclusions, their undesirable behaviour often continues unchanged ('It won't happen to me').

Patients can and do make healthcare decisions in the face of clearly demonstrable evidence that mitigates against those decisions. The pervading concept in your editorial is that of 'taste'.

I would like to add two similar words to the discussion. 'Truth' and 'trust'. These are particularly relevant with respect to the point you raise regarding 'professionalism versus commercialism', and whether we should follow the lead taken by the rest of society. Just because something is 'new', it does not automatically mean it is 'better', nor does it mean it is 'good'.

The Advertising Standards Authority requires that advertisements be 'legal, decent, honest and truthful'. The mere fact that such an institution exists to ensure this, logically indicates that some advertisements would not meet these requirements without such regulation, and the Authority has already made an adverse judgement involving dentistry, in the case of a dentist's advertisement deemed inappropriately to use the title of 'Doctor', a situation which, I would suggest, was entirely predictable.

There is a great deal of psychology involved in advertising and marketing, which makes it possible to convey a desirable impression to the consumer, and to the vendor's advantage, not by telling lies exactly, but by economising with the truth.This suggests deception, which I would hope we would not want to be associated with any field of human endeavour which calls itself a profession. An advertisement may promote a treatment as if it were suitable for everyone, but it may not be so.

It may tell no lies. It may tell only truth, but is it truth 'full'? I do not disagree with the professions, including ours, being permitted to advertise, but they must do so with caution and responsibility. The reason is very simple. Professions, traditionally, have expected, and continue to expect, the respect, honour and trust of the public. I personally feel it would be impossible for me to treat patients without their trust. If we do not demonstrate honour and truthfulness, we have no right to expect trust.

If we wish our patients to trust us, and that can be difficult enough already, let us not risk the abandonment of truth by allowing it to be cosily diluted or sacrificed on the altar of the individual's definition of 'good taste'.

Otherwise, we will be inviting abuse, and human nature being what it is, that is precisely what we will get, and the result will be the erosion of our cherished professional standing. Traditionally, the professions have been charged with the responsibility of setting and upholding standards of behaviour and moral values for the rest of society. We are expected to be role models. Are we now to give up that role and determine our behaviour along the lines exhibited by 'the rest', some examples of whom can be seen on popular television audience participation programmes, expounding their views, exposing their prejudices, parading their self-interest, and are enough to undermine the thinking persons' faith in democracy? I hope not.

Within the last year, we have received the report of the Office of Fair Trading, which called for a number of improvements in the way our profession relates to its consumers. I would suggest that some of the shortfalls highlighted could be attributed directly to the profession's inclination to follow business practices which might otherwise be associated with the less reputable.

Rather than taking our lead from the rest, should we not, as professionals, be helping to form the vanguard and setting examples for them to follow instead? I conclude with a modified quotation: 'There are lies, damned lies, statistics.... and advertising'.... if you're not careful. Ars...Scientia...Mores?