Reflection: “A frog in a well”

There is an old Japanese expression and similar sayings in other countries, “A frog in a well knows nothing of the great ocean.” Often we get in a routine of doing things the same way over and over again and expecting different results, often described as insanity. Too often it is easy to dismiss evidence-based decision-making and inquiry into the quality of evidence by rationalizing, “I am a clinician.” Some evoke possibly 20 years of experience as the validation, but was it 20 years with growth, change, and reflection, or was it 1 year, repeated the same way 20 times? Clinical experience is still very important but in juxtaposition with a more comprehensive approach such as evidence-based clinical practice (EBCP), which considers quality of evidence, particular clinical circumstances, patient-values (autonomy), and clinical experience. If it is only clinical experience, then is the person who is in practice the longest the expert? Hathaway and Long¹ quote Dr. David Sackett as saying, “We cannot confidently infer anything about efficacy through the study of patients outside of a trial.” Likewise, Dr. Carl Sagan, the famous astrophysicist, said, “Extraordinary claims require extraordinary evidence,” the Sagan Standard. Have we come far enough since evidence-based dentistry was first described in 2004 by Ismail and Bader in the Journal of the American Dental Association²? Many experience-based orthodontic practices show enough treatment and financial success to tremendously support a practice. Yet some level of treatment success does not necessarily equate to treatment efficiency and effectiveness.

At the recent 2017 AAO Annual Session in San Diego, it was gratifying to see many high-quality evidence-based presentations, while on the other hand, there were still presentations showing only cases with limited records, no evidence, and personal opinion.

The problem may not be solely with the clinician who is resistant or overwhelmed by the challenge that EBCP entails, but more a lack of educational resources to interpret research findings in a friendly and understandable way. There are currently some excellent social media blogs such as those written by Dr. Kevin O’Brien and Dr. Peter Miles that interpret research findings and present clinical implications. There are also two books on evidence-based orthodontics by Huang, et al.,³ and Miles, et al.,⁴ that can be helpful to the clinician. Also this journal, Orthodontic Practice US, presents some relevant clinical research in an interesting and friendly way, whereas often journals publish esoteric research that has little to no clinical impact or importance.

Let’s challenge ourselves to see the great ocean and not be the frog in the well, and reflect on our practices, so they are evolving, embracing change, and the challenges of EBCP.  — Dr. Dan Rinchuse