‘Satisficing’ in dentistry: who decides? who benefits?

‘Satisficing’ is a word made from combining ‘satisfy’ and ‘suffice’. It means choosing something, or a solution, that is sufficient for it to be satisfactory for the purposes at that time. ‘Satisficing’ is often used as a contrast to ‘maximizing’. ‘Maximizing’ involves seeking the single, supposedly best, outcome or solution to a problem.

Satisficing might sound like a new and unfamiliar word – or one invented by the authors of this article – but in fact ‘satisficing’ was described as long ago as 1956 by an eminent American economist and psychologist named Herbert Simon who went on to win the Nobel Prize for Economic Sciences in 1978. In his acceptance speech, Herbert Simon stated that decision-makers can ‘satisfice’ either by finding optimal solutions for a simplified world, or by finding satisfactory solutions for a more realistic world.¹

‘Satisficing’ in daily life

Satisficing is a ‘cognitive heuristic’, which is a posh term in psychology for what most dentists would call a ‘rule of thumb’. Heuristics are shortcuts that our minds take to arrive at an acceptable decision quickly. We do that frequently in real life, but not necessarily when it comes to dentistry, or when dealing with unusual dental problems.

An example of ‘satisficing’ could involve the following scenario:

• You want to go on a holiday and ideally you would like to be picked up by your chauffeur at mid-day, fly first-class, stay at a seven-star hotel, in a penthouse suite, with an absolute guarantee of perfect weather throughout your trip… but that's not really feasible. Instead, you examine your real requirements and priorities, and then choose an airline and ticket(s) to leave at a reasonable time, from a convenient-enough airport and opt for an appropriate destination, at a time of year that offers a reasonable prospect of getting your preferred weather conditions, and a hotel that appears likely to satisfy your needs and requirements. You then book that lot instead, and usually you are reasonably content with your choices – if your main expectations are met. That's ‘satisficing’ and we do it subconsciously every day, when choosing a car, a house, a restaurant or – dare one say – a partner (but don't tell them that). (Ever).

‘Heuristics’ often look second best to people who think that all decisions should be optimal, and all outcomes perfect (or within touching distance of perfect). They can also feel second best to healthcare professionals and others like us who have a scientific background and place a high value upon certainty and accuracy. However, in the real live world, rules of thumb are essential and often offer the best practical option in the time and resources that are actually available.

The primary reason we have evolved to ‘satisfice’ is that we must make decisions in a very uncertain world. When that is the case, those decisions are often very different to what we might do when we have all the relevant information, all the time and resources in the world, and when every single factor is known and controlled. It is precisely because that isn't the kind of world we inhabit, that we rely on heuristics simply to get us through life rather than becoming buried under and trapped by all its complexity. And we can do so with reasonable confidence and comfort because our scientific background also tells us that today's certainties only last until they are disproved by tomorrow's scientific and technological discoveries and advances.

So, what has satisficing to do with dentistry?

This article is deliberately challenging. It invites the reader to reflect upon the ways in which they and/or their professional colleagues use and apply their knowledge and influence to present treatment options to patients and perhaps steer them towards a more (or less) interventive or destructive approach. At one end of the spectrum of treatment possibilities the options are simpler or more pragmatic, while at the other they tend to be more perfectionistic. Along the way, this article will ask who (really) benefits from the approaches being advocated or promoted (or ‘cui bono’ as lawyers quietly murmur). It will question why some clinicians might cling to their favoured approach, even in the face of compelling evidence that equally good – or perhaps more appropriate – outcomes could be achieved in other ways.

Any professional or highly specialized field creates a profound imbalance of power and influence, as well as of technical knowledge and understanding. The customer/recipient of the service is almost always at a significant disadvantage and will be heavily reliant, usually, not only upon the knowledge, skills and advice of the service provider, but also on their ethics and professionalism.

Standards are central to any kind of professionalism. True professionalism requires adherence to acceptable and sensible contemporary standards, which in turn implies and demands an up-to-date awareness and understanding of them.

Philip (‘Phil’) Crosby is widely recognized as having been one of the most influential contributors to the field of quality and its management in organizations internationally. Crosby always maintained that quality relies on the consistent achievement of defined standards, but in the same breath he emphasized that this is too simplistic a view. The following short extract from one of his many books summarizes a key theme of his approach and has a particular resonance for many dental practitioners:²

‘True quality is determined not by the person providing the product, but by the end customer.

Too many businesses have a selfindulgent, inward-facing perception of quality in a technical sense, and too few of them measure quality in terms of how well the product or service meets the needs, expectations and demands of the customer.

They are preoccupied with their own parameters of quality and they will place the highest value on whatever they think they are best at.’

Quite understandably, people who have acquired highly specialized skills will place a high value upon them, but the downside is that they might dismiss or undervalue equally important, but more commonplace skills, or might ‘rubbish’ alternative treatment approaches that might call into question the claimed pre-eminence of their own preferred skillset.

Any of us might have a subconscious bias whereby we value, recommend and provide treatment that plays to our strengths and preferences, and ultimately our self interest. But, when selecting areas for improvement, or making decisions about what to audit, or how to ‘position’ ourselves, our practice, or our ‘brand’ in a marketing sense, we should ensure that our efforts not only make sense in their own right, but that they will also be beneficial in a currency that patients will recognize and benefit from. Even the highest technical standard of dental treatment is of questionable quality or of real patient benefit if it is not necessary, or not what that patient wants, or not in that patient's best long-term interests. It is the height of self-indulgence, bordering on narcissism, to do precisely what we choose to do in order to satisfy our own preferences and priorities, while trying to convince our patients, ourselves, and others that we have higher and more honourable motives (Clinical Case 1).

Clinical Case 1Contrasting ‘satisficing’ and ‘maximizing’ approaches for managing two dead and discoloured maxillary central incisorsA 35-year-old male presented at an acute dental care department with two failed free gingival grafts. They had been placed 4 days previously at the labial aspects of two dead, discoloured, maxillary central incisors. The patient was in considerable distress from the pain from the donor and the recipient sites (Figures 1–4).

Figure 1. The patient presented with two failing free gingival grafts.

Figure 2. One graft had sloughed off, and one painful one was about to fall off. Note the cracks.

Figure 3. Palatal wound 4 days after the free gingival grafts were taken from there.

Figure 4. Two free gingival grafts had been sutured to the attached gingiva and also ‘lassooed’ around the central incisors.

The immediate management was conservative with analgesia, gentle debridement, and reassurance while waiting for the second necrotic graft to fall off (Figures 1–4).At a subsequent review, the detailed history obtained was that the two upper centrals had been traumatized during a bike accident 20 years previously, after which both maxillary central incisors had been root treated in a general dental practice. There had been no real problems in all that time with symptoms or signs. The patient did not like the dark colour. Cracks were present and there was a repaired incisal tip (Figures 1 and 2).Apparently, a new dentist that the patient had recently consulted about the appearance, had said that ‘because of the cracks in the upper central incisors he had to have two post crowns’. However, ‘because of some gum recession, he needed to have two free gingival grafts carried out first by a gum specialist who visited that practice, and who would undertake those for him in order that the gum margins of the crowns would look better’.It appeared that those two free gingival grafts had been done in that general practice by a visiting ‘periodontist’ a few days before the patient attended as an emergency at King's College Hospital, London, where he was seen very soon afterwards by one of the authors of this article (MGK). The patient was in most pain from the palatal wound where the graft had been taken, but also from where one graft had fallen off and from the one that was hanging on grimly to the labial aspect of the discoloured upper right maxillary incisor (Figures 1–4).The patient was managed pragmatically while the various surgical areas healed slowly (Figure 5).

Figure 5. Healing at 2 weeks. Note cervical recession, cracks and discolouration.

Subsequently, at a later appointment after other details had been obtained, including photographs and mounted casts, lengthy discussions ensued about his ‘BRAN’ options (meaning benefits, risks, alternatives, nothing) and their likely limitations.After those discussions and agreement, an alginate impression was taken to make a customized mouth guard for inside/outside bleaching using 10% carbamide peroxide (Figure 6).

Figure 6. The plaster model was blocked out palatally and labially to provide reservoirs of the viscous bleaching gel on both sides of just the central incisors. The customized bleaching device extended just beyond the clinical necks of the teeth. Two windows were cut over the adjacent lateral incisors to allow access for the salivary peroxidase and catalase to inactivate the carbamide peroxide and thereby prevent their inadvertent bleaching.

After written confirmation had been received, access was gained at a subsequent appointment to undertake about 10 minutes of ultrasonic cleaning, which removed all the resin composite tags and the gutta percha root filling material, and the vast bulk of the old blood breakdown iron-containing pigments from the pulp chambers of both of the discoloured central incisors (Figure 7). The ultrasonic tip was then extended down inside the root canals to remove all the old gutta percha root filling material to 3 mm below the cemento-enamel junction (CEJ) (Figure 8).

Figure 7. Both pulp chambers were accessed and the gutta percha root filling materials and all the internal composite tags were removed to allow 10 minutes of ultrasonic vibrations to remove the vast bulk of the discolouring iron-containing old blood breakdown products inside the dentinal tubules.

Figure 8. Prolonged ultrasonic cleaning using different fine tips removed the vast majority of blood breakdown products from the dentine within the chamber, as well as all the composite resin tags, and were used to cut back all the GP down to 3 mm below the CEJ.

As no peri-apical area radiolucency, or sinus, or discharge existed, and there had been no symptoms before the grafting procedures, the residual GP was deliberately not covered with any restorative material. That was a deliberate choice because the bleaching 10% carbamide peroxide gel (which releases just 3.5% hydrogen peroxide) is an oxygen-releasing antiseptic. As such, it kills off any potential anaerobic micro-organisms, but it cannot penetrate through any restorative material.A bent soft metal needle was attached to a tube of 10% carbamide peroxide (10%CP) (Figures 9 and 10). While applying gentle pressure, the needle was inserted to the full extent and then gradually withdrawn, thereby filling the root canal and neck areas, and all the chamber with the 10% thixotropic carbamide peroxide gel, which released 3.5% hydrogen peroxide.

Figure 9. A soft metal needle attached to tube of 10% carbamide peroxide was used by the patient to inject the viscous gel up in to the teeth to get it below the discoloured necks of both incisor teeth.

Figure 10. The soft metal needle should only be gently bent to allow easy flow of the viscous, low concentration (3.5% hydrogen peroxide) bleaching gel to get down well below the discoloured necks of the teeth.

The central incisor areas of the bleaching device (Figure 6) were filled from a separate tube of 10%CP and immediately inserted in the mouth. The 10%CP gel, therefore, was held both inside and outside the discoloured teeth, and it was protected from any salivary enzymes by being inside the mouth guard.The patient injected the bleaching gel down below the CEJ every 2 hours and last thing at night before refilling the bleaching device and immediately re-inserting it (Figures 6, 9 and 10). Carbamide peroxide gel releases hydrogen peroxide most rapidly for the first 2–4 hours to the most important areas of discolouration and hence why the patient used the soft metal needle (Figures 9 and 10), attached to a tube of the viscous bleaching to get it up inside the tooth to 3 mm below the exposed necks of the discoloured teeth (where the enamel is only 0.7 mm thick) (Figures 1, 2 and 5).The combination of the 10% carbamide peroxide gel inside the bleaching device (Figure 6) and the fresh gel injected inside the teeth was worn continuously, apart from eating and including overnight for 48 hours (Figure 11).

Figure 11. After 2 days of that inside and outside bleaching, the patient expressed satisfaction with the colour changes.

The viscous bleaching 10%CP gel was protected from any salivary peroxidase and catalase by being within the customized device, which also protected the gel within the tooth from any largely theoretic infecting Gram-negative anaerobic bacteria.After 2 days and nights of continuous bleaching, the access cavities and both pulp chambers were cleaned out ultrasonically and dried. They were sealed effectively by injecting contrasting colour radiopaque glass ionomer cement (Ketac Cem Radiopaque, 3M-ESPE) using a similar soft metal needle as that in Figure 10 as an interim measure.That radiopaque, visibly opaque, white-coloured conventional GIC does not match any internal tooth colour and conveniently, it also has a poor edge strength (Figure 12). The benefits of using it are that this ensures that, if it is ever required in the future, the last bit of conventional GIC inside the chamber is easy and safe to remove with just ultrasonic tip vibrations and with no danger of perforation, or further alteration of the internal anatomy.

Figure 12. Temporary material sealing in the radiopaque white conventional GIC for 1 week before composite bonding.

Lengthening the upper central incisors to be just longer than their adjacent lateral incisorsThe patient asked whether the tips of the upper central incisors could be made ‘a bit longer’. A possible outcome of lengthening the edge-to-edge relationship of the upper central incisors with the opposing lower incisors was mocked up on the dried, but unetched, enamel using chilled hybrid composite shade A1 (Figure 13). That mock-up was photographed on his phone as a record of what had been promised, no more and no less. The composite mock-up was then flicked off and photographs taken of the edge-to-edge clinical position, but with the discolouration not now being a problem for him.

Figure 13. The teeth were dried, not etched, and a quick mock-up was done using chilled direct composite to simulate the expected outcome and to obtain valid consent.

However, while the patient expressed enthusiasm for those proposed changes in his appearance, the proposed lengthening with direct composite would mean that just those upper incisor composite tips would be placed in shear and tensile stresses from the intact four lower incisors. After further discussions, it was decided to use additive direct resin composite bonding pragmatically to load the much stronger, intact, upper premolars, canines and lateral incisors that could take more occlusal forces and thereby protect those proposed upper central incisor composite tips from shear or tensile loading.Although some very old amalgam restorations were present (Figure 14), the marginal ridges were largely intact and therefore, were deemed to be capable of being directly bonded with additive resin composite and thereby loaded in compression (rather than in shear or tensile stresses) to take more occlusal loads preferentially. That pragmatic additive composite to the upper lateral incisors, canines and maxillary premolars created space between the upper and lower front teeth to allow the previously edge-to-edge maxillary central incisor to be made just longer than the upper lateral incisors, as requested by the patient (Figures 15–17).

Figure 14. The occlusal aspects of the upper teeth were examined for their residual, mainly intact, marginal ridge ring structures.

Figure 15. All the upper premolars, as well as the palatal aspects of both lateral incisors and maxillary canines were bonded pragmatically (without any stents) to be loaded reasonably evenly in ICP. They were adjusted/shaped to separate the tips of the upper central incisors from the opposing four mandibular incisors during all movements. In other words, simple canine guidance was provided, but with the intact maxillary lateral incisors being mainly involved during protrusive movements to reduce shearing forces on the now longer composite tips of the maxillary incisors.

Figure 16. The patient was followed up for 6 years. Apart from a minor polish every couple of years, there was nothing else required.

Figure 17. Question: given the low lip line present, what was the justification for the ‘maximalist’ destructive approach of two free gingival grafts prior to two post crowns (top), as opposed to a ‘satisficing’ pragmatic approach maintaining the residual tooth structure, but still solving the patient's perceived problems?

Who cares and so what?The main point of this clinical case is to illustrate that the ‘satisficing’ approach adopted here meant no destruction of the existing dead discoloured central incisors. However, it did involve extensive discussions (largely to regain patient confidence because of the unfortunate circumstances of the original presentation) and employing sufficient bleaching and bonding techniques to be satisfactory for that patient. This approach needs to be contrasted with the elective ‘maximizing approach’, which had been started so ‘painfully and disastrously’(Figures 1–4) and which involved unnecessarily costly, painful and structurally weakening procedures.

‘Satisficing’ in dental practice

Many dentists have learned by intuition, or by experience, how to ‘satisfice’, and that ability might account partially for why so many are able to work under the NHS UDA (or fee-per-item) systems, and/or under monthly capitation systems and/or in private practice for that matter.

Both dentists and patients ‘satisfice’ because of the many factors outside their control, such as the time, money or skills actually available at that time and/or because of prevailing demands, situations and/or circumstances. Experienced dentists get used to finding reasonably satisfactory solutions quickly for their patients in their real world, rather than endlessly searching for ‘ideal solutions’ for an imagined utopian world that some academics, GDC regulators or opportunistic lawyers seem to believe that dentists and patients inhabit.

Many dental ‘educationalistas’ spend much of their time teaching how to make decisions under idealistic conditions. However, the vast majority of decisions that busy dental clinicians have to make are not of those kinds at all. Relevant information is often only partially available and important factors, such as that patient's cooperation, compliance, or commitment, are unknown at the moment when decisions need to be made. In spite of those inconvenient truths, NHS dentists are required to specify all of the required treatment and to provide a written quotation to a complete stranger, all at the first visit, and they often have to satisfice because of various changes, problems or factors that only become much clearer later on.

Satisficing involves examining the realistically available options until a minimum threshold is met that is deemed to be acceptable. While it would be lovely to have all the time, money, knowledge and skills to make the supposedly ‘best’ decision first time, every time, both patients and dentists ‘satisfice’ to get an acceptable solution that they can live with, or ‘will do’. That probably accounts, in part at least, for the reported wide variation in clinical treatments offered – and accepted – for what might appear at first sight to be similar sorts of problems.

And before any of us goes into denial at this point, let's ask ourselves if we have ever decided to live with a not-quite-perfect impression, or a not-quite-perfect interproximal contour or the ideal contact zones? Or a lower complete denture that is ever-so-slightly less stable than its maxillary counterpart, but is still heaps better than the rocking-and-rolling version that the patient walked in with?

‘Satisficing’ versus ‘maximizing’ in dentistry

‘Maximizing’ is very different to ‘satisficing’ because it involves searching exhaustively for the allegedly ‘optimal’ dental solution. In order to get to that, one has to sift through lots of questionable information and theoretically possible options. Sorting through all those issues systematically, and then mentally debating the risks and benefits of each one, with that particular patient, may take far more time than it's worth to achieve a supposedly ‘best’ treatment plan – bearing in mind that there will still be ‘unknown unknowns’ out there, which might mean that this allegedly ‘best’ plan doesn't turn out to be the best plan after all. It is this inescapable reality that keeps a lot of lawyers (and expert witnesses who earn their living from claimant instructions) lucratively employed – and they wouldn't have it any other way.

People who maximize rather than satisfice will often second-guess their choices, and some continue to debate the merits of each choice obsessively before ending up suffering from ‘paralysis by analysis,’ and often then doing nothing practical that would probably solve most of that patient's problems –or referring them to someone else.

‘Maximizing’ can only lead to one, allegedly optimal, answer or plan – referred to by some in dentistry as ‘the treatment of choice’, which in turn invites the supplementary question, ‘whose choice?’ It follows that all of the other choices are deemed to be less than optimal. Taking an extreme example, one could argue that no clinician should ever carry out a procedure if there is someone more knowledgeable, experienced, or skilled out there somewhere, who might be able to achieve a better result for the patient. Only the very best will do, so every patient in the country would end up being referred up the line to Dental Superman or Wonderwoman, and they are going to be kept pretty busy. Clearly, this would be a ridiculous and unworkable state of affairs, and the fact that it doesn't happen means that every one of us ‘satisfices’ when it suits us to do so. We don't refer most or all of our patients up the clinical feeding chain because we usually persuade ourselves (and some patients sometimes pressurize us into believing) that we can do the job ‘well enough’ for their available resources and those circumstances.

One ironic thing about maximizing is that while one is aiming to get the most out of every choice, one can lose a lot, such as time, money, or other opportunities. Furthermore, there is no guarantee that the supposed ‘ideal treatment plan’, possibly promoted by some academic or some charismatic dental guru, will suffice. That is because, even though those aspirational criteria might be met, maximizing might not prove to be technically possible, nor even ‘the best’ for that patient, as they perceive things. This is, of course, the very blind spot that Phil Crosby warned against.²

One pertinent question to ask is: ‘is it really worth all the time, worry and stress to make the supposedly ‘best decision’ when a wider range of possible decisions could prove to be satisfactory for very different people? There are plenty of practical people who prefer satisficing over maximizing, and we do not have the right to impose our narrow, possibly biased, views on them – and especially not if we use questionable arguments and justifications to persuade them. Many experienced and highly capable dentists are happy to make quicker and appropriate decisions with less guilt to help many patients effectively, as long as it is sufficient to satisfy their requirements and has a responsible body of dental opinion to support it (i.e. it would pass a ‘Bolam Test’¹⁰).

Criticisms of ‘satisficing’ by ‘maximizers’

‘Satisficing’ as a philosophical concept in dentistry doesn't appeal to everyone, and it is often frowned upon and criticized fiercely by some devoted ‘maximizers’, including some academics and/or ‘specialists’ within a sub-branch of dentistry, some of whom have vested interests.

Whatever the dentist has done (or not done), it is always possible to suggest that they should have done more things, much better and/or more often, or perhaps done different or fewer things, and the world would have been a much better place had that happened. However pretentious or subjective that nonsense might be, a whole industry of opportunistic lawyers and supposedly expert witnesses has evolved to purvey it, if their price is met. However, some regulator's or some avaricious lawyer's ‘hired gun assassins’ are well paid to find something about which to criticize the defendant dentist, choose some subjective aspirational ‘maximalist’ standard, rather than judging things against the appropriate ‘Bolam Test’ standard,¹⁰ which demands the ‘average skill’. The Bolam Test judge's view (Mc Nairn J) was that a doctor (for which read dentist) is not guilty of negligence if he (for which also read she) has acted in accordance with a practice accepted as proper by a responsible body of medical men (for which also read women) skilled in that particular art at that time’.¹⁰

In other words, there is no legal requirement to demonstrate the supposedly ‘ideal’ or ‘highest level standard’, which some maximalist, possibly someone with some vested or concealed interests, might allege to be ‘the best’ approach to solving a clinical problem.

Discussion

So what does ‘satisficing’ mean for ‘quality in healthcare’

Defining quality in healthcare has long been a contentious issue in many parts of the world due to the widely differing perspectives of clinicians, patients, managers of health services and thirdparty funders, amongst others. Well developed, ‘first-world’ countries face the dilemma of an increasingly ageing and yet more consumerist, aspirational, and demanding population. There is an everexpanding menu of treatments and drugs theoretically available to prolong life (and enhance quality of life) at ever-increasing costs, and yet a shrinking workforce of taxpayers to pay for it all. Add to this the kind of turbulent global environment and highly volatile economic picture of the past 10–15 years, and there is a legitimate debate to be had over what healthcare systems should look like, and what type(s) of treatments we should be prioritizing or encouraging.

Australia is a good example of a highly consumerist, first-world economy, albeit one with all the challenges of wide economic inequalities and the logistic obstacles of rural and remote service provision across vast distances. The Australian government, having recognized that healthcare resources are finite, while ‘need’ and potential demands are infinite and complex, has legislated to prohibit healthcare professionals from encouraging ‘the indiscriminate or unnecessary use of regulated health services’ either directly or indirectly (e.g. through promotion or advertising).⁵ This restriction is actively enforced through all its healthcare regulators, including the Dental Board of Australia (equivalent to the GDC). As a result, many advertising or promotional activities that are commonplace (and increasingly popular) in the UK, would be against the law in Australia, and those participating in them would also be vulnerable to disciplinary action and sanction.

The leadership demonstrated by the approach taken in Australia does rather throw down the gauntlet to other jurisdictions in terms of wider public policy, and not least in relationship to ethics, equity and professionalism in healthcare. Collectively, as a profession, how comfortable do we feel about some patients getting so much more dental intervention than they need, perhaps on the enthusiastic recommendation of a healthcare ‘professional’, when so many other patients are denied even the most basic dental care and treatment that they badly (or urgently) need?

Conflicting priorities and ‘satisficing’ in UK dentistry

In the UK, we have an example of the kind of complex environment in which dental healthcare choices and decisions have to be made. For the past 75 years, it has been known affectionately (at least in some quarters) as the ‘National Health Service’ (NHS), but all three elements of that description are now barely recognizable. Many observers consider the words to be potentially inaccurate and misleading. It is not national. It's parochial. It's not about health. It's about disease and certainly not about practical prevention … and as for a service? Well, many might have diametrically opposing views on that.

Until 2006, the relevant regulations⁶ covering NHS dentistry's ‘General Dental Services’ and ‘Personal Dental Services’, essentially, general dental practice, included a definition of the term ‘oral health’, which was the ultimate objective of all service provision. It stated:

‘Oral health’ means such a standard of health of the teeth, their supporting structures and other tissues of the mouth, and of dental efficiency, as in the case of any patient is reasonable having regard to the need to safeguard his general health’

Note the word ‘reasonable’ and the stated all-important context of sufficiency for the purpose of safeguarding the patient's general health. Not only were dentists required to provide all the care and treatment necessary to secure and maintain the patient's oral health as defined above, the regulations went further and stressed that a practitioner should not provide any care and treatment in excess of that which was reasonably necessary to secure and maintain that ‘reasonable’ level of ‘oral health’. That was all clear enough, and well enough understood for the system to work. Indeed, this remains the situation in Scotland and Northern Ireland, where fee-per-item is still alive and kicking even today.

However, in 2006 the radical new UDA system was introduced in England (and Wales) and the regulations were changed,⁷ conveniently removing the above definition of ‘oral health’ entirely, together with the specification of ‘reasonable’ as being the required standard. Although the new system was government imposed, not a penny of additional resources was made available, but coinciding with this change, NHS England published on its website and in NHS documentation a statement to the effect that NHS patients had a right to expect care and treatment of a ‘high standard’. Whatever happened to ‘reasonable’, one wonders?

At the same time, a detailed list of approved ‘reasonable’ materials, deemed to be suitable for use in NHS treatment, was withdrawn. Dentists were now free to use the most sophisticated and expensive materials available, and they could no longer argue that the NHS only permitted the use of ‘reasonable’ materials. Even now, the same NHS website states that dentists must not suggest that NHS treatment is ‘sub-standard’, without any further explanation of what ‘sub-standard’ might mean in this altered context. What this illustrates is that the government itself is no stranger to ‘satisficing’ where its own money is concerned, nor opposed to ‘maximizing’ when other people's money is being filched – either directly or indirectly.

Compromises and ‘satisficing’ in relationship to guidelines

The NICE guidelines on dental recall intervals⁸ are another good illustration of these sorts of conflicts in action. NICE was conceived in the twilight years of the John Major (Conservative) government and implemented in 1999 by the incoming Labour (Tony Blair) administration with the self-congratulatory, rather grandsounding title ‘National Institute for Clinical Excellence’, abbreviated to ‘NICE’. There was a live debate about how best to deploy NHS funds at a time when expenditure was increasing rapidly, and greater consumer (patient) demand and expectation was on a collision course with opportunities created by technological and scientific advances, and new (but expensive) drugs. NICE quickly earned the sobriquet, the ‘National Institute for Cost Effectiveness’ among more cynical observers, who suspected that its main purpose was to sprinkle a pseudo-scientific gloss on decisions that were primarily economic and politically awkward.⁹ At that time, a fee-per-item remuneration system still applied to NHS (GDS) dentistry throughout the UK, and it was already well documented that the more often people attended a dentist, the more dentistry – and repeat dentistry – they tended to receive (and for most patients, the greater the resulting cost to the state).

The choice of altering the recall intervals as NICE's first dental guidelines in 2004, was therefore no great surprise. It was a determined, if rather clumsy, attempt to break the perceived tyranny of the time-honoured 6-monthly check-up, and justify much longer recall intervals for most patients. It was a great example of a government attempt at ‘satisficing’ because – both then and now – it asked the question of how far recall intervals could be lengthened without obviously adversely impacting the oral and general health of the majority of patients. The state knew that its money was safe for as long as they could keep dentists and patients apart, and it was convenient that the NICE controlling guidelines served as a timely enforcer.

Recent and ongoing crisis in accessing NHS dentistry

The recent dental access crisis illustrates the same point nicely. Politically, any government wants to maximize the number of patients who (they can claim) can access some kind of dental care, with someone, regardless of the outcome, while somehow controlling how much of what sort of statefunded care they can access when they get there. The government seems happy as long as dentists and patients are paying the financial and other costs, and that there is no downside price to be paid at the ballot box.

In Scotland and Northern Ireland, the persistence of a demand-led fee-per-item system makes this circle a difficult one to square, while in England and Wales the UDA system provides the government with many more direct and effective control levers that they are clearly in no great rush to relinquish.

But that wholly self-interested distinction is not unique to those in government. Faced with the reality of having to maintain a viable business on the one hand, alongside the paymaster (i.e. the government) surreptitiously raising public expectations about NHS availability, quality and standards – while progressively reducing direct real-term funding levels – the NHS dentist has a really unenviable predicament to resolve. The UDA system operating in England and Wales, for all its many faults, at least takes away any perverse incentive to maximize, because this would not be matched by any additional income.

Theoretically, in any healthcare system, one could aim to deliver the highest possible standards for every patient on each and every occasion, allocating the maximum amount of time and using the best and most expensive materials and laboratory support, irrespective of any financial losses incurred … or one could compromise in some way. The purist would argue, no doubt, that a true professional will never compromise; they will only ever have one standard (the very best) and will always deliver that, irrespective of the costs to them and possibly going bankrupt. More sane observers might argue that the purist is an unrealistic ass, and every human encounter ends up being a compromise of some kind or another.

Anyone sensible and experienced in the real world knows that in any deal, one can get one or possibly two out of three of the following words ‘excellent’, ‘quick’ and ‘cheap’, but you can't get all three in any long-term deal. So, which two is it to be? If it is cheap and quick, it won't be excellent. If it is quick and excellent, it won't be cheap. The UK government needs to be much more honest that it cannot possibly provide good, quick and cheap healthcare for all of the people, or all of their dental and medical problems, and it needs to spell out to voters and dentists what is realistically available when matching the resources that they choose or wish to spend on dentistry.

Standards and the law

The common law position is that a clinician cannot be found guilty of negligence if they can be shown to have acted in a way (and to a standard) that would be accepted as being proper, by a responsible body of opinion among others working in the same field and professing to have the same skills – the Bolam Test, reflecting a landmark legal decision in 1957¹⁰ (although Scotland had its own separate legal precedent along similar lines from 2 years earlier). That supportive opinion must be logical and reasonable, as well as responsible. Put another way, the law does not expect or demand ‘perfect’. It demands ‘good enough’, taking all the relevant circumstances prevailing at that time into account.

We all know, however, that clinical opinions differ and fortunately, the law recognizes this fact too. Significantly, it is sufficient in terms of defending yourself against an allegation of negligence that you can show that a responsible body of opinion would support your actions. The fact that a different body of opinion, however ‘authoritative’ or written by a committee of members of some specialist dental society, perhaps one with undeclared vested interests with its members partially benefiting, would disagree with your actions, is then rendered immaterial and irrelevant.

On the other hand, mutually agreed contractual terms can still enter the frame and spoil the party. Under the 2015 Consumer Protection Act, goods and services must be ‘as described’. What this means is that if you are foolish enough to promise, or imply, ‘excellence’ and/or ‘perfection’ in your signage, on your website, in your correspondence, Facebook or Instagram posts, then that is precisely what you are required to deliver, in default of which you would be in breach of contract. In short, you would have taken a conscious, elective decision to raise the bar so high, possibly in search of increased market share, that you render yourself more vulnerable to coming up short in delivering just that. This would remain so, even if you have carried out the work to a standard sufficient to refute any allegation of clinical negligence.

Tom Peters is recognized as arguably the most influential source of management knowledge, insights, and advice of the late 20^th century, especially in the (then) emerging field of customer care. He most famously exhorted companies never to make excessive or grandiose claims about their products, skills or services, but instead to ‘under-promise’ and ‘over-deliver’, thereby consistently exceeding customer expectations and ensuring satisfaction and customer loyalty.¹¹ Over-promising and ‘hype’ seems to be designed into much of today's dental marketing and social media activity,¹² but that makes Tom Peters’ mantra even more relevant today. He was equally prescient in his observation that the successful management of change is not so much about being the first one to embrace a new idea, but being the first to forget an old one,¹³ that, too, has huge resonance in dentistry and how it has been evolving in recent years. Parts 2 and 3 will expand on the concept of satisficing as it might be applied in sub-branches of dentistry.