Interview on human factors in dentistry

Franziska Beier, Dental Tribune International

Mon. 11. October 2021

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During the upcoming 2021 European Association for Osseointegration (EAO) Digital Days, Dr Franck Renouard will explain how human factors influence treatment outcomes in his “Tell me more about” session on Wednesday evening. Dental Tribune International spoke with the passionate expert, who is a past president of the EAO, about how he became interested in the topic and how awareness of human factors can change the careers of dental professionals.

Dr Renouard, when reading the programme of this year’s EAO Digital Days I saw your lecture and thought this topic is not usually covered at congresses. How did you become interested in the topic of human factors?
Yes, you can say that normally we don’t find this topic on any programme. In medicine, there are more lectures about it but, in dentistry, we continue to focus on the technical aspects of our work.

I realised the importance of human factors because, in 1995, I was a helicopter pilot and I crashed during take-off. It was a large helicopter, and the accident was not an easy experience because I destroyed other aircraft during the crash. Afterwards, the first reaction was to blame the helicopter, focusing on the technical aspect. We do the same in implant dentistry when a fracture occurs: we blame the implant system, overloading or the assistant. The second step was to really understand what had happened, and we quickly discovered that I had made a mistake during take-off. However, because nobody got hurt or died, the investigation was discontinued. I was a good pilot, so I tried to understand why I had made this stupid mistake. I knew the procedure, but I used it in the wrong way. Then I started to read papers on the topic and began to investigate the field of neuroscience. And today, I can say I am an expert on human factors. For 15 years, I have tried to convince my colleagues that this can change their lives. We need to change our attitudes and change dental education.

In your EAO Digital Days session, you will speak about how the surgeon’s attitude influences the treatment outcome. What exactly are you referring to with the word “attitude”?
Maybe the simplest way to explain is to point out that there is a difference between our competence—what you know and what you have been taught—and our performance. Our performance can be influenced by so many factors: stress, problems with your child, relationship problems, fatigue, sickness, difficult patients or problems within the team. And in many cases our performance is not on the same level as our competence.

Let me give you an example. In a study, about one million surgeries, either performed on the surgeon’s birthday or not, were compared, and the mortality within 30 days after the operation was assessed. It was found that, if doctors operated on their birthday, the patient mortality was increased by 23%. This is because there are more interruptions, because surgeons look at their mobile phones more often and because they want to join their family earlier. And these are human factors that we are now talking about.

An example in implant dentistry would be when an implant surgeon places an implant too close, which increases the risk of peri-implantitis. The problem is: this mistake doesn’t happen because of lack of knowledge. The clinician knows exactly how to measure the correct distance. So, the question really is: why did he or she place the implant too close? The answer is probably because of stress, time pressure, lack of preparation and so on. That is the attitude. And that’s the cause of complications.

“The human attitude is a key factor in making practices more secure and in improving human performance”

How can dental professionals be educated about this topic in order to reduce failures in the future?
We already have all the data. There is no doubt that human factors influence our life, but there are several obstacles to including this knowledge in dental education and practices. University professors continue to to be reluctant to introduce this topic, because it would change their role dramatically.

For surgeons, using a checklist—which decreases the risk of mortality by 30%—means accepting their own weaknesses and admitting that they can forget important steps. In addition, very often nurses are not encouraged to monitor and correct doctors.

A general problem in medicine is that, if you share errors, you can be sued by the patient. Medical regulations ensure that this information is not disclosed, whereas in aviation, the principle of Just Culture is applied, meaning that people who report errors may not be sued for sharing knowledge that helps the entire community.

Another problem is the patient’s expectations. Every patient expects their doctor to be well prepared, fit and mentally in a good state. So, it is hard to accept that surgeons are also just human beings and make mistakes, but that’s life! The human attitude is a key factor in making practices more secure and in improving human performance. The problem is not the knowledge—it is how to use the knowledge.

You maintain a private practice in Paris, focused on oral and implant surgery. How have you organised your practice in order to minimise the risk of human failure?
Regarding the internal organisation, we have many protocols which are non-negotiable, and we use systematic checklists. My assistant and secretary can and should report errors. In addition, my assistant not only should, but also must, monitor me!

As for me, I work on decreasing my stress level. I have some very important protocols: before every surgery, I mentally prepare myself. For example, I don’t go straight from a phone call with a friend into the surgery; I need to have a routine that ensures I am ready and aware during the surgery. In addition, I try to share complications with colleagues, so that we learn from one another.

“Digitisation is already here, so it is time to talk about its threats”

One of the major trends in dentistry right now is digitisation. The products usually come with the promise that they prevent human error. What’s your opinion on this?
That’s an excellent question! People believe that, because of digitalisation, we will reduce the number of complications. That is totally false. Errors are not made because the software, the product or the team are faulty. The problem arises in the communication between the different entities, for example when you give your nurse a wrong order or when the patient gives you wrong information.

When you introduce digitisation to your practice, you increase the number of entities and the number of connections. And digitisation comes with its own difficulties. One problem is that dentists don’t have the time to learn all the details about the new systems. More and more dentists trust these machines without having gained the proper knowledge. For example, many dentists use Invisalign without any orthodontic knowledge. They make an impression, send it to the computer and receive the aligner. However, as a result of this, many patients have dramatic issues with their teeth. Digitisation is already here, so it is time to talk about its threats.

Is there anything you would like to add?
I would advise everyone who is interested in this topic—not only dental or medical professionals—to read the book Thinking, Fast and Slow by Daniel Kahneman. The author makes you understand that the workings of the brain are not an unfathomable mystery, and he really explains how the brain works.

Editorial note: More information about the 2021 EAO Digital Days and registration can be found at digitaldays.eao.org.