Mo-vember is a two way street

Movember Foundation is a charity that aims to raise awareness and resources to promote mens health. It all started in 1999 in my home town of Adelaide, South Australia. A group of 80 Adelaidean men started growing their moustache in November to support several male friends who had experienced cardiac events. Movember is now a global phenomenon that has raised over $100 million for men’s health. I’m signed up and I’m raising money by growing my Mo – an Australian and New Zealand colloquialism for moustache. However, the purpose of this article is to draw attention to another issue – than men engage in more high risk activities which make them (ummm….us) a public health problem.

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It has been postulated that men may be less adaptive physiologically and emotionally to stressful life events and this may contribute to the doubled risk of heart attack. But cardiac health is not the only matter that places men at higher risk. Our own research has shown that:

  1. When periapical tooth abscess leads to infectious complications in patients having open heart surgery….73.8% of such patients are male.
  2. When patients have to be hospitalized due to tuberculosis – a condition that is relatively rare in the US……64% of patients are male.
  3. When periodontal disease worsens outcomes of stem cell transplant in hospitalized patients…..63.9% of patients are male.
  4. When people are hospitalized due to mouth cellulitis…..55.8% are males.
  5. When periodontal disease causes complications among patients undergoing heart valve surgery…..62.9% are males.
  6. When adolescents have to go the emergency room due to a sports injury…..76.8% are male.
  7. When children and adolescents have to go to the emergency room due to a facial fracture…..74.7% are male.
  8. When firearm injuries result in facial and intracranial injuries……89% are male.
  9. When firearm injuries result in injury to a child….89.2% are male.
  10. When facial fracture reduction is necessary in US hospitals…….80% are male.

*all of these are preventable!

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Source: https://clipartxtras.com and http://www.manchestereveningnews.co.uk/

Broader research has shown that men engage in more high risk activities but it is still not understood why. There is some evidence that all risk activities link back to men trying to raise their attractiveness to potential sexual partners. Another theory is that women just have better risk perception as an evolutionary consequence of learning to protect their offspring. Whatever the etiology, it is important that more men die from injury and violence than women:

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Source: http://www.who.int/violence_injury_prevention/key_facts/VIP_key_fact_6.pdf?ua=1

Focusing on men’s health in November is a great public health campaign, but, it cannot be done in isolation – there is a lot that men can do to reduce their own risk of certain conditions. Therefore, Mo-vember is a two way street – we must raise awareness and resources to understand men’s health but men must reduce their own risk with prudent decision making.

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Are we exploiting dentists who are foreign trained?

Foreign trained dentists have a challenging time entering and practicing dentistry in the US. And perhaps it should be like this. The American Dental Association (ADA) has been effective since it’s establishment in 1859 at limiting anything that threatens it’s members. In fact, ADA is a role model association with membership close to 80% – this compares favorable to the medical equivalent (American Medical Association) whose membership is 15%!!

Sathish.jpgSource: http://www.vasandental.com/about.html

Many would argue that it’s easier for a physician to move to the US and start practicing than it is for a dentist even though physicians could, potential, cause much more harm. There’s one state in the US that allows foreign trained dentists to practice in it’s community health centers under the supervision of a US licensed dentist. At first this seems very supportive to foreign trained dentists, however, in implementation these foreign trained dentists earn about half as much as their US licensed counterparts for equivalent work. This sounds more like exploitation.

One state in the US evaluates foreign trained dentists on a case-by-case basis. If a foreign trained dentist’s training is deemed equivalent, once licensure is gained they must work under the general supervision of a US licensed dentist approved by the board. Consider the risk of exploitation here – the foreign trained dentist must practice for three consecutive years under general supervision of one dentist. That dentist has power to limit the types of services authorized. Moreover, general supervision doesn’t even require the supervisor to be physically present.

Another state allows foreign trained dentists to take the hygiene board exams and practice as a hygienist. However, I feel this is a slap in the face of our hygienists. Dental hygiene is a specialized field and I know I couldn’t do a cleaning to the standard of a hygienist – my hygiene team are my preventive specialists. How can a foreign trained dentist whom the state is not willing to license as a dentist be allowed to practice as a hygienist? I suggest this also speaks volumes about how we value prevention in this country………that is…..we don’t.

himym-slap-bet.jpgSource: http://uproxx.com/tv/history-of-slap-bet-himym/

Finally, it is widely documented that International Dentist programs (an abbreviated program that foreign trained dentists must go through to gain full US licensure) is usually half as long but equally as expensive as a domestic DDS/DMD program. Whether this is reasonable or not is questionable. International Dentist Programs are ultra competitive – only about 2% of applicants gain entry. This leaves a large cohort of talented but frustrated individuals who are underemployed in the US. There are several programs at US dental schools available to foreign trained dentists to strengthen their CV’s – they include observerships and externships and some of them cost as much as $80,000. Again, this sounds like exploitation to me! One could also argue that observerships/externships add little to the strength of an application other than one extra line in the CV. What foreign trained dentists need is training that will walk them through the cultural, social and professional differences between their country and the US. They need a mentor who will help refine CV’s and personal statements and provide feedback on interviewing technique. To our knowledge, these observerships/externships do not offer any such support.

At University of Michigan we are concerned about this issue and have developed a program especially for foreign trained dentists that specifically addresses their needs. This course is provided at cost (our financial goal is to break even….not to make a profit) and more information is provided here.

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The goal of this blog is to draw attention to the issue of exploiting vulnerable foreign trained dentists. I believe we should continue to hold high standards for entry in our dental programs across the United States, however, for those that fail to enter….let’s not exploit them. Let’s support them – they are our colleagues. Let’s not charge $80,000 for them to shadow us. Let’s not pay them 50% for equivalent work. Let’s not insult hygienists by allowing them to work only as hygienists. Let’s have a standardized approach to dealing with foreign trained dentists. And let’s be transparent about it.

 

Would you like to be randomized to the “no dental care” study group??

Research has demonstrated that physician knowledge of the interactions of oral and systemic health is limited. However, physicians should be able to discuss the importance of oral health in a variety of circumstances: For example, when diabetes is diagnosed oral health should be discussed because it is well known that poor oral health can worsen diabetic state. When prescribing new medications oral health should be discussed because many medications are xerostomic or increase the likelihood of stomatitis and caries. These are just two examples of oral health concerns that are often overlooked in the high pressure environment of medical practice.

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Source: www.tes.com

Ignaz Philipp Semmelweis was a physician who suspected that the failure of doctors to wash hands was resulting in puerperal fever and high mortality rates. At the time, this mode of reasoning was contrary to mainstream medicine and his important findings were dismissed for several years. Many continued to die, unnecessarily, through puerperal fever. Simply because there are no randomized controlled trials to support causal connections between oral and systemic health should we continue to treat the mouth separately from the rest of the body? Numerous studies identify possible associations between oral and systemic disease and it is little wonder – the mouth is part of the human body! The importance of oral health should not be ignored simply because we haven’t been able to conduct case control trials – would you like to be randomized into the “no dental care” group?

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Source: npr.org

A recent study released by United Concordia health insurance has demonstrated several interesting findings: in patients who received dental preventive care the overall medical cost of managing diabetes, stroke, heart disease and complications from pregnancy were much lower – statistically significantly lower. Additionally, there were far fewer hospital admissions for those who received preventive dental services. However, it is not common practice for medical doctors and dentists to collaborate on patient care. In fact, there are major barriers within the United States (US) healthcare system that inhibit these collaborations. For example, dental care is delivered in silos: Dental offices are rarely co-located with a medical center and it is up to individual providers to create collaborative relationships between the medical and dental professions. In fact, most dentists are in a solo-practice setting which is in conflict with interdisciplinary collaboration.

Previous research has shown that the matter of oral health problems that present to US hospitals is a major issue in the United States. For example, over $1.2 billion in hospital charges are incurred each year by patients hospitalized for an oral health problem in the US. Further, in the year of the study 277 people died in US hospitals after being admitted due to a dental problem. Were the dental problems mismanaged to the extent that people died? Were the dental conditions neglected to the point that they were fatal? Did the dental condition exacerbate a medical condition that caused death? The exact cause of death is not known. What is exceedingly obvious is that the entire medical team (not just dentists) need to be able to manage and diagnose dental problems as well as educate patients about the importance of oral health and have a basic knowledge of how to help the patient access dental services. However, the most important reason to train physicians to evaluate the mouth is yet to be addressed – oral cancer.

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Source: http://www.janaburson.wordpress.com

Alarmingly, close to 100% of Medicare supported patients who were diagnosed with late stage head and neck cancer had been seen by a medical doctor in the year prior to their diagnosis. It is possible that none of these visits included an oral screening and the opportunity for early diagnosis was foregone. Due to the limited knowledge of oral health by non-dental healthcare professionals patient care is compromised. Firstly, patients that present to emergency rooms, urgent care facilities and hospitals with dental problems are often poorly managed and a dental visit is still necessary afterward. What is necessary is a structured, educational curriculum to prepare medical doctors for a career in patient centered, outcomes driven practice. Any such practice must include the evaluation, diagnosis and management of oral health complaints. Medical curriculum must change for physicians-in-training and continuing medical education must mandate the training of basic oral health management skills. It may not be practical for every patient to have an oral health screening, however, physicians should have the skillset to be able to implement an oral screening on patients they know to be at high risk or oral cancer or oral disease. The health of the nation depends on it.

 

 

 

 

 

On being a patient

I injured my shoulder while on vacation in Jamaica. I was in severe pain and I went to the local hospital where an extensive clinical exam was completed by a nurse – there was no doctor available until the next morning. I was a 90 minute drive from Montego Bay (which was the nearest xray machine) and a 1 hour flight from Kingston (which was the only MRI machine). The nurse’s exam suggested partial tear of the transverse humeral ligament or (less likely) a dislocation. I decided to wear a sling and return to the United States for ongoing care.

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When I returned to the US the shoulder pain began to dissipate but I started feel numbness in my right hand. Being a clinician who still practices, this was very frightening! I went to urgent care in the US and requested an MRI because I was convinced there was no bone damage. However, the doctor informed me that it was hospital protocol to have an xray first. After my xray (which was clear) I was informed that, in order to have an MRI, I needed to meet with my primary care physician. Although frustrated, I complied. After a repeat examination with the PCP I was scheduled for an MRI. Now this is where it gets interesting.

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I arrived for my MRI at 1pm…….and was finally taken in at 3.30pm. An extremely frustrating wait and two fellow patients decided to leave because they got sick of waiting! Experts have considered why patients don’t comply with imaging orders and issues of convenience and child-care were common. Then I slipped into my hospital gown and entered the MRI room where I was told about the protocol for the MRI – my first. When my patient bed was inserted into the scanner I realized (for the first time) that I was claustrophobic! Ashamed, I asked the technician to immediately take me out because I didn’t think I could handle this! With some calming words, I was again inserted into the scanner. This time I lasted about 3 minutes before asking to be rescued again! The story is long but the technician was very patient and I got through my 35 minute scan. A review of the evidence shows that 11.7% of children could not comply with prescription for an MRI and there is no such research among adults. Research has also shown that lower levels of education, coming from further away, and being female were risk factors for no-showing to MRI’s. I represent none of these factors and I almost didn’t make it!

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Source: http://www.morningjournal.com/article/MJ/20160128/NEWS/160129510

What I take home from this experience is that I am a patient in one of the best health systems in the country and the world….yet, it’s not pleasant. It’s just not nice to be a sick. Diagnostic tests are not fun, waiting is not fun, not knowing is not fun, being a patient is not fun. When I’m taking care of patients I will remember to be more thoughtful, more patient and more kind. While it’s just a regular working day for me, my patient could be having the worst day of their life! Unfortunately, we have a reactive insurance structure and health system in the US that focuses on disease management rather than primary prevention. Subsequently, we are often coping with problem focused visits and the stress of a sudden dip in health.

Oh by the way, after my urgent care visit, the PCP visit, the xray and the MRI….my diagnoses is partial tear of the transverse humeral ligament. The same thing the hospital nurse told me in Runaway Bay, Jamaica!

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The Knowing-Doing Gap in dentistry. Part II.

See Part 1 here.

The gap between ignorance and knowledge is smaller than the gap between knowing and doing. So how can we overcome the knowing-doing gap?

1.Be willing to try something new.

Franklin Delano Roosevelt is quoted as saying “It is common sense to take a method and try it; if it fails, admit it frankly and try another. But above all, try something.” When the America Dental Association (ADA) releases new guidelines and recommendations they have been tested broadly. Dentists should seek information for themselves to confirm a practice guideline or recommendation presented to them – this overcomes the creditability bias. If the evidence stands up to evaluation, then the ADA’s guideline will only confirm what the dentist knows and implementing change will not be difficult. Similarly, the hygienist, dentist and dental assistant should work together to reinforce information for their patient. For example, when a major home care change is needed, each member of the dental team should have time during the patient visit to deliberately re-emphasize the value of the new habit. Although this may currently happen in an ad hoc manner, dentists should structure their office workflow in a way that affords time for each team member to underline the same message. Hearing the message multiple times from multiple perspectives helps patients overcome the creditability bias.

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Source: http://www.farm5.staticflickr.com/4089/5033096126_e1d36eae86_b.jpg

2.Knowledge of change is insufficient.

Structures must exist that help move knowledge into actionable steps. The gap between ignorance and knowing is much smaller than the gap between knowing and doing. When research reveals a new method or material that is beneficial, there is a need for a dentist study group or informal collaborative group that allow dentists to discuss and develop an implementation plan for their own unique offices. This way, dentists form a support structure that will be available for mentorship and advise for new implementations. ADA’s release of the knowledge alone is completely insufficient.

Patients need an implementation plan too. For example, telling them to wear their nightguard regularly is not enough. Dentists should discuss an implementation plan like “Leave the nightguard next to your toothbrush. After you brush at night insert it. In the morning take it out and brush your teeth and your nightguard. Then put your nightguard back next to your toothbrush.”

 

 

3.Don’t be such a perfectionist. Research has shown that there are two types of perfectionism – normal perfectionism which can aid a dentist in doing high quality work, and neurotic perfectionism which involves setting unattainable goals and result in frustration when you fail to attain them. The dental profession attracts people who are perfectionists and this makes them very good at their work as a dentist. However, it can impede change and innovation as perfectionists tend to be over-analytical. Try something in a controlled environment and accept that errors and imperfection may occur – for example, practice a digital impression technique on a dentoform, then on family members or longstanding, trusted patients before moving it into regular clinical practice. Create comfortable environments to “practice” so that you are willing to evolve your clinical skills. Perfectionism and status quo bias can inhibit our patients’ willingness to try something new too. Dentists must create an environment for patients where it is acceptable to fail.

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Source: Flickr.com

4.Drive out fear. The existence of anxiety and fear of failure fosters the growth of the knowing-doing gap. The biggest fears in dental medicine are litigation, adverse patient outcomes or even death. Consider the example of a patient who, under new guidelines doesn’t need antibiotic coverage but had antibiotics at their last dentist just 6 months ago. The new dentist is likely to provide antibiotics because risk of overprescribing are perceived as less severe than under-prescribing. However, the truth is that overprescribing can result in Clostridium difficile and patient mortality. The fear of overprescribing is easily overcome by utilizing our considerable training in pharmacology and medicine and using our critical thinking to make a judgment on the best approach for each unique patient. Fear should not influence the decision.

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Source:www.signalvnoise.com

5.Overcome self-serving bias.
In order to improve as a clinician, dentists must be open to feedback and learning. To that end, the most effective and constantly improving dental offices abolish hierarchies and allow dental assistants, front desk staff and hygienists to offer feedback to their dentist. Patients embarking on new habits like quitting smoking or improving dentist attendance should be given the freedom to suffer setbacks without judgment. Research has shown that many patients fail to attend their healthcare provider out of embarrassment and fear of criticism. A non-judgmental dental office will win over such patients’ loyalties forever.

CONCLUSION

The gap between ignorance and knowing is smaller compared to the gap between knowing and doing. To overcome the knowing-doing gap, dentists and patients need the following supporting structures.

  1. Have an attitude that is willing to try something new
  2. Develop an action plan for implementation of the change – knowledge of the benefit of the change is insufficient to cause change
  3. Abolish hierarchies and be more open to feedback from a variety of sources – even those who may be lower on the hierarchy than you.
  4. Create non-judgmental, low risk environments to “practice” the desired change.
  5. Build an office environment for you, your staff and your patients where failure is acceptable

The Knowing-Doing GAP in Dentistry. Part I

Research has shown that removing amalgam without rubber dam (RD) results in a significant increase in mercury levels in plasma and urine. A Cochrane study in 1989 showed that RD also reduces the transmission of infectious material. Do you use RD as often as possible? I know I am guilty of failing to do so and I blame time and convenience. However, there is extensive research that, once you overcome the short learning curve, utilizing RD is actually quicker than not using it. Research has shown that it takes about 2 minutes for a dentist to place RD and the remainder of the appointment can be faster and more efficient. Moreover, we assume patients hate RD even though literature shows that 77% of patients believed it to be comfortable. One study even found that dentist stress levels were lower when working with RD. Even though the benefits are ample and evidence is unequivocal we fail to comply 100% of the time. Why?

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Image source = https://farm2.staticflickr.com

In business management there is a recognized concept called the knowing-doing gap. The knowing-doing gap is the idea that, in spite of education, training and research evidence, it is difficult for us to truly change our ways. We suffer from various biases that preclude us from succeeding. Firstly, confirmation bias – we tend to recall the information that confirms our perception more than experiences that contradict them. For example, if I have 10 patients for whom the RD experience was uneventful and 1 who had a really difficult time I am more likely to remember the 1 that confirms my bias that patients hate RD.

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Source: https://farm8.staticflickr.com

Secondly, evaluation bias means people tend to value the information they have more than information they gain from other sources. This means that people are slow to “trust” new ways of thinking and many dentists may be guilty of this. My first boss is someone I regard highly and he advised me “Never be the first dentist to adapt a new technology but never be the last either.” This is “bandwagon effect” or “herd mentality” where people do something or believe something because many others already do. I valued my boss’ advice and acceded his mantra until recently – why not be the first to adapt something new?

Patients suffer from the knowing-doing gap too. Though we advise them to floss once per day, brush twice per day, control their snacking and limit their consumption of pop they do the very opposite. Creditability bias is the concept that people consider information to be more creditable when they share that viewpoint. But this inhibits learning new information from your healthcare provider and promotes re-confirming perspectives you already have. For example, dentists frequently diagnose bruxism with severe attrition, cheek biting and abfractions in multiple teeth. However, patients find it hard to process this new information because they are not aware of their habit and have difficulty accepting an alternate viewpoint. It’s easier for them to believe that the dentist is just trying to make more money by advocating for a costly therapy.

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Source: https://farm3.staticflickr.com

Similarly, self-serving bias helps us maintain our self-esteem by attributing failure to uncontrollable outside factors and attributing success to ourselves. Hence, patients complain that their oral health status was inevitable for them because a parent had “soft teeth.” But failing to take ownership of an issue will inhibit resolution of that issue.

Finally, status quo bias affects dentists and their patients. It is a fact that people have an emotional preference for their current state and any change represents discomfort and stress (in spite of potential benefits gained). For example, a dentist may ask their new patient “did you receive antibiotic prophylaxis when you last went to the dentist?” This, however, is an irrelevant question that serves to maintain the status quo – we should not ask the patient about the past but use our expertise to make a judgment on what is needed for the patient today. Dental Association antibiotic guidelines update frequently, a patient’s health status can change and their last dentist may have been overprescribing or under-prescribing.

How do you overcome the Knowing-Doing GAP??? Wait for the next post…

Dentists were the 1st successful anesthesiologists……but the dental profession forgot all about it.

William Thomas Morton was a dentist in Boston in the 1800’s. In 1846 he administered diethyl ether to patient, Ed Abbott, who enjoyed the first painless surgery – the removal of a neck tumor by surgeon, John Warren. This is how anesthesiology began – with a dentist. However, the dental profession has moved far away from their formative role in anesthesiology.

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Source: https://www.britannica.com/biography/William-Thomas-Green-Morton

Today, dental anesthesiology is one of the forgotten dental specialties – it is not a board certifiable specialty and the median income is well below other specialties in dentistry. Unfortunately, research has shown that debt encumbered dental school graduates tend toward more lucrative specialties and this is a threat for dental anesthesiology.

Now I want to tell you about a patient of mine whom we will call Nigel. Nigel is a recovering alcoholic with 23 carious teeth. As a teenager he also abused drugs and had very poor oral health habits. However, I’m pleased to tell you he is getting his life together again. He has been married for 8 years and last month he had his first child. Moreover, he started a business 6 years ago and it is really flourishing. When we completed his oral examination we found that he needed 15 fillings, 3 extractions, 2 implants and 5 crowns – something he could easily afford with his new financial situation.

He is not nervous about dental care but he is a very busy man – he has limited time to attend dental appointments and averages 1 to 2 appointments per month. Unfortunately, this means that Nigel’s treatment will get stretched out which introduces risks of disease progression and loss of motivation by the patient. What if we could offer him all his treatment in one visit under general anesthetic or intravenous sedation?

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Source: http://www.dental-health-index.com/picturesofbadteeth.html

Unfortunately, many dental offices are not set up for GA or IV and, as we discussed, few oral health experts are trained in anesthesiology in the United States. Society and the dental profession tend to restrict GA and IV for patients who are very apprehensive and difficult to treat. We encourage GA or IV for complex wisdom tooth removals but what if your patient just wants a lot of simple restorative work completed rapidly? This could increase patient satisfaction, increase demand for the profession of dental anesthesiology and could eventually put to rest historical views of perceived pain when you visit the dentist. Of course, we must balance this with the increased risks of GA and IV (the latter of which is pretty safe and may be the best option). However, insurance mechanisms don’t support this kind of dental care.

If Nigel wants to maximize his insurance benefit (which has a $3,000 annual limit) he will have to stretch out his treatment over a decade which is unrealistic and ridiculous. However, imagine if the insurer covered all of Nigel’s care in one appointment. It may completely change Nigel’s overall health outcomes, however, insurers don’t see the value of this. They don’t see the value even though insurance claims data has shown that when gingival disease is treated, a patients’ annual diabetic costs reduce by $2,840; a patients’ stroke costs reduce $5,681; and a patients’ pregnancy complication costs reduce $2,433. There are financial benefits to the insurer of incentivizing good oral health!

dentalinsurance.pngSource: http://mckinneydentist.com/dental-insurance.html

We need to move towards patient centered care – not what’s best for the insurer or the dentist. This may mean following pathways we never used to….like changing our concept of who may benefit from a General anesthetic or an intravenous sedation. Remember, a dentist was the first person to complete successful anesthesia!

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