Diagnosing surgeon

Dentistry is procedure based. Generally speaking, we do all kinds of procedures to fix problems with the teeth, gums and jaws. That’s what dental school trained us to do. With the exception of some newer “medical model” treatments, most dentists spend their days doing fillings, crowns, root canals, extractions, placing implants, making removable prostheses and doing periodontal therapy. These procedures typically have a starting point and end point (except dentures in dental school…those never really end) that is easily denoted.

That isn’t to say that dentists aren’t diagnosticians. We become expert at recognizing all kinds of pathologies of the teeth, gums, jaws and muscles. In order to treat our patients effectively (usually using procedures at which we become more and more proficient), we need to effectively diagnose their problems and communicate to them what we’ve found and their options to treat (or not treat) as the case dictates. Most dental offices are one stop shopping unless the dentist chooses to refer procedures out to specialists.

Broken armOur colleagues in the medical industry operate differently. In many cases the physician that diagnoses the problem doesn’t actually treat the problem. If I fall off a ladder and break my arm it’s likely that an ER doc is going to assign a differential diagnosis to the problem and order a radiograph that’s read by a radiologist, who diagnoses the fracture. At that point, it’s likely that I would be referred to an orthopedic surgeon to treat the broken arm.

What you don’t see very often in this multidisciplinary track of care is the patient being concerned that there is “overtreatment” going on. For one thing, it’s often very problem based. I wouldn’t have shown up in the ER if my arm wasn’t bent in a funny direction. For another thing, there are several clinicians that are coming to an agreement about the care you’re going to receive. That’s a big difference from what typically happens in dentistry. Not that we don’t refer to specialists, but it’s pretty rare that a patient’s diagnosis and treatment plan is put together with that many brains.

Some patients, especially ones that don’t know you very well, may believe that you are treating problems that they don’t have. A big cavity can remain painless until the pulp is involved. Sometimes even after the tooth is abscessed the patient doesn’t feel pain. Gum disease is almost always painless. Often the patients don’t realize they have a problem even though it’s obvious to you as a clinician. I find this to be one of the less fun parts of being a dentist. I’ve got to be the guy to deliver unexpected news in a way that doesn’t seem like I’m hoping to cover my boat payment. And it’s always a boat payment, right?

Spear Online education posted a video that I found helpful. It’s entitled “Managing Fear When Presenting Findings to Your Patients.” I related to a lot that he discussed. One thing I walked away with is that presenting findings is a lot different than presenting a treatment plan. That may seem obvious to you, but sometimes I get hung up in that. When I’ve got two hygiene checks per hour and I’m doing a bunch of time consuming restorative dentistry at the same time, I often don’t separate the two.

“A treatment plan scares people away.”

Dr. Frank Spear

I need to remember to share the findings of my exam. A few months ago I moved my microscopes from my treatment operatories to my hygiene operatories (I only have two scopes). Each one of the microscopes has an HD camera that’s connected to monitors in the operatory. I do all of my hygiene and new patient exams through the microscope. This has been the greatest tool I’ve ever used to explain conditions to patients without automatically moving to a treatment plan. Also, I get a lot less of the “boat payment” comments now, too. I’m still just beginning with this technique. I think my patients have a much better understanding of their condition than I’ve ever been able to offer. Another pleasant surprise…treatment acceptance is way up!

I just need to remember that my exams are not just a way to create a treatment plan for a patient but a chance to explain the conditions that I’m seeing to the patient. It’s about diagnosis and education. The treatment plan will come from that discussion.

Questions or comments? Please leave them in the comments section below or email me at alan@meadfamilydental.com.  If you’re a dental peep you owe it to yourself to listen to my dental podcast. It’s called The DentalHacks Podcast and it’s made with 50% unicorn tears and 50% sweat from Chuck Norris’s brow.D

Delivering bad news

Most dentists have gotten really good at the delivery of bad news. Most of us are pretty good at explaining our findings in a dispassionate way. We’re supposed to explain what we’re seeing, recommend different treatment options, explain the pros and cons of each option and then let the patient ask questions and make a choice. The trick is that you can’t own the patient’s problem. It’s really important that you don’t care more than the patient does.

Straightforward stuff, really. I mean, it’s not like we’re oncologists or something. The great majority of dental problems are not life and death.

I’m here to tell you…I still struggle. I’m not as good at delivering the bad news. I sometimes struggle because I do care more about the problem than the patient does. I think that’s because I understand the problem better.

Tooth decay doesn’t hurt until the tooth is in real trouble. Gum disease is painless right up until the teeth get wiggly. I see what’s going on in their mouth in HD. I use high powered loupes or even a microscope to see what’s going on and sometimes it’s hard for the patient to get as concerned about it as I do.

Some days I get really discouraged about it. I’ve got to let people know what I’m seeing. Modern dentistry can do some amazing things, but getting people to choose that is the difficult part, in my opinion. Some days I get burned out. Sometimes I have patients with multiple and serious problems that have no clue. That is so hard for me. It’s times like those where I don’t even know where to start.

But I’m a doctor. I owe my patients the truth. I don’t have to be mean about it, but I have to be truthful to the best of my ability. Patients need to understand that I don’t enjoy giving bad news any more than they enjoy hearing it. But we’re in this together. They always have the choice to do nothing, but my duty as a doctor is to let them know what’s going on and give them ideas on ways to treat it. We’ll get through this together.

Don’t just do something, sit there!

Last week we had an emergency patient. She left a message on the answering machine over the weekend because her tooth was “killing her.” The appointment went kind of like this:

patient: “The tooth really hurt all weekend long. I was ready to take it out myself with pliers!” (they always say this)

me: “Tell me more about ‘really hurt.’”

p: “Any time I drank anything cold it would give me these little zingers. Ice cream REALLY hurt. Also, I couldn’t really chew anything on it. All I really had to do was press on the tooth and it would get really sore. I look some ibuprofen but it didn’t really help.”

m: “Wow. That sounds really awful. How does the tooth feel now?”

p: “It feels better now. The gum is a little bit sore, but other than that it’s fine.”

So I did an exam and took a PA. The tooth had a small occlusal amalgam that was serviceable. The patient was a regular and never missed a preventive maintenance appointment. The radiograph was within normal limits. No widening of the pdl, no evidence of radiographic decay. I couldn’t elicit the patient’s chief complaint with hot, cold or a tooth sleuth. Percussion was negative. The palatal gingiva looked slightly irritated. So slightly that I may have been seeing things that weren’t there.

In short, I couldn’t find anything. The patient told me that she was in serious pain throughout the weekend, and I couldn’t find the source of her problem.

There’s something incredibly unsatisfying about that. Dentists are trained as diagnosticians and surgeons. We’re supposed to figure out what’s wrong and then fix it. The patient is looking me in the eye and telling me that she was really hurting and she wants me to a) tell her why it was hurting and b) make it so it doesn’t hurt again.

I did have a differential diagnosis list forming in my mind and I laid that out for her. She may have gotten some food impacted between a few teeth (e.g. “Did you eat any popcorn this weekend?).  That can be very painful, but it almost always resolves itself with some effort at hygiene or by just working its way out. Or maybe the patient accidentally bit on something hard (think olive pit, chicken bone) and didn’t really remember doing it.

Who hasn’t had some kind of transient tooth pain at one time or another? If the patient has a low pain tolerance, this kind of thing could account for it as easily as anything else.

The bottom line was that the patient wanted an answer. And I wanted to give it to her. But I had nothing. Zip. Nada. My training as a diagnostician gave me nothing to go on.

My training as a surgeon said “let’s do something!” Hey look, when patients present with a problem, I gotta fix it, right? And if I don’t, I look ineffectual.

Put that drill down, cowboy.

Everyone remembers the radiograph of the patient that had endo in every tooth on the upper. The patient kept having pain and the doc kept doing root canals. The moral of the story was that the patient suffered from severe, chronic sinusitis and ended up needing surgery for her sinuses, not her teeth. How do you think that dentist looked after a mouthful of root canals placed without solving the problem?

I’m here to tell you that there’s nothing wrong with a good, old fashioned “let’s wait and see.” So long as the patient is comfortable, what’s the rush? Let the patient know that you have some ideas about what may have been happening but you’re not sure. Let the patient know that you’re there for them and if it happens again, you want to see them right away.

John Kois says “the best dentistry is no dentistry.” Especially when working from a lame differential diagnosis.