RELATED ARTICLESApril 21, 2009 | Modern Hygienist
Patients: Web exclusive
Treat the cause, not the symptom
Working with the whole patient.
A few years ago, I was traveling by air, and stumbled upon an article in the airline’s seatback publication. If memory serves, the article was called “A Western Physician Looks East,” and it detailed the story of Dr. David R. Schlim, an American physician who became weary of the constraints of the U.S. health care system. Looking for a deeper medical and personal experience, he traveled to Nepal, intending to spend a few weeks reassessing his life and goals as a physician. He ended up staying some 15 years, and grew what became the world’s busiest destination travel medical clinic in Kathmandu.
Aside from encouraging development of more natural compassion as caregivers, one of the major tenets of his article (and subsequent book, Medicine & Compassion: a Tibetan Lama’s Guidance For Caregivers, with Chokyi Nyima Rinpoche, Wisdom Publications, Boston 2004) was that we’re great at treating symptoms here in the U.S.A. We’re not so great at treating the underlying cause or downstream consequences. Treating the whole patient is something we’ve left to our colleagues in the Eastern Hemisphere. Why is that? And what exactly did he mean by that? He cited a great example, which resonated with me because I had recently undergone a similar experience.
Over the course of several months, I had repeatedly developed severe laryngitis on approximately six-week intervals—after going nearly 40 years without a single episode I could recall. Each time I would lose my voice completely. After the sixth occurrence, I felt it was time to have it checked. The doctor asked a few questions and stated matter-of-factly, “you just gave me the textbook definition of reflux laryngitis.” He prescribed Aciphex®, a proton pump inhibitor, intended to treat the reflux. Treating the downstream consequence (laryngitis) would result from treating the reflux.
However, failure to look at the upstream cause is a type of “anchoring” error, described by Harvard Medical School’s Dr. Jerome Groupman in his best selling book, How Doctors Think (Mariner Books, New York 2008). Convinced he had found the cause of my problem, my doctor had dropped anchor and prescribed treatment.
The reflux itself was only a symptom, not my primary diagnosis. No questions were asked about my personal life, stress level, dietary habits, exercise, or anything else that might help explain the reflux. He simply prescribed a bottle of pills to treat the outcome. Had the physician not been so busy, he may have taken the time to ask the appropriate questions which would have led to a non-medical treatment of my problem.
But managed care does not promote the asking of questions. It promotes production, according to a schedule prescribed by someone whose alphabet soup usually includes MBA, not MD or DDS.
Since I am a dentist and engineer, I tend to think logically. Understanding that the reflux caused the laryngitis, I examined both the upstream causes and downstream consequences of my reflux and laryngitis. I realized I needed to eat better, work less and exercise more regularly to address the upstream cause (stress) and potential downstream consequence (esophageal cancer). Once I committed to these lifestyle changes (simple enough to prescribe, less simple to comply with), my problem was resolved on its own. Compliance takes supervision. Supervision takes time. We are not rewarded in the present system for taking our time with patients.
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Making the dental connection
Comparing this experience to the everyday practice of dentistry, I recognized several situations in which we tend to treat only symptoms. One example is the treatment of attrition. In cases of dentin exposure we often prescribe occlusal fillings. In severe cases, where loss of vertical dimension of occlusion occurs, we may prescribe cast restorations and/or an occlusal guard. In such cases, we’re still treating symptoms. We may treat the attrition, but not the bruxism, malocclusion, or underlying stress. If we want to treat the whole patient, we need to understand the patient and the path they’re on. So why don’t we?
As in medicine, it’s because we’re only rewarded for treating symptoms from the managed care world we insist on participating as a profession. And as any dentist can attest, misguided patients only want to do what their insurance will pay for. Insurance payers are usually seen as the “good guys.” They’re the ones paying for treatment after all. The dentist is the one who is being paid. So why would the patient trust you?
Finding solutions
What is the solution to this conundrum? First and foremost, proper patient education—not random Web searching on their part, and not sensationalizing what may go wrong on behalf of the dentist. Second, if you want to treat the whole patient and get paid for it, forget managed care. All we need to do to treat the whole patient is take the time to assess all of the diagnostic information we can gather. Then, offer a candid explanation of cause and effect, with a realistic sense of urgency for treatment, without regard to cost.
Generally, patients have several options. Usually, there is time to decide. Helping your patients to understand their needs and options is the best care you can offer them. They are capable of making intelligent decisions that do not always revolve around cost. They always come down to value—quality of care per dollar spent. What may not be obvious is that properly educating patients often leads to more treatment in the short term, so that a lifetime of remakes can be avoided. This is because it involves the treatment of upstream causes and potential downstream consequences.
Why don’t we do this for every patient who comes through the door? Because it takes so much time to gather and study the data, get to know the patient’s pertinent history, consider procedure options and present them to the patient, before we finally get around to providing the actual treatment. The present system only rewards us for the data gathering and provision of treatment, but not the provision of care.
Since managed care is unlikely to vanish overnight, our profession needs an efficient system for guiding the rapid assimilation of knowledge and prescription of care with a blind eye on benefits. The biggest consumer of time is treatment planning and the presentation of options. Let your patients be participants in this. How?
Avail them of proper information about diagnoses and treatment options. Explain to them the upstream causes (primary diagnoses) and potential downstream consequences (secondary diagnoses). Give them the time to consider their options and discuss them with someone involved in the decisions about their care. Use modern tools to facilitate this process. Once the patient understands, you will have much more efficient discussions about their concerns and questions. You will spend more time treating patients and less time explaining—the part the system rewards you for. And you will have gained patients for life.
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Dr. Thomas J. Greany is Chief Operating Officer of Symbyos, developer of ToothIQ.com, a peer-reviewed, HON Certified oral health information resource for consumers and health professionals—including dentists. Available on the Web in 35 languages,ToothIQ™ provides unbiased content to facilitate informed choice and guide decision-making for patients and their dentists. Professional memberships are available at ToothIQPro.com, which provide dentists with access to a catalog of dental procedure animations and practice-building Web microsites within ToothIQ.