Posted tagged ‘patient care’

Dentistry in the hospital: A Q&A

April 18, 2018

Photo of Dyani Gaudilliere (right) in OR; by Vladimir Nekhendzy

In the U.S., medicine and dentistry are separate — they typically have different insurance systems, training regimes and workplaces. So I was intrigued when I heard about hospital dentists. To learn more about what they do, I spoke with Dyani Gaudilliere, DMD, a clinical assistant professor of surgery and chief of the dental section at Stanford.

Why did you choose to combine dentistry with medicine?

“I started on the path towards dentistry in my teens, planning to become an orthodontist. I became increasingly interested in public health, with the goal of treating underserved populations.

At my dental school (Harvard), the dental and medical school courses were combined for the first two years with the goal of fostering a more integrated approach to dentistry, which prepared me well for my current work.

The split between medicine and dentistry is, in fact, completely artificial. The bacterial diseases of the teeth and gingiva affect the entire immune system and can cause serious systemic consequences. In addition, many systemic diseases and medications have oral manifestations.”

What do you do at Stanford?

“The majority of our patients at Stanford are being treated for cancer, organ transplantation, cardiac disease or joint replacement. Our goal is to rid these patients of bacterial disease in their teeth and gums prior to their treatments. It may be risky to treat them outside the hospital, without access to the their full medical records or emergency services. Lack of dental insurance can also be a barrier for patients whose chronic disease prevents them from being employed.”

Can you tell me more about your patients?

“One large category of patients we see are those with cancer of the head and neck. Targeted radiation to this area and chemotherapy have serious long-term side effects, ranging from dry mouth resulting in rampant tooth decay to severe jaw infections. For this reason, we perform dental examination and patient education prior to these treatments. We also partner with the head and neck surgeons to remove infected teeth during their cancer resection surgery. And we create special oral positioning devices to aid the radiation oncologists in spacing and immobilizing the tissues during radiation therapy.

We also see patients before medical treatments that will leave them immunocompromised, such as chemotherapy or organ transplantation. Chronic tooth or gum infections can suddenly become life threatening in a patient who is immunocompromised.

A third example is trauma. It is common for patients to get in minor bike accidents and fly right over their handlebars onto their teeth. We see these patients in the emergency department urgently in order to put the teeth and supporting bone back into place and then stabilize them with cemented splints.”

Are there many hospital dentists?

“I believe there isn’t enough awareness of the medical necessity of dental care, nor are there enough hospital dentists. Some hospitals are lucky to be affiliated with dental schools, whereas most have no in-house or emergency dental team at all. We regularly receive patients transferred from outside hospitals with large infections or oral trauma, because these hospitals didn’t have anybody with the right expertise to treat the conditions.

There are a lot of barriers we need to cross in order to fully integrate dentistry and medicine, but I think this integration is way overdue.”

What is your view on the separation between dentistry and medicine?

“The reason for the separation seems to be a combination of history and politics. Tooth extractions and other surgeries were historically performed by barber-surgeons rather than physicians, and oral care developed as a separate track from care of literally every other part of the body. Fast forward to today and you have dentists lobbying to sustain this separation in order to spare their profession from the regulations and changes occurring in the medical care world.

The idea that dentists would not need medical knowledge is laughable considering how much surgery they perform. Dentists who don’t understand medications and their mechanisms would not last long after their patient on blood thinners loses pints of blood after an extraction.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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How to improve care for LGBT patients

October 18, 2017

No one facing health concerns should have to worry about receiving inequitable care because of their sexual orientation or gender identity. But studies and surveys show that many lesbian, gay, bisexual and transgender individuals experience discrimination by healthcare providers — including clinicians who refuse to provide needed care, refuse to touch them or use excessive precautions, are disrespectful or simply blame them for their health status.

Fortunately, healthcare providers can improve clinical care of their LGBT patients by taking proactive steps, as outlined in a recent viewpoint in JAMA. In particular, Alexia Torke, MD, and Jennifer Carnahan, MD, professors of medicine at the Indiana University Center for Aging Research, focus in the paper on how to optimize care for older LGBT adults, who are the first generation to be more open about their sexual orientation or gender identity.

The authors recommend that clinicians use inclusive language, such as using a patient’s preferred name and pronoun and asking about a spouse or partner regarding marital status. Forms disclosing sex should also include options for transgender patients, such as “male-to-female,” they say.

In addition, they recommend that physicians learn about the medical concerns specific to LGBT patients, such as hormone treatment and gender affirming surgery for transgender individuals. They also state that screening and diagnosis for medical conditions should be based on a person’s anatomy rather than their gender identity, giving the example that a female-to-male transgender patient is at risk of gynecologic cancers if he has not had a hysterectomy.

Torke and Carnahan also indicate that clinicians should better understand the unequal treatment that many sexual and gender minority patients face, which can have financial, social and health consequences. For instance, these individuals may not have access to health insurance due to employment discrimination or as an unrecognized spouse.

They also recommend that LGBT-friendly clinicians register as a “safe physician” with organizations like the Gay and Lesbian Medical Association.

A key to improving care for these patients is training, according to the authors and other experts. So the Human Rights Campaign has established best practices for health care organizations and provides free online training for healthcare providers.

The campaign also evaluates the implementation of these best practices and publishes an annual report. In the 2017 report, almost 600 healthcare facilities participated in the related survey and more than 900 non-participating hospitals were also researched. Happily, over 300 of the participating facilities were rated as a “leader in LGBTQ healthcare equality” with a score of 100 — including Stanford Health Care.

The authors conclude in the paper:

“Although lesbian, gay, bisexual, and transgender older adults face barriers to good health and health care, clinicians can take proactive steps to improve the care they deliver. These steps include education about prior discrimination and major health needs, as well as policies that ensure respect for the individual patients and equal treatment in all health care settings.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Commentary expresses “building resentment against the shackles” of electronic health records

August 15, 2016
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Photo by Daniel Sone

Current electronic health records, also known as EHRs, have many failings. That’s according to a commentary written by Stanford faculty members Donna Zulman, MD; Abraham Verghese, MD; and Nigam Shah, MBBS, PhD, that appears today in JAMA.

Zulman, assistant professor of medicine, elaborated in a recent email:

“Many physicians are frustrated with the dominant role of EHRs in today’s clinical practice, which is experienced physically in the exam room in the form of a computer that sits between the doctor and patient.

While EHRs facilitate certain tasks, such as medication orders and medical record review, they’ve shifted clinical care away from the profound interactions and relationships that motivate many physicians to pursue careers in medicine. Our objective in this essay was to describe the need for EHRs to evolve in a way that frees physicians to focus on the caring that only they, as humans, are equipped to provide.”

According to the commentary, specific failings of EHRs include: lengthy records that don’t prioritize meaningful information, the generation of too many non-urgent alerts that continually interrupt physician workflow and the absence of key information about patients’ environmental and behavioral stressors. EHRs are basically “designed for billing” rather than easy use by healthcare providers, they write.

Zulman added:

“Many record systems house data for large populations that could potentially inform treatment decisions for individual patients. By synthesizing information about other patients with similar demographic and clinical characteristics, EHRs could provide recommendations to help guide therapy decisions when traditional evidence is lacking. Expanding the types of information in EHRs to include social and behavioral determinants of health would greatly enrich the data available for these purposes, since we know that these factors are often fundamental to a patient’s treatment response and health outcomes.”

The authors also describe ways to improve how information is presented in EHRs, particularly when a patient has a complex medical history. For instance, they suggest capturing the key events of a prolonged illness in a single graph, so physicians and patients can easily visualize the clinical course of the disease and treatment. Overall, they argue that existing technology can be used to more effectively track, synthesize and visualize EHR information.

The authors concluded in their piece:

“There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale.

Current records miss opportunities to harness available data and predictive analytics to individualize treatment. Meanwhile, sophisticated advances in technology are going untapped. Better medical record systems are needed that are dissociated from billing, intuitive and helpful, and allow physicians to be fully present with their patients.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Most primary care doctors have favorite patients, study finds

July 27, 2016

As a teacher, I try to treat all my students equally but I definitely have favorites. I’m sure other teachers have favorite students too, so it makes sense to learn that physicians have favorite patients.

A team of researchers led by Joy Lee, PhD, a postdoctoral fellow at the Johns Hopkins Bloomberg School of Public Health, interviewed 25 primary care physicians who worked in clinical settings within the Johns Hopkins medical system about their favorite patients. The participating physicians were predominantly white and about evenly split between male and female.

The doctors were a bit uncomfortable with the term ‘favorite patient,’ the researchers reported in Patient Education and Counseling. It raised concerns regarding boundaries and favoritism. However, all but three of the participating physicians admitted to having favorite patients.

The goal of the study was to identify the common attributes of these physicians’ favorite patients and examine how having favorite patients impacts their physician-patient relationships.

Who were the favorites? Surprisingly, they weren’t typically the most compliant patients or the ones most similar to the doctors. Instead, they were long-term patients who spent more time with their physician while going through a major illness. So the doctors were very familiar with their favorite patients’ personalities and health histories — allowing them to provide the best care.

“For patients, these findings highlight the importance of having a usual source of care, a primary care doctor with whom they can establish a relationship,” said Lee in a recent news release. “Favorite patients might not be consistently sick, but when a crisis comes they have an existing relationship to work off of.”

Of course having favorites isn’t the same as playing favorites. The participating physicians argued that their awareness of having both favorite and challenging patients helps them prevent favoring the care of certain patients over others. They also generally like most of their patients.

“This concern demonstrates that physicians are striving to be fair and to give all their patients the best possible care,” Lee said. “We discovered that doctors really thought about their relationship with patients, which is encouraging from a patient perspective. Their thinking really humanizes the patient-physician relationship.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.


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