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 (e.g.–treating the biofilm, evaluating the airway, etc.), 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.

Our 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 least fun parts of being a dentist. What’s the right way 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 featuring Dr. Frank Spear 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 years ago I put dental microscopes in my hygiene operatories. 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.

Since I’ve been doing this for a couple of years, my patients have come to expect it. As I’m doing the exam I’m trying to be a “dental cinematographer” so that we can show the patient the exam after the fact. Honestly, until now I’ve been recording the exam and having them watch as I do it, but I’m not convinced that’s enough. It’s impressive, but I’m not sure that I’m taking enough time to let them really understand what I’m seeing.

I’m contemplating a slight change in how I do this. I may move patients into the consult room right after the exam and allow my team to review the exam with them. The team tends to be more disarming anyhow. They can just use me if the patient needs me to answer any questions. As Dr. Gary DeWood said in episode 199 of the Dental Hacks Podcast, he doesn’t like to “present treatment” as much as he wants the patient to ask what can be done about what you’ve he’s them!

We just need to remember that the exam is not just a way to create a treatment plan for a patient but a chance to explain the conditions that we’re seeing to the patient. It’s about diagnosis and education. The treatment plan will come from that discussion.