Wisdom Teeth: Extracting some meaning

Ow.

Wizzie glamour shot! Day 3?

Wizzie glamour shot! Day 3?

My chipmunk cheeks are NOT cute.

I have had the privilege of being a patient on a few occasions, some less serious (Bells Palsy, Pityriasis Rosea) and some more serious (Transverse Myelitis). I'm fortunate to be pretty healthy overall and try to steer clear of trouble.

I do go to my GP who is an amazing full-scope, old-school, dedicated doc. Even though I think he's amazing, I still say "no" sometimes. Most recently he suggested some screening blood work, and I declined. He gave me the requisition anyway, but needless to say I did not donate any blood to the cause.

With that said, it will come as no surprise that I never wanted my wisdom teeth out. 

Healthy Debate has a timely article, Is wisdom teeth removal really warranted?, covering all the evidence and the information one needs to make a decision about whether to get impacted teeth extracted. 

My wizzies (that's what cool kids call wisdom teeth) were sitting in my mouth, just being teeth, maybe impacted but not really causing any trouble. Until... they started to peek out in my 20s, and now age 30, one of them (right, lower wisdom baddie) created an unreachable space between him and his neighbour molar. Boom! Infection. Periocoronitis. Yuck.

I did all the conservative stuff and tried to keep baddie's space clean and happy but no matter the fancy syringe or amount of peroxide I blasted in there, the infection continued, slowly smouldering. My dentist suggested I see the oral surgeon.

He also suggested a bunch of other things, like braces, which I said no to. While I am fortunate enough to have a great dental plan, I did not want the headaches and hassle of that just for cosmetic reasons and the chance that it would slightly improve the way my teeth were wearing. Dr Dentist listened to me and agreed. That was nice! The alternative of leaving my wisdom teeth in would be possible, but the infection would wax and wane and it could do this when I'm out of the country or could require repeated courses of antibiotics, visits to the dentist, etc. So I agreed to go see the oral surgeon (Dr Surgeon) who said all my teeth definitely needed to come out.  Oh, and I'd need a CT scan first to see if the tooth roots were wrapped around the inferior alveolar nerve. 

Dr Surgeon was awesome at discussing the risks. He also offered an alternate plan if the teeth were intertwined with the nerve. The CT really wasn't optional, as it was needed for planning the technique. I asked if I could just get baddie out, but he suggested it was better to do all of them at once so I wouldn't have to go through the surgery later in life if there were more issues. Getting wisdom teeth out after 25 is not ideal to begin with, and doing it on 4 separate occasions (if needed) would indeed be torture. 

The reason wisdom teeth are much easier to remove in teenagers is that the teeth don't contain much wisdom at age 18

Now, my jaw is recovering from having a crowbar go exploring in it. Well, actually I'm sure Dr Surgeon was as gentle as possible but they were stuck in there pretty well. My right side (where the infection had been) healed very well, the left basically did the maximum amount of swelling/trismus possible and I even got a shiner. Round the clock ibuprofen, lots of ice, etc. was somewhat helpful but mostly it just took time to settle.

Compared to others who've had the same surgery, I got off easy. My inferior alveolar nerves were fine. I didn't get a nasty infection like my brother did when there was a perforation into his sinus(!). I didn't die from complications of the anaesthesia. Phewf!

Every time I am a patient, I learn things about myself and especially about doctoring.

If I look at this from a patient-centered experience, I would say there were some good things:
- able to schedule it at a time that worked for me
- very clear and upfront about the price, the risks, the recovery process
- printed instructions were very detailed and included contact info for the surgeons
- the clinic called to check up on me
- when a large fleshy lump developed inside my cheek, they were able to fit me in quickly and verify that it wasn't an abscess, reassuring me + my spouse
- I hardly ever had to wait in the clinic, everything was basically on-time which was incredible!

 

Popcorn Addict. Used (unfortunately without permission, but it's too perfect to not post)  from Sam on Flickr

Popcorn Addict. Used (unfortunately without permission, but it's too perfect to not post) from Sam on Flickr

On the other hand, there were a few parts that made it hard to navigate:
- one side of my jaw was not bad and the other with terribly terribly painful, which made me wonder if some complication was happening, it would have been helpful to know that this is "common"
- I was given a prescription for antibiotics; this was not mentioned in the handout or by the surgeon to my spouse so I was unsure if I should take them or if they were a delayed prescription (eg. take if a complication arises); when the clinic called to check on me the day after surgery I asked the caller whether I should take the antibiotics. She said "yes, of course." And I tried to clarify, "oh, I wasn't sure if everyone takes these or if they were just if some complication developed; I didn't want to take them without being sure because of the risks of antibiotics" and she told me "there aren't any risks."
[I got a bit upset at that point! Maybe it was the gnawing jaw pain or maybe I was just outraged... I might have mentioned that I was a physician, a card I try not to use because it makes me feel like an entitled a*hole, and that 'yes indeed there are risks...'] 
Anyway she told me it was routine and I relented. My scan of the evidence didn't confirm that, but because I'd had a chronic infection pre-op I figured Dr Surgeon would probably strongly recommend I take them. I probably could have handled that better by asking about it earlier in the process, but I didn't know there would be antibiotics until I emerged from the post-anasthesia haze at home
- the handout was great but I wish I would have received a copy before the day of the surgery; one of my values as a patient is "eating popcorn" and I was a bit sad to find out on the operation day that I would not be allowed popcorn for 3 months!!!!!!!!

What I might apply to my own practice:
- handouts are useful!
- people like to know what to expect, so it's good to invest the time explaining some of the possibilities and timelines
- when doctors or clinics are accessible, it helps! Even if you don't need to call or go there, somehow it feels better knowing that if you need them, it is not impossible to reach them
- when estimating recovery times, it is probably better to under-promise/over-deliver; I was told to have 3-5 days off work and I wound up needing 7 before I even could see properly out of the eye on the side that was swollen/bruised and open my mouth wide enough to speak clearly
 

In the end, did I get the right amount of medicine? Maybe. I'm not sure! In hindsight, I would certainly have asked a few more questions (eg. about antibiotics) and I might have opted for removal of just the one baddie wisdom tooth.

Overall it was very challenging being a patient with a background in health care. When I went numb from the waist down two years ago, I basically dismissed it for three days before my dad (a nurse) insisted I seek attention - and there turned out to be an inflammatory lesion on my spinal cord ('transverse myelitis'). So now, I try really hard to mention things that seem odd or wrong and let other doctors decide if they are important. The consequence of that is that I probably come off as a worrier, but I'm sure I'll find a balance with more adventures as a patient. 

I just hope this is all the medical adventuring I'll have for a little while, at least.

Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals | National Post

In our disposable culture, it is unsurprising that the bleed of this trend into healthcare has gone largely unchecked.

Operating rooms now use scads of throwaway equipment, saving sterilizing time and shaving off some intra-operative minutes by using devices that are slightly more specialized for components of the procedure.

Surgeons, nurses, and patients are all unaware of the cost. In fact, "Surgical residents and staff have a generally poor knowledge of the cost of common consumable products used in the operating room," according to a recent study in Laryngoscope by Canadian otolaryngologists.

Tom Blackwell of the National Post highlighted the issue and discovered some of the simple changes that administrators and surgeons could make to save costs without significantly impacting operation times. These efforts would also reduce landfill waste, something not emphasized in the article, but a very important consideration for the long term sustainability of our health care system.

See the video and article: Showing surgeons ‘massive’ cost of disposable supplies leads to big savings for hospitals.



Source: http://news.nationalpost.com/news/canada/s...

Giving Doctors Grades - The New York Times

Kelly Blair's illustration of health care grades

Kelly Blair's illustration of health care grades

I write a lot about well-intentioned tests and treatments for patients leading to (unintended but very real) negative consequences.

For example: high cholesterol is linked to heart attacks and heart attacks kill. We have a kind of drug that lowers cholesterol (statins). Give the drug, lower the cholesterol, lower the number of heart attacks. So, we put everyone on statin drugs, yay! 

Except, no. Physiology is not logic; lowering cholesterol with statins may NOT lower the number of heart attacks or it may not do so in most people. And statins don't actually save lives in people who don't already have heart disease. But many people (~1/10) given this statin drug will experience unpleasant side effects, like daily muscle cramps. (theNNT.com)

Good intentions, bad results. Surrogate markers are not meaningful.

 

That understood, it should not be surprising to see this thinking error applies not only to physiology but also to the health care system, a system (like the human body) that does not follow the simple rules of logic.

Well-intentioned quality or performence measures can lead to unintended and very negative consequences. This NY Times article, Giving Doctors Grades, illustrates this problem perfectly.

While trying to ensure high quality care, some metrics are set. These metrics are meant to be measured repeatedly to ensure that whatever changes are made result in better and better patient outcomes, lower costs, etc. Unfortunately, the choice of metrics can drive physicians to behave badly, in order to score higher on their report cards. To get the best outcomes, surgeons stop helping the sickest people and surgerize the healthy instead.

Bad things happen to patients that did not need things done to them.

My own provincial medical association, Doctors of BC, and many other organizations in Canada have discussed measuring physician performance. We as physicians want to be accountable to our patients, and the public wants this too. Our common goal: that dangerous, unsafe practices be weeded out and high quality care be supported and applauded.

We must proceed very very carefully when we put measurements in place lest we incentivize the wrong thing and do more harm than good.

Read more in the NY Times.

Source: http://www.nytimes.com/2015/07/22/opinion/...

Choosing surgery wisely: the importance of evidence-based practice

* RESEARCH FIRST LOOK *

Very little research has been done so far in the area of appropriateness in health care, so it is is always a delight to see what is being worked on.

You may remember Roland Grad, a family physician and research at the University of McGill, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign.

Two ambitious McGill medical students, Nicholas Meti and Mathieu Rousseau, worked with Dr Grad to extend that work and look at InfoPOEMs that dealt specifically with surgical interventions which are considered unnecessary or harmful to patients.

Many agree that there's room for the Choosing Wisely campaign to improve; this research presents a potentially fruitful way to do so, particularly for the orthopaedics recommendations which have been heavily criticized to date.


Choosing surgery wisely: the importance of evidence-based practice

Meti, N., Rousseau, M., Grad, R. Medicine, McGill University, Montreal, Canada.

An emerging trend among physician organizations is to attempt to control or reduce the rate of unnecessary medical tests and treatments. Until recently, the principle manner to release updated recommendations for practice was through meetings where experts discussed which tests or treatments needed to be questioned.  

We developed a novel means of analyzing nascent research articles for their applicability towards improving the “Choosing Wisely” topic selection process [1]. This method is based on analyzing the ratings of daily POEMs, collected from physician members of the CMA. POEMs are tailored synopses of primary research or systematic reviews, selected by searching over 100 journals. POEMs are delivered to over 20,000 members of the Canadian Medical Association (CMA) by email on weekdays.

At the 2015 ‘Preventing Overdiagnosis’ conference, one of us (RG) will report on the top POEMs of 2014, as rated by CMA members with respect to their potential to help them to ‘avoid an unnecessary diagnostic test or treatment’ [1]. Of the topics addressed by these top 20 POEMs of 2014, only 2 were discussed in the Choosing Wisely master list of recommendations. Of the remaining 18 topics, three were related to surgical interventions; we highlight their important findings.

In a study published in The Bone and Joint Journal, Kukkonen et al. used the Constant Shoulder Score to show that among patients with symptomatic non-traumatic supraspinatus tears, physiotherapy alone is as effective as physiotherapy combined with acromioplasty after 1-year follow up [2].

In a study published in the New England Journal of Medicine, Sihvoven et al. investigated whether arthroscopic surgery would improve outcomes for select patients with a degenerative tear of the medial meniscus. The researchers conducted a multicenter, randomized, double-blind, sham-controlled trial involving patients without knee osteoarthritis, but with symptoms of a degenerative medial meniscus tear. Surgery was found to be ineffective for non-traumatic partial medial meniscus tears [3].

A study published in JAMA by Primrose et al. [4] questioned the routine practice of intensive follow-up after surgery for colorectal cancer, as there existed no evidence to support this common practice. In a randomized controlled trial, 1,202 participants were assigned to 4 groups: CEA only, CT only, CEA+CT, or minimum follow-up. Their results demonstrated that among patients who had undergone curative surgery for primary colorectal cancer: 1) intensive imaging or CEA screening each provided an increased rate of surgical treatment of recurrence with curative intent, compared with minimal follow-up; 2) there was no advantage in combining CEA and CT; and 3) there was no statistically significant survival advantage to any strategy.

One concern about the development of top five lists in Choosing Wisely is the potential for individual specialties to choose the low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included no major surgical procedures in their top 5 list, despite evidence of wide variation in elective knee replacement and arthroscopy rates [5]. This observation is not meant to be a criticism of orthopedic surgeons per se, as many surgeons are strong advocates for their patients (see http://www.thepatientfirst.org). [Less is More readers will remember one of the founders, Dr James Rickert, from What Can Patients Do in the Face of Physician Conflict of Interest]

Our point is to drive home the underlying philosophy of the “Choosing Wisely” campaign: ‘routine’ testing or treatment without evidence-based support can be found insidiously entrenched in all disciplines.


References

1. Grad RM, Pluye P, Shulha M, Tang DL. POEMs Reveal Candidate Clinical Topics for the Choosing Wisely Campaign. Preventing Overdiagnosis Conference, Bethesda, MD, September 2015.

2. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014; 96(1):75-81.  
http://www.ncbi.nlm.nih.gov/pubmed/24395315

3. Sihvonen R, Paavola M, Malmivaara A, et al., for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369(26):2515-2524.    http://www.nejm.org/doi/full/10.1056/NEJMoa1305189

4. Primrose JN, Perera R, Gray A, et al., for the FACS Trial Investigators. Effect of 3 to 5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer. The FACS randomized clinical trial. JAMA 2014; 311(3): 263-270. 
http://www.ncbi.nlm.nih.gov/pubmed/24430319

5. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—the politics and economics of labeling low-value service. N Engl J Med 2014; 370:589-92. 
http://www.nejm.org/doi/full/10.1056/NEJMp1314965

Shrinking demand for blood products behind closure of blood donor clinics

Too much blood.

Remembering last year's crisis  – a severe shortage of blood products in Canada – it was surprising to read that Canadian Blood Services will be shutting down four permanent and 16 mobile clinics.

I am a blood donor.* It is with delight that I learn we have too much blood.

Experts cite five main reasons for this surplus:

  1. Minimally-invasive/robotic surgery reduces the amount of blood needed for each patient
  2. Doctors are transfusing when patients have symptoms, not for an arbitrary hemoglobin number (thanks to recommendations that have been made more popular thanks to initiatives like Choosing Wisely, eg item 5 on this list)
  3. Pre-surgery management can help increase patient's blood counts
  4. Better drugs during surgery prevent blood loss
  5. Blood supply is better managed by sharing blood products through hospital networks

It would be interesting to know which of these is has been the most effective at reducing the amount of blood required, but it sounds like most of these are in the best interests of patients and it results in a savings of $2.9 Million annually. However it happened, this is a big win for Canadians.

 

Well, I have donated blood, but every time I travel overseas (often to areas where malaria is present) it seems to prohibit me from donating for a year, and then I got my weird medical condition, so it has been about 3 years since I last donated.

Source: http://www.thewesternstar.com/News/Local/2...