Dr. Tom Viola tells us about the power of the medical history and why you shouldn’t ask the patient if they take any medication…
With over 30 years’ experience as a pharmacist, educator, speaker and author, Tom Viola, R.Ph., C.C.P. has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.
Tom’s homepage – http://www.tomviola.com/
Pharmacology Declassified – http://www.tomviola.com/welcome-to-the-pharmacology-declassified-blog/
This TIPisode has been transcribed for your viewing pleasure:
Michelle Strange: A Tale of Two Hygienists presents this week’s TIPisode: Quick and easy tips to keep you up to date, and presented by the experts in the profession. Now, get ready for your unofficial TIPisode.
Tom Viola: Hello, everyone. This is Tom Viola from Pharmacology Declassified and tomviola.com. Thank you so much for joining me today for our TIPisode. Today’s TIPisode is based on a topic that is near and dear to my heart and, I believe, the hearts of the students at the 16 schools where I teach pharmacology currently. Ask any one of them and I’m sure they will tell you Viola is definitely a proponent of the power of the medical history.
I have often told my students that when they’re taking a medical history, they need to ask three questions. The first question is what do you take? Now, why should you ask that question? Well, you need to know what medications they’re taking, right? Nope. Don’t say the word “medication”. You’re saying, “What do you take?”
By avoiding the use of the word “medication” or “drug” or anything like that, you get them to tell you everything, right? Not just the prescription drugs they may be taking but also the over-the-counter drugs, dietary supplements, and even the substances they use illicitly. Get them to tell you everything.
Then what? Well, the second question is why do you take it? “Well, I feel foolish asking the patient why they take it. Shouldn’t I know?” my students say. But that’s the point. You want to know if they know. Why? Because that way they can have an understanding of the medication, what is being used to treat, but also what conditions they have. Why would they be taking that medication unless they had a condition that went along with it?
But, in addition to that, you get some fundamental knowledge of their underlying conditions that maybe you couldn’t just glean from the medication itself. Maybe they’ll give you more information about exactly how severe the condition is. All of that’s valuable info, and all you’ve got to do is just get them to talk. So ask them these open-ended questions.
The third question, well, did you take it today? That’s a great question to ask. Why? Well, that’s a measure of compliance. It’s great for my patient to tell me they’re on blood pressure medication, but if they haven’t taken it in a week, what’s the point? Same thing with medications for diabetes, et cetera.
So those three questions asked over and over again until the patient figuratively wants to vomit makes them tell you everything. And, that way, you have a much greater understanding of not only the medications but also their conditions.
Now, if you read between the lines here, my friends, you also discover quickly what? Knowing the medications means you know the conditions, right? If they tell you they’re on a certain medication and you know what it’s being used for, you automatically know the condition. They may not be able to verbalize the condition that they have, but you’re able to deduce it from the information they’ve given you. So this information is extremely valuable and, therefore, not something you could overlook.
Now, you might be saying, “Really, Viola? Well, in my office, I barely have time to breath and use the bathroom and you want me to sit there and quiz these people for ten minutes?” I get that. Trust me. I’m not the ivory tower academic, okay? Even though I may teach at all these schools, I’ve been around dentists and hygienists long enough to know what your day is like, especially hygienists. You walk in with a schedule and that’s about it. If you walk out at the end of the day with your skin still on, I’m thinking it’s a good day.
And imagine having to carve out more time out of your busy schedule to conduct one of these exhaustive interviews. So, instead, choose wisely, my friends. Ask those questions and get the conversation moving, but make sure it’s as complete as possible. The more information you glean from this conversation, the more information you’re armed with to make good clinical guideline or clinical treatment planning decisions.
But, at the same time, remember that, as I’ve often said, the greatest blessing ever bestowed upon dental hygiene was what? You get to take the patient’s medical history directly from the patient themselves. And the greatest curse ever levied against dental hygiene is you get to take the patient’s medical history directly from the patient themselves. So you can take this history down, but if they’re not good reporters, your information is limited to whatever information they do tell you or want to tell you.
“What?” you say. “My patients would tell me everything that’s going on, wouldn’t they?” Well, I’d like to think so, but in my experience, that’s not always the case. And so, recently, I read an article that was published in the Journal of Dental Research’s Clinical & Transational Research [sic], and it said, basically, that underlying medical conditions were misreported in about 15 to 30 percent of dental patient records.
What? Up to a third of dental patients do not accurately report their pre-existing medical conditions such as diabetes or high blood pressure to the clinicians? That could seriously affect treatment planning and patient outcomes. I mean, you have to have accurate information. Well, again, maybe it’s not purposely, but maybe they just aren’t good reporters.
Now, the authors of this article stated that policies that support the integration of medical and dental records would meaningfully increase the quality of health care delivered to patients, particularly those dental patients with hypertension and diabetes. I agree, and I’m sure you do too. But why would you agree?
Well, here’s the thing. We are all aware in dentistry of the inevitable convergence of medicine and dentistry. It sounds odd to think that I’m saying that medicine and dentistry will eventually converge. Aren’t they one in the same? But, as you all know, that’s not the case, that we’ve been on parallel paths for a long time. Yet, in the distance, they seem to be converging. That’s good.
Why does it impact dental hygienists especially? Well, that’s one of the reasons why I love you guys. Because, if anybody knows about how the oral-systemic connection is paramount in our decision-making, it’s you. You know that systemic inflammation is more than likely the common ancestor to cardiovascular disease and diabetes. You know this. And you also know that one of the causes of systemic inflammation is thought to be advanced periodontal disease. And you know as dental hygienists that the American Dental Association says one of the best treatments for periodontal disease is the services of a well-trained, skilled hygienist.
So, my friends, you are well aware of oral-systemic connection and, therefore, you are well aware of the convergence of medicine and dentistry.
And, here, this study points out that even though there is that evidence — okay? That evidence that shows the connection between oral health and systemic health — dental care continues not to be a part of primary medical care. And, in many cases, dental records are not integrated with patient medical records and they don’t contain the same information. What? And, since inaccurate information poses a problem for especially dental hygienists, this study was aimed at determining to what degree patients misreport their hypertension and diabetes.
Why’d they get there? Well, researchers analyzed the medical records of a diverse group of patients that were seen at the University of Texas Physicians Outpatient Practice and treated also at the University’s dental school. That’s prefect because that’s exactly what we’re looking for.
All right. Well, about 1,000 patients were identified that had either hypertension or diabetes or both using non-integrated records contained in the organization’s databases. Okay. What that means in easier languages, they went out and looked for the patients that had diabetes or hypertension. First, they looked in the records for the medical school, and then they went to look for those same conditions and those same patients in the dental school. And here’s what they discovered: misreporting rates for pre-existing conditions were significant.
So patients who misreported pre-existing medical conditions. 410 patients were identified as having diabetes; 15 percent of them misreported the fact that they had diabetes in their dental records. 905 patients were identified as having hypertension; 29 percent of them misreported they had hypertension in their dental records. And, to me, the most stunning, approximately 300 patients were diagnosed with both diabetes and hypertension — both conditions — and yet only 65 percent of them accurately reported both conditions. I find that staggering, and I’m sure you do, too, because that is a big number.
If we broke it down a little more, we could say what? What are the misreporting rates? Well, if you had these 300 patients who had both diabetes and hypertension, here’s how the results broke out: 19 percent of them misreported diabetes but accurately reported they had hypertension, 13 percent misreported hypertension but accurately reported diabetes, 4 percent misreported both.
Again, the authors stressed that misreporting was likely not deliberate but likely due to other factors including things like length of time since the diagnosis. But, as we have just said, a lack of knowledge of the oral side effects contributed to the conditions and even the appearance of stigma. But let’s not leave out one other factor, human error, which they state could have contributed to information being left out of the electronic records.
Well, as for the limitations, this study did not allow for the evaluation of the time between medical and dental visits. Now, that’s big because that means what? Well, they may not have reported it in their dental visit, and then some time elapsed until their medical visit, and by then they were diagnosed with a condition. Fair enough. So we do have some outlying factors here.
And, again, misreporting gaps can be closed within an integrated health care system like this, but I’m sure many of you out there don’t have the luxury of working within a [sic] integrated or closed health care system.
So all I can say, my friends, is it’s never been more important to take a medical history and to take a complete and accurate one because now you’ve got to operate under the premise that perhaps the patient who’s not a good reporter for whatever reason is going to rely on you to make sure you fill in those gaps. And guess what? You’re going to rely on you to make sure you fill in those gaps.
Well, how am I supposed to manage this one, Viola? Give me some clues. Give me some advice. It’s easy. I’ve often said this to my students: Know your patient’s medications; know your patient. All you have to do is take all of their information down. All of the things they tell you, write it all down or enter it all into the electronic health record. And, when you’re all done, go over each medication and make sure that the condition that they’re reporting matches the drug they’re reporting and vice versa.
They may not be able to tell you that they have hypertension, but if they’re taking a drug for hypertension, you can bet they have hypertension. But, just in case, question number two bails you out, remember? Why do you take it?
Now, that’s something to be considered, for example, if I’m taking an ACE inhibitor. Okay. ACE inhibitors can be used for hypertension, but they could also be used for trying to ameliorate the kidney disease that’s associated with diabetes. So what do you take? ACE inhibitors? Why do you take it? Now I’ve got two paths. Is it for hypertension or is it for kidney disease? And that leads me down two different treatment-planning paths as well.
But the fact that I have a working, basic knowledge of pharmacology means I can fill in those blanks just by asking those questions and getting the answers down. And then, as I tell my students all the time, once you write it all down, once you get the complete medical history down, read it like a book.
What does it mean to me if my patient takes these medications and, therefore, has these medical conditions? How does that affect my treatment plan for this patient for today?
So, my friends, a lot to think about. And I do appreciate your time. Please feel free to visit me any time at my website tomviola.com. You can email me at email@example.com, and please visit my Facebook page; it’s facebook.com/pharmacologydeclassified. Until next time, my friends. I hope you stay well, and I look forward to seeing you soon.