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Can Surgeons Learn Lessons from Olympians?

Posted on 13. Oct, 2012 by .

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An interesting article titled “Performing to a world class standard under pressure—Can we learn lessons from the Olympians?” by Serryth D. Colbert and et. al. appeared in the 2012 issue of the British Journal of Oral and Maxillofacial Surgery (50, pp 291-297).

With the Summer Olympics this year in London, the authors decided to ask Team Great Britain Olympic rowing squad what makes a winner. The authors state:

“We explored the concept of ‘mental toughness’ and the impact this has on successful performance under intense pressure. Our aim was to use their experiences to possibly improve oral and maxillofacial surgeons’ performance in critical situations.”

The researchers consulted a leading performance development consultancy and made a questionnaire which was given to both the rowers and the surgeons at a joint conference.  The results were that the rowers responded to the questionnaire with more ‘mentally tough’ responses than the surgeons. This difference in response averaged 12% on the Likert scales (were 1 is strongly disagree, 2 is disagree, 3 is neither agree nor disagree, 4 is agree, and 5 is strongly agree).

The researchers speculate that

“The superior performance demonstrated by the athletes on the Likert Scale may reflect the desire that athletes require in order to perform at elite levels. This presumes a high level of self-belief in ones ability to achieve competition goal…”

The responses by the rowers when asked to define mental toughness were interesting:

“Mental toughness is not being affected by anything but what’s going on in the race. It’s being able to block out what’s not important.

The British Olympic rowing team identified one of the key components of mental toughness as learning how to condition the mind to overcome frustration, i.e. don’t allow frustration to undermine confidence or focus. The rowers view on this was to regard being positive ‘as a discipline. . . and the more adversity faced, the more positive one must be.’”

It is interesting to note that Olympians take control of negative self talk and reframe it into positive task-oriented suggestions.

The authors state that:

“…both male and female international athletes use a wider range of psychological skills (goal setting, imagery, activation, self-talk, emotional control, negative thinking and relaxation) in training and competition than those of a lower standard. This research could possibly be progressed to consider the extent to which trainee oral and maxillofacial surgeons employ psychological skills in training to facilitate the learning process.”

The authors in the conclusion state:

“Motivation is the foundation of all athletic effort and accomplishment. Without the determination to improve performance, all of the other mental factors mentioned such as confidence, intensity, focus, and emotions, are meaningless. Athletes recognise the prime importance of motivation. However true motivation must come from within, it cannot be taught.”

I found this piece on looking at the top Olympic performers and looking for insights to improve surgical skill to be  fun and interesting. Learning how to foster and improve psychological skills can be powerful for anyone to help improve performance.

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Why People Hate the Dentist

Posted on 14. Oct, 2011 by .

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Numerous posts on the internet have attempted to shed light on the why people hate the dentist.

Tom over at OralAnswers.com has a two part series on why people hate the dentists located at http://www.oralanswers.com/2011/09/why-people-hate-the-dentist/ and http://www.oralanswers.com/2011/09/why-people-hate-the-dentist-my-theory-part-ii/

Dr. Joe Bulger DDS in Canada changed the name of his blog to hatedentists.com and his written several posts on the topic of people who hate dentists located at http://www.hatedentists.com/1319/hate-dentist/ , http://www.hatedentists.com/1326/dentist-haters/ , and http://www.hatedentists.com/1363/top-10-reasons-people-hate-dentists/

SaneDentist.com has a post by Dr. Mujtaba Ali regarding 5 reasons why people hate the dentist located at http://www.sanedentist.com/here-are-5-reasons-why-we-hate-the-dentist-and-what-a-dentist-thinks-about-them.html

Reading, over these posts and potential explanations for hate towards the dentist just doesn’t seem to do the hate justice and doesn’t touch on all the issues.

So here are some reasons why I think people really hate dentists (subjective opinion):

1) Being motivated by money to the point of detrimental care to their patients

Let’s face it, people go to work to make money so they can survive and look after their loved ones. However, dentistry is not a business and should be about making people motivated to practice healthy habits and not pushing unnecessary surgeries and care. This is touched on on the controversy page of this site and in this post on if dentists are ethical or scam artists. People want to know the facts regarding their care and if it will be helpful or harmful.

Now yes doctors and dentists do have increasing outrageous tuition costs at the undergraduate and professional levels http://blog.teethremoval.com/lets-give-our-kids-a-chance-to-succeed/. What should be happening is strong leadership and organization in dental professional societies to help insure tuition costs do not continue to spiral out of control. Of course dentists should be fairly compensated for their efforts and skills but the current fee schedules often times do not promote health to the fullest.

2) Not factoring liability into the patient side of the equation and ensuring patients who are injured receive fair compensation.

As discussed on this website and well known, doctors and dentists have concerns with liability when they see a patient. Numerous physician groups in the U.S. such as the American Medical Association and American Association of Oral and Maxillofacial Surgeons are actively pursuing legislation to limit non-economic ‘pain and suffering’ damage caps to $250,000. http://blog.teethremoval.com/the-war-on-healthcare-patients-who-hate-doctors/ and http://www.teethremoval.com/legal_standpoint.html

The American Association of Oral and Maxillofacial Surgeons continues to recommend and say that most healthy wisdom teeth should be removed when a patient is young and healthy such as a teenager but yet also push for damage caps of $250,000 at the national level. Several cases are illustrated on this site at http://www.teethremoval.com/complications.html and http://www.teethremoval.com/dental_malpractice.html in which a damage award of $250,000 for certain cases is just downright unfair, unjust and ridiculous.

In fact I argue that you should avoid having wisdom teeth extracted in any state such as California and Texas which have $250,000 non-economic damage caps. There are other potential approaches instead of the current medical malpractice system such as discussed here http://www.teethremoval.com/legal_system_medical_malpractice that dentists should be advocating for for their patients. This includes such things as a no fault insurance for negative outcomes, a no-fault approach, or health courts.

3) Lack of focus on research

Let’s face it many people simply do not like the dental drill and needles and other instruments used by a dentist. New approaches should be further explored. For example, extract wisdom teeth without the need for all these tools with perhaps some other method to prevent wisdom teeth from even growing.

Further echoing back towards #1 many dentists and doctors are motivated to go into specialties that pay higher instead of going into more academic and research oriented careers. This works to hinder much needed progress and discovery.  In addition many patients who want to know the latest up to date research are left in the dark.

Further it is my belief that patients and their reactions both positive and negative to treatments should be investigated. Often times there will be no record of how a patient responded to a treatment.

4) Engaging in conspiracy, collusion, and trying protect themselves from potential liability to the detriment of their patients

There are numerous complications that can occur from having wisdom teeth extracted as indicated here http://www.teethremoval.com/complications.html.

However, when I had my wisdom teeth extracted I consented to only around 8 such complications and was never made aware that there are numerous other potential serious risks involved. Furthermore the fact that healthy wisdom teeth are not extracted in the U.K. due to the risk of harm was not disclosed.

Still to today I have yet to see any informed consent forms that list permanent headache as a known complication from having wisdom teeth extracted.  As discussed on wisdom teeth removal stories by others other patients have had headaches occurring from having wisdom teeth extracted and were told as was I that it was not related to the surgery. It is my belief that patients have a right to know about serious potential risks before consenting to a potentially life altering surgical procedure.

In addition, other dental websites on the internet fail to disclose many of the potential risks and complications from having wisdom teeth extracted.  Some of this may have to do with dentistry being focused on the oral cavity and so some do not like to readily admit that teeth have implications on other aspects of the body and health. Another reason of course is going back to #1 where their is a push towards selling procedures and care instead of providing information to patients to better help them make health decisions.

Patients get angry when they are lied to and feel like they have been taken advantage of. In some cases patients are told they had to have impacted wisdom teeth extracted even though no scientific evidence currently supports having healthy impacted wisdom teeth extracted. Further patients get angry when they are lied to by their dentist and office staff about complications that have occurred from surgery.

5) Pain

Ultimately going to the dentist can cause a lot of pain. Some of this pain may just be due to their teeth hurting or it could be due to a lasting horribly painful complication from treatment.

6) Anxiety

Since patients know that dentists can cause them a lot of pain they get anxious about seeing a dentist. This may even cause them to have nightmares and be unable to sleep for days prior to seeing their dentist.

7) Giving patients a hard talk

Some patients may need to be told that certain things they are doing to take care of their teeth are not good. Some dentists may discuss this in a way with the patient that they take offense to, although it really shouldn’t be taken that way.

8 ) Taking sexual advantage of patients

As discussed here http://www.teethremoval.com/sexual_assault_under_anesthesia_for_wisdom_teeth_removal.html some dentists have sexually assaulted their particularly young female patients during treatments and procedures. This has absolutely no place in dentistry. Certainly dentists are people and can have urges but this has no place in the workplace with paying customers.

9) Dental boards and organizations not protecting the public

I had no desire whatsoever to create this website. It is very unfortunate that high quality care and protecting and providing information to the public so they can make an informed choice about dental treatments is not the top priority.

Many oral surgeons continue to recommend that healthy impacted wisdom teeth be extracted in young patients http://blog.teethremoval.com/the-truthiness-of-extracting-wisdom-teeth-james-r-carey/ without adequately providing information on the facts, evidence, risks, and harms of surgery.  Again this goes back to #1 .

10) Poor service

Ultimately all of these issues set up for poor service and unsatisfied patients. It can be hard to please every patient and know how different patients will react. However, poor service really encompasses all of the issues already touched upon. Other things that could be a problem is lack of knowledgeable dental staff or a dated dental office.

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Dumb Americans Trust Their Doctors for No Valid Reason

Posted on 13. Sep, 2011 by .

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Gawker has written an article titled “Stupid Americans Trust Doctors” written by Parenne and published on June 17, 2009, located over at http://gawker.com/5294409/stupid-americans-trust-doctors in which it says:

” Doctors are lazy and greedy and do not care about you. But Americans do not know this! Because of the TV, they think doctors would come up with a good national health care plan. They would not. If the doctors made a plan, it would involve paying them even more money to not bother keeping up with advances in their fields and not ever letting you sue them when they hurt or kill you.”

Here is one female doctor’s view on why she went into medicine via http://www.nybooks.com/articles/archives/2009/jul/02/the-health-reform-we-need-are-not-getting/?page=3

“I am a doctor and… yes, I love the money! Its amazing, you gomers keep coming back to us and we just sprinkle a little Rx here or a little there and bam, we charge it. I get about 175/hr if I moonlight. Can’t help it if you losers were too busy thinking you could become awesome investment bankers or physicists when you could look around you and see that physicists are selling pizza in their spare time to make ends meet. Me, i looked around saw the benz’s and the $$$ and no doctors selling Pizzas and knew that I was gonna hit this field up.”

According to Wikipedia gomer is:

“a medical slang term for a patient in a hospital who is demented (and not fully conscious) or bordering on death, hence taking up room unnecessarily in the hospital.”

One man’s views on doctors is the following:

“I finished my phd recently and worked closely with recent graduate MDs. These people are disgusting, greedy and self-entitled. I say, lets shove money down their throats and see if they become happy. I have lost my hopes of good doctor-patient relationship, and just pray I will never need their services.”

At a recent GOP debate a question was asked to Ron Paul

“… a healthy 30 year old young man has a good job makes a good living but decides you know what I am not going to spend $200 or $300 a month for health insurance because you know what I am healthy I don’t need but something terrible happens and all of a sudden he needs it.”

Audience members of the Tea Party debate cheered and yelled out support for allowing this hypothetical uninsured man to die. See for yourself…

When you can’t trust your doctor because many of them are operating a business designed to maximize profit and some members of society don’t consider a human life as sacred then how can you put any credibility in the “free market” applied to healthcare.

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Professionalism of Medicine in the 21st Century

Posted on 22. Aug, 2011 by .

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An article is titled Medical Professionalism in the New Millennium: A Physician Charter in the Annals of Internal Medicine, vol. 136, no. 3, pages 243-246, February 5, 2002, http://www.annals.org/content/136/3/243.full?ijkey=49cf14ffb35a6afdba3a14871f01fb39ad23066f&keytype2=tf_ipsecsha

In the second paragraph appears the words:

“…conditions of medical practice are tempting physicians to abandon their commitment to the primacy of patient welfare”

The article then goes on to discuses a preamble

“Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.”

The article talks about 3 fundamental principles of medical professionalism:

  1. Principle of primacy of patient welfare
  2. Principle of patient autonomy
  3. Principle of social justice

The article then discusses a set of Professional Responsibilities

  1. Commitment to professional competence
  2. Commitment to honesty with patients
  3. Commitment to patient confidentiality
  4. Commitment to maintaining appropriate relations with patients.
  5. Commitment to improving quality of care
  6. Commitment to improving access to care
  7. Commitment to a just distribution of finite resources
  8. Commitment to scientific knowledge
  9. Commitment to maintaining trust by managing conflicts of interest
  10. Commitment to professional responsibilities

The second to last sentence of the article ends with

“To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society.”

As indicated clearly on my website many physicians need to take the time to reaffirm their dedication to professionalism and perhaps reassess why they went into medicine.

As indicated current scientific knowledge does not support or refute the extraction of healthy wisdom teeth except for under clear indications. http://www.teethremoval.com/controversy.html. However the American Association of Oral and Maxillofacial Surgeons (AAOMS) continues to not provide this information on their website regarding wisdom teeth http://www.aaoms.org/wisdom_teeth.php

An article is titled Government Policies in Violation of Human Rights as a Barrier to Professionalism in JAMA, vol. 306, no. 5 pages 541-542. August 3, 2011, http://jama.ama-assn.org/content/306/5/541.full

In the article it says

“However, deeply embedded institutional and organizational impediments often beyond the control of the physician (eg, inequitable access to care and reimbursement systems that create disincentives to proper care) can undermine physicians’ ability to adhere to these professional obligations in clinical practice”

Clearly much work still needs to be done.

Additional Source: Professionalism, social justice, and the primacy of patient welfare. Don McCanne MD, Friday, Aug 12, 2011, http://pnhp.org/blog/2011/08/12/professionalism-social-justice-and-the-primacy-of-patient-welfare/

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The Lack of Importance of Research in Oral and Maxillofacial Surgery Residency Programs

Posted on 12. Jun, 2011 by .

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A current article in press 2011 (at the time of this writing) will appear in the Journal of Oral and Maxillofacial Surgery. The article is titled Attitudes and Opinions of Residency Directors and Residents About the Importance of Research in Oral and Maxillofacial Surgery Residences by Ali E. Mohammad, Al M. Best, and Daniel M. Laskin.

The conclusion of the article is quite grim

The failure of all residency programs to provide actual research experience for their trainees has resulted in a decrease in the contributions that such programs have traditionally made to the literature and the advancement of the speciality. It is important that steps be taken to reverse this trend.

The article describes a study that was conducted to determine the research status done by residents in oral and maxillofacial surgery training programs.  A questionnaire was developed for both program directors and residents and sent to 101 oral and maxillofacial surgical residency programs in the U.S. in 2008. Forty-three percent (44) of program directors responded and 29.1% of residents (277 of 951) responded to the questionnaire.

A real startling result about this study is the question that was asked to both program directors and oral and maxillofacial surgery residents. The question was:

Do you believe that research experience is important for someone pursuing private practice?

A total of 15 (34.1%) of program directors said No and a total of 29 (65.9%) said Yes. A total of 177 (63.9%) of residents said No and a total of 100 (36.1%) said Yes.

To me this is very negative result. Research is absolutely necessary to continue to improve medical care. Anyone who is a visitor to teethremoval.com knows that I take research seriously and really am troubled by the fact that medicine has in the past for the most ignored evidence of treatments and only more recently have we seen evidence based medicine emerge. Further any sane individual who has seen my site also knows that the current methods of extracting wisdom teeth even in completely healthy young adults can in some individuals really lead to very serious life long problems.

Research in the area of wisdom teeth and other topics for oral and maxillofacial surgeons is certainly essential to have a successful practice for a long time with satisfied patients.

The article says (by citing numerous studies)

Although it is often said that research experience helps future practitioners evaluate the literature more critically and that it is important for developing the skills needed for critical thinking and lifelong learning there is no direct evidence to support such claims.

I would argue that being able to have research experience would directly correlate with the ability to successfully treat the largest number of patients, meaning those with better awareness of the literature and critical thinking skills will most likely be able to benefit their patients the most.

John Wennberg is well versed in the unwanted variations in practice. Medicine suffers from supply sensitive care where supply of physicians, healthcare facilities, and medical equipment can influence what kind of medicine patients receive. In a recent article by John Wennberg. Time to tackle unwarranted variations in practice. BMJ. Vol. 342, pages 687 – 690.  March 26 2011 he states

Those living in regions with a high intensity pattern of care—who, by virtue of where they are treated, receive more visits, imaging examinations, and admissions—have worse or no better survival than those living in low intensity regions.

Certainly all clinicians need to have the necessary skills to conduct and assess research. If they don’t then they really need others who may not be clinicians (or former or limited) but well educated researchers performing this task and informing them of the results which they can carry over into practice.

The real underlying problem here is directly related to financial and economic.  It is well known that in the U.S. in particular the cost of Medical School is out of control and extremely expensive. For example let’s look at the cost of Harvard Medical School over 2010-2011 which is $45,050. Over four years the cost of tuition alone would be over $180,000.

The residents where asked

Would you spend an extra year in their residency performing research if it were a funded position?

To which 103 (90%) said No! and 11 (10%) said Yes. When asked to clarify

If no, is this because of already existing debt?

Then 47 (44%) of residents said No and 60 (56%) said Yes. Clearly some are greatly impacted by the high costs of education particularly those in medical school programs (MD – dual degree).

Even more surprising is the fact that 25% (11 of 44) of program directors said their residents do not engage in a research project and 41% (114 of 277) said they do not perform research during their residency. This is in violation of Accreditation Standards for Advanced Specialty Education Programs in Oral and Maxillofacial Surgery which state that advanced specialty education students/residents must engage in scholarly activity.

The mean annual salary of an oral and maxillofacial surgeon is $212,120 (May 2010) according to the United States Department of Labor Bureau of Labor Statistics.  http://www.bls.gov/oes/current/oes291022.htm.

The mean annual salary for someone like myself (I have a masters in biomedical engineering) is $84,780 (May 2010) according to the United States Department of Labor Bureau of Labor Statistics.  http://www.bls.gov/oes/current/oes172031.htm

The mean annual salary for someone living in the U.S. is around $41,000 (2009) according to the U.S. Social Security Administration. http://www.ssa.gov/oact/cola/AWI.html

Why should someone like myself or someone worse off financially than myself (like the average American Citizen) pay oral and maxillofacial surgeons such a high wage when the current residencies programs are producing surgeons who fail to have research experience which consequently is lowering the quality of literature and research.  This huge difference in salary is ridiculous. Oral and maxillofacial surgeons command on average over 5 times the salary of an average U.S. citizen and over 2.5 times the salary of a well educated professional like myself.

Salary is based on the ability to perform and add value to people’s lives. It is time for these oral and maxillofacial programs to get their act together. Even if they make some strides to do so I still don’t believe the current salary is anywhere close to justifiable when they cannot even evaluate the literature on wisdom teeth which is causing thousands of Americans each year to be left with permanent injury unnecessarily.

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