Thursday, 23 June 2011

Caring for patients: evidence, patient values and your experience

With the final year moving on to their post-undergraduate life I got to reflecting on my learning of their learning over the last year. Not to detract from their achievement a few things came up that I feel I need to work on with the next cohort:
  1. Remembering to do the preventive work with their patients
  2. Stabilising disease before starting on the restorative phase of the treatment plan
  3. Understanding the evidence for the intended treatment and for the alternatives
  4. Discussion with the patient about the treatment alternatives
As many of you will know, I am an enthusiast for asking questions and seeking evidence. I am also an enthusiast for including patients in making decisions about their care. Here are some questions I ask myself when managing patient care - plus one at the end for all you poor students ;) :
  1. How uncertain am I about the diagnoses? (does this affect how I proceed?)
  2. How uncertain am I about the prognosis of my patient's teeth? (what are the consequences for definitive restoration?)
  3. How am I going to prevent further disease in this patient?
  4. How good are those preventive methods at preventing what they're supposed to prevent?
  5. How will I stabilise my patient's disease?
  6. What happens if some teeth, despite my best efforts, fail to respond to my interventions?
  7. What restorative treatment options are there?
  8. What is the evidence about how effective they are?
  9. How long can the patient expect to retain the restorations I place?
  10. What is the patient prepared to have done and what are their preferences?
  11. What are you going to do when two tutors tell you two different options for managing your patient?
The reason I raise these here is to encourage students to think holistically and in an evidence-based way.

As you will be aware, evidence-based dentistry combines three things:
  • The best available evidence
  • The patient's values
  • Your own experience
You will have limited experience of many of the things you do but nonetheless you should draw on what you have - over time you will build on this.

You can ask your patient right from the outset what they would like to achieve through treatment, what they're willing to put up with, and what their preferences are.

And you can use those skills you learned a little while back to seek the best available evidence. Here's a reminder of how:
  1. Form a clear question
  2. search TRIPdatabase / Pumed for articles
  3. filter out the low level studies
  4. and appraise the ones you're left with
And if you've got any questions, get in touch.

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