#525 - "Oral Health Screening, EBM and Phronesis (What?!), Be Your A-Game"
Take 3 – Practical Practice Pointers©
From the USPSTF
1) Oral Health Screening/Prevention for Children, Adolescents, Adults
Dental caries is a common chronic condition of childhood; in 2011 in the US, more than 50% of children aged 6 - 11 had dental caries in primary teeth and 17% had caries in permanent teeth. Social drivers of health (nonbiological factors) associated with increased risk of oral health conditions include low socioeconomic status, lack of dental insurance, and living in communities with dental professional shortages.
More than 90% of US adults are affected by dental caries, and for an estimated 26% these are untreated. Untreated dental caries can lead to serious infections and tooth loss. An estimated 42% of US adults older than 30 years have periodontal disease, increasing to nearly 60% at age 65 years or older. Untreated periodontitis can contribute to destruction of tissues that support the teeth and is the leading cause of tooth loss in older adults.
In 2021, the USPSTF published a Recommendation for Oral Health Screening for children younger than 5 years. The include:
- Concluded that the current evidence was insufficient to assess the balance of benefits and harms of routine screening examinations (asymptomatic) for dental caries performed by primary care clinicians in children younger than 5 years. (I statement)
- Recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride (B statement)
- Recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B statement)
The USPSTF recently released recommendations regarding screening for oral health conditions for those age 5-17 and for adults. They include:
- Concludes that the current evidence is insufficient to assess the balance of benefits and harms of both routine screening and preventive interventions performed by primary care clinicians for oral health conditions, including dental caries, in children and adolescents aged 5 -17. (I statement)
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement)
Mark’s Comments:
Remember, the task force is not suggesting that primary care providers stop all oral health screening of children and adults or that they never discuss ways to improve oral health. They’re merely saying there isn’t sufficient evidence (nor will there likely be any time soon) to make a global recommendation and strong push for it. Having said that, with “sweets” consumption up this time of year, we thought the reminder to consider looking in mouths, particularly for those at highest risk, was timely.
References:
From an Ethics Column
2) Leveraging Practical Wisdom to Complement “The Evidence”
The evidence-based medicine (EBM) “movement” (what else to call it?) started as counter-culture. At the time, a few “clinical epidemiologists” began to argue that the old apprenticeship and expert-opinion-based model of medical education and knowledge translation was to blame for the lack of research-proven interventions getting into practice in a timely manner for the benefit of our patients. They saw EBM as standing in opposition to the old ways in medicine: “eminence-based medicine” (expert authority), “vehemence-based medicine” (involving stridency and volume), and “eloquence-based medicine” (snazzy clothes and compelling slide presentations).
More than two decades into the movement, it is not surprising that some re-evaluation of EBM is occurring. One particularly thoughtful example of this re-evaluation was published recently in the Journal of the American Board of Family Medicine. The authors used ancient Greek conceptions of knowledge to describe the tension between episteme (knowledge) and phronesis (practical wisdom) as a major source of our current discomfort in primary care.
The authors describe the corruption of the ideals of EBM by algorithms, metrics, and marketing. Even more, they lament the use of EBM to “remove the context” from our decision making for our patients by overvaluing strict adherence to guidelines…which are sometimes manipulated to advance a point of view rather than provide an objective summary of the evidence. The authors end up advocating a balance between phronesis and episteme in primary care, and make several noteworthy points along the way:
- Phronesis is developed not through unsystematic recollection of clinical experience but through “deliberate practice” – a method of structured reflection about what works in practice (look for the work of Anders Ericsson in Medline).
- EBM has always included a role for phronesis – the application of “clinical expertise” and elicitation of patient values – which, unfortunately, is more difficult to measure and incentivize than the episteme (knowledge of the evidence) it also includes.
- Humility about our clinical and scientific knowledge are essential in primary care, where diagnoses, management pathways, and treatment plans are often uncertain. To imply that EBM is the answer to uncertainty in the complex, science-based, socio-cultural endeavor that is primary care is just too simple.
- Inappropriate application of EBM can lead to over-medicalization by over-standardizing and over-measuring. Leaping to pharmacologic treatment of mild depression, “pre”-diabetes, and “early” hypertension is the result of excessive emphasis on the “bio-” aspect of our primary care model to the exclusion of the “-psychosocial” aspects.
- In primary care, we frequently use “abductive reasoning” – reasoning from incomplete information to address the most likely solutions. This reasoning often relies on some amount of creativity (often characterized as the “art” of medicine), which is susceptible to cognitive biases. Awareness of decision-making processes and ways to counter cognitive biases are essential to the proper application of abductive reasoning.
John’s Comments:
This was a heady article to read…even more to try to summarize. I have heard the types of cautions and criticisms in this article many times through the years and have seen many examples of their truth. And yet, to advocate for no role for research evidence in the practice of medicine hardly seems like the right path. There is a bit of “leadership wisdom” that has helped me confront the arguments over phronesis vs. episteme. It is the saying by the engineer George Box, “All models are wrong, but some are useful.” The “definition” of EBM as the combination of best research evidence, clinical expertise and patient values does not presuppose a precise formula for the combination, but instead simply exhorts use to integrate them in our decision-making. The skill of the primary care clinician is finding balance in this integration for each patient amid the uncertainty and complexity of our daily practice, for example:
- We can universally screen for depression as recommended by the USPSTF, but we should work to broaden our skillsets in treating mild depression with non-pharmacologic therapies instead of just writing for antidepressants.
- We can recommend COVID vaccination to all our patients over age 6 months as a rule, but we can save our counseling time and energy for those who would be best protected by it.
- We can be aware of newer, more aggressive guidelines for blood pressure management, but focus our energy on optimizing medication regimens for our patients who are at highest risk while getting the rest of our patients to a reasonable level of control.
References:
From PeerRxMed ( www.PeerRxMed.org )
3) Setting “Be” Goals For Your “A Game”
“The privilege of a lifetime is to become who you truly are.” ― Carl Gustav Jung
One of the ways I focus my day each morning is to set an intention around the question, “Who and how will I show up this day?” In other words, what will be the “experience of myself” for others as I navigate the many gifts, challenges, frustrations, and “surprises” that await and interact with my family, friends, colleagues, patients, care team, neighbors, and strangers, recognizing there are many “Marks” who have the potential to appear.
A few years ago at a leadership conference, I had the incredible opportunity to understand much better how I would like to answer this question. In preparation for the conference, we were asked to participate in a process I have come to call the “A-Game, D-Game” exercise. We first sent an anonymous survey to at least 10 people in our professional world with whom we worked closely, asking the following questions:
- Describe the most effective/best version of me for you – my "A" game. ie: "When I am on my A game for you/from your perspective, I am _____" (provide 3 adjectives, descriptors, or qualities)
- When I am being my "A" game self for you, how does that make you feel?
- Describe the least effective/worst version of me for you – my "D" game. ie: "When I am on my D game for you/from your perspective, I am _____" (provide 3 adjectives, descriptors, or qualities)
- When I am living out of my "D" game for you, how does that make you feel?
We then did the same process by phone (video wasn’t prevalent then) with at least 3 people who were close in our personal lives.
The next step in the preparation process was to collate all the descriptors into 2 groups: our “A-Game” and our “D-Game” selves. The lists were longer than I expected and once I got past my ego-defenses, were surprisingly accurate with what I “know” about myself when I am vulnerably honest. What was most revealing was when I read the list of “A” Game attributes, words such as encouraging, present, curious, and inspiring, and reflected on those aspects of me, I liked me being that me – and so did they. And when I read the list of “D” Game attributes, words such as stubborn, guarded, distracted, and moody, even I didn’t like me being that me – and neither did they.
All of which led me to some breakthrough, literally “life-changing” insights. When I am being my A-Game “better” self by embracing those qualities (which feels like my “Truest” self), I am “Attracting” others to me and my impact increases. When I am being my D-Game not so effective self, I am “Distancing” myself from others (and myself) and my impact diminishes. And when I’m intentional about consciously deciding who and how I want to be, the choice is mine to make … moment by moment, decision by decision, interaction by interaction.
And coming to that conclusion and reminding myself of it daily has allowed me, one interaction at a time, to become who I truly am. After all, I’m going to be someone today, and so are you. We might as well choose wisely. Let’s be on our “A” Game – for their sake … and ours ….
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Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Email: mhgreenawald@carilionclinic.org