Oral Health - A Lipid Proverbial Diagnosis of the Future

Transcription

1 Wanted Physicians who understand oral health Wendy E. Mouradian, MD, MS Associate Dean for Regional Affairs and Curriculum and Professor Pediatric Dentistry/Pediatrics, Dental Public Health Sciences, Health Services University of Washington School of Dentistry

2 Oral Health in Medical Education Where we have come from, and where we need to go.

3 Overview Oral health is left out of medical education Why does it matter? How did this happen? Putting the mouth back in the body Lessons learned A roadmap for the future

4 Take home messages Integrate oral health into medical education at all levels (medical school, residency, CME) Leverage health reform provisions and current federal programs (eg, Title VII) as part of new Oral Health Initiative Develop policies to support integration Pilot and evaluate new models to integrate OH into primary care Assess OH outcomes and costs of care

5 Some personal history. Or how I forgot the mouth was part of the body in Medical school Pediatrics residency Practice in a rural / underserved area Developmental pediatrics fellowship

6 National Survey of Pediatricians 2000 national OH survey of pediatricians only 9% could answer 4 oral health questions although most thought it was important 2008 AAP OH survey of pediatricians >90% believe they should examine teeth and provide oral health counseling Only 54% examine teeth in > 1/2 of yr olds Lack of education most common barrier 75% reported no previous OH training Lewis et al, 2000; 2008

7 National Survey of OH in US Medical /Osteopathic schools (Silk H, et al, 2010)

8 Why does it matter?

9 Physicians lack of oral health knowledge contributes to disparities When physicians do not screen for dental caries, periodontal disease, oral cancer, other craniofacial conditions; Identify important oral-systemic complications in their patients; or Collaborate effectively with dental professionals

10 Bad outcomes result. Like abscesses, cellulitis

11 Rampant decay- which is preventable

12 Periodontal disease - which is preventable

13 Oral cancer which can be detected early, but isn t

14 Osteonecrosis of the jaw due to bisphosphonates

15 Patients on bisphosphonates not told of risk of osteonecrosis by their physicians Migliorati CA et al Jr Amer Dental Assoc, May 2010

16 Consequences of the medical - dental gap Missed diagnoses and avoidable complications for patients Costs of preventable diseases Low public oral health literacy Lack of awareness in policymakers Oral health left out of important decisions Duplication of costly infrastructure / high costs of dental education

17 How did this happen?

18 Some professional history 1840 First dental school opened at the University of Maryland 1910.Flexner Report* for medicine 1926.Gies Report* for dentistry Similar; favored integration Professions remained separate *Reports funded by the Carnegie Foundation

19 Gies Report conclusions A policy of health service.which ignores oral hygiene, or neglects dental maladies cannot be expected to commend itself to enlightened public opinion. Fortunately this disregard in the medical profession is gradually being replaced by serious attention to oral conditions, especially among the physicians who are engaged in public health services, and among public-health nurses and teachers acting in their behalf.

20 Gies (con t) This desirable movement promises to attain its logical development among practitioners of medicine in general when medical schools give to their students suitable instruction in oral hygiene, and in the correlations between clinical medicine and clinical dentistry. William Gies, 1926

21 Craniofacial Clinic, Seattle Children s s Hospital, One of few models of integrated, inter- professional, coordinated team care Includes e.g., pediatrics, plastic surgery, neurosurgery, ophthalmology, ENT, oral surgery, orthodontics, communication disorders, audiology, nursing, social work, psychology, etc as determined by pt need Necessary for habilitation of the child At weekly team meetings we discussed cases, educating ourselves and our trainees

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23 Putting the mouth back in the body Gained insights from Craniofacial Clinic Noted general neglect of OH by medical colleagues Saw children w dental abscesses admitted to the hospital An ethical crisis (disparities in the disparities) in the most vulnerable

24 National work, Seattle Conference: Children Our Future: Ethics, Health Policy and Medical/Dental Care for Children,, UW/Children s s Hosp, 1998 (NIDCR, Packard Fdn, MCHB, among others) Work at NIDCR (NIH), in association with the Surgeon General s s Report on Oral Health. Organized / chaired The Face of a Child: Surgeon General s s Conference on Children and Oral Health, 2000

25 Putting the mouth back in the body at the UW, Oral Health and Primary Care (HRSA- BHPr ) 2005) - UW one of 8 funded sites Trained 10 Family Medicine residency sites across Washington, Wyoming, Montana Alaska and Idaho (5-7 7 hrs training average) Barriers: Low OH knowledge; angry at dentists; unsure of evidence base; just too busy Opportunities: Cared about kids in pain, recognized knowledge gap, wanted to answer pts questions Collaboration among the funded sites led to the national Smiles for Life curriculum

26 Lessons learned at the residency level Family Medicine residents got it -but v busy Faculty needed development too Partnering w dentists caring for underserved diminished animosity and ensured referrals Involving staff, utilizing change mgt plans Needed a faculty champion at each site Leveraging other resources (CHCs, local dentists often ABCD dentists, MCHB- funded leadership trainees in pediatric dentistry)

27 Going upstream: Medical student education at the UW Residency training too late - many other urgent priorities by then Medical mind-set: worse case scenario, hard to focus on OH Medical student survey students interested, but had little knowledge OH Curriculum Committee was created in School of Medicine (SOM)

28 Core OH Competencies for Medical Students 1. Public Health context: : OH disparities; fluoride, preventive interventions 2. Caries: pathogenesis, recognition, risk factors counseling, referral 3. Periodontal disease :pathogenesis, recognition, risk factors, counseling, referral 4. Oral cancer: : pathogenesis, recognition, risk factors counseling, referral 5. Oral-systemic interactions,, effect of medications on OH, diabetes Mouradian et al, 2005

29 Spiral curriculum Start with basic sciences, reinforce in clinical sciences, use oral health examples, teach oral exam (in traditional curriculum) Reinforce in key clinical clerkships (eg, pediatrics, family medicine, OB-GYN, internal medicine, rehab/palliative care, others) Identify key courses for inclusion, work with faculty- offer to teach or provide materials Progress v slow, only partially accomplished

30 UW - Oral Health Elective Covered core competencies Added dental trauma and emergencies Engaged pediatric dentistry residents (from MCHB leadership training program) and dental students to teach hands-on labs Sessions co-taught by medical and dental faculty who generally liked the collaboration Very well rated, but resources lacking to offer each year (Mouradian et al, 2006)

31 Lessons learned at the medical school level Faculty champions needed in each school Supportive SOM leadership essential Students get it! Have to create opportunities for scholarly work for medical faculty (eg, educ research) Faculty not supported for inter-professional education needed resources Did set up favorable environment for more collaboration

32 For example: RIDE -WWAMI program featuring co-training of medical, dental and dental hygiene students (est 2007) Targets students for rural/underserved practice in Eastern Washington Builds on 35 yr WWAMI (WA, WY, AK, MT, ID) experience w regional medical training Extensive clinical education for dental students in CHCs in rural/underserved sites Partnership of UW SOD, SOM and regional universities

33 American Dental Education Association (ADEA) - Association of American Medical Colleges (AAMC), Convened a panel of medical and dental experts to discuss education for medical /dental students Recommended addressing OH gap for medical students, adding more systemic training for dental students Cross-cutting competencies for both Macy Foundation

34 AAMC-ADEA ADEA collaboration Published as a report in Jr Dental Education, Feb 2008; and as Contemporary Issues in Medicine: Oral Health Education for Medical and Dental Students, a Medical School Objectives Project (MSOP) Another important AAMC-ADEA ADEA collaboration: online publication of peer- reviewed medical AND dental curricula in MedEd Portal

35 Road map for the future

36 Title VII Advisory Committee on Training in Primary Care Medicine and Dentistry, 7 th Annual Report, December 2008 Coming Home: The Patient-Centered Medical-Dental Home in Primary Care Training

37 Recommendations to Congress 1. Develop curricula for under-graduate and graduate trainees and faculty 2. Train leaders including clinician educators and education researchers 3. Pilot /evaluate programs to integrate OH into primary care in diverse educ settings 4. Develop educational infra-structure (eg. E.H.R., QI protocols, etc) 5. Develop the requisite infra-structure, authority, funding with HRSA as lead

38 Key objectives of recommended curricula Ensure sufficient knowledge of each other s fields [need to define sufficient,, along with roles and responsibilities] Skills for inter-professional collaboration [need to go beyond medical / dental] Ensure all professionals have competencies for patient-centered, culturally-competent competent care

39 Address policy issues in practice Role of Reimbursement / financing State practice laws Credentialing bodies Professional organizations

40 Role of Professional Bodies American Board of Pediatrics added OH exam questions, 2002 American Academy of Pediatrics (AAP) new OH policies, 2003, 2008, online trainings, training of state champions and more Society of Teachers of Family Medicine, ( Smiles( for Life curriculum) Residency Review Committee, Family Medicine hands on OH experience Liaison Committee on Medical Education some standards there

41 Take home messages Integrate oral health into medical education at all levels (modest goals) Don t t want MDs teaching tooth-brushing can t t afford/culture Target other health professionals RN, NP, PA, Pharmacy Leverage health reform provisions and current federal programs (Title VII)?OH Initiative Develop policies that support integration Pilot /evaluate new models to integrate OH into primary care

42 Take home messages Private public partnerships necessary to push this agenda forward eg, NC, WA and Colorado efforts to integrate OH into primary care all involved private and public partnerships National Summit on Children s s Oral Health, American Academy of Pediatrics Special Issue on Children s s Oral Health (Academic Pediatrics, December 2009) Smiles for Life Curriculum

43 Where will the next crossroads take us?

44 Contact information Wendy E. Mouradian, MD, MS University of Washington Schools of Dentistry, Medicine and Public Health Box NE Pacific Street, Seattle, WA Telephone: ; Fax: