A former professional football player and nonsmoker, he noted a lump in his neck at age 39. Biopsy revealed squamous carcinoma. Exam, endoscopy, and biopsy demonstrated unknown primary and chemoradiation was carried out. First the patient presented for postradiation mucositis, fibrosis, trismus and myalgia—then for osteoradionecrosis, then for hyperbaric oxygen therapy, then for hemimandibulectomy, then for vascularized osseous reconstruction, then for infected recipient site, then for implants, then for lingual nerve repair for dysesthesia, then for neurectomy.
At age 45, he is free of tumor but battling chronic facial pain, fatigue, dysphagia, narcotic dependence, the side-effects of 5 other prescription drugs, mandibular hypomobility, xerostomia, cachexia, and depression. At last visit, the oral and maxillofacial surgeon's 50th visit with the patient, they talked and worried together for over an hour. Each of the patient's issues was again sorted out. Phone calls to the patient's physicians, family, and to social services ensued.
Surgeons and Chronic Disease
Most oral and maxillofacial surgeons are ill-prepared to treat patients with chronic conditions. The training of all surgeons necessitates episodic care directed at a particular condition; however, few residents receive the training necessary to understand the needs of the chronically ill patient.
Both the American Association of Medical Colleges (AAMC) and the nursing profession have recognized the need for education in continuity of care, coordination of care, and management of chronic diseases. Nursing has a continuity of care initiative to build the nurse-patient relationship for those with chronic diseases. In 2009, medical schools are undergoing a nationwide curriculum initiative to educate medical students and residents in the skills needed to manage patients with chronic diseases. While medical students develop training in assessing level of care needs as well as end of life issues, dental students and OMS residents do not benefit from this education.
The accreditation standards for OMS residency education require that the resident must be a full participant in the planning, execution follow-up, and assessment of outcomes for all surgical procedures for which they scrub (a widely violated rule). But currently there is no specific residency or continuing education for the oral and maxillofacial surgeon directed toward the skill sets needed to treat the chronically ill patient, though this task may fall to the OMS due to the specific aspects of the patient's condition and the unique knowledge and skills of the OMS. Thus, the ill-prepared OMS might find themselves in a family conference to consider withdrawal of care, or speaking to a pain clinic regarding their drug recommendations, or other tasks for which those in nursing and medicine have been better equipped through their education and training.
It is rare for the surgeon in training or in practice to see the long-term effects of oral and maxillofacial diseases as many of these patients withdraw from surgical care. Orthognathic patients may not be seen after the initial weeks following surgery. Trauma patients, while suffering from continued symptoms, may be lost to follow-up. “Geographic cures” (so-called as the surgeon assumes a good outcome when the patient does not return) occur when the patient, such as the multiply operated TMJ patient, tires of surgical intervention and seeks other modes of care. These problems result in a fundamental lack of understanding on the part of the surgeon as to the long-term effects of oral and maxillofacial diseases and the long-term results of surgical interventions. While many of our patients may never fully recover, their surgeons may be oblivious to their continued needs.
While the patient's primary care physician (PCP) is generally in the best position to perform these tasks for general chronic illnesses such as diabetes or congestive heart failure, most PCPs are not equipped to provide knowledgeable disease management when the condition is maxillofacial. Examples of some conditions in which the OMS may be best equipped to actively participate in chronic disease management include chronic osteomyelitis/osteonecrosis, the multiply operated TMJ patient, the severely damaged trauma patient, facial neuropathic pain, and craniofacial disorders.
Pointers for the Surgeon Treating the Chronically Ill Patient
To participate effectively in the care of the chronically ill patient, the OMS must be a part of an ad hoc team specific to the patients needs. The hallmarks of good management of chronic diseases include “five C's”.
Comprehensive attention to all details of the chronic disease:
A full problem list and a plan to address each of the problems along with those responsible for completing the tasks.
Continuity of care:
Assuring the appropriate next steps and timeline for care of the patient are in place and are followed.
Coordination of care with decision-makers:
All of the team members taking responsibility for those tasks for which they are best suited.
Commitment to the patient and the task of improving their status:
Managing the chronically ill is not a gratifying task for surgeons who are used to quick procedures and cures. It is uncomfortable to recognize that not all patients improve and that some are destined to deteriorate. It is a discomfiting but necessary task to remain committed to these patients as they continue to have oral and maxillofacial health care needs. It is, however, an absolute requirement for a health care provider to meet the needs of all patients regardless of diagnosis and prognosis consistent with your knowledge and skills.
Cooperation with other care givers, physicians and family in addressing the patients' needs:
Care of the chronically ill affords the opportunity to interact with other professionals. Working cooperatively and consistent with the other goals of treatment will build relationships with many unforeseen benefits.
Our Specialty's Needs
Clearly there is a need for an initiative in dental education and in OMS residencies to address the issue of the chronically ill patient. We should look to the results of the AAMC project and develop a complementary program for our residencies.
Our Journal is filled with new technology, new techniques, and evidence-based information on clinical decision making. The Journal has a scientific opportunity to encourage investigations into the treatment, management, and outcomes of chronic oral and maxillofacial diseases states.
But there are no patients on these pages, no live people to talk with and to act upon. Only the clinical education setting can provide these skills with the underpinnings of sound didactics. Improved care of the chronically ill oral and maxillofacial surgery patient remains an important task for the consultation room and the bedside.
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