The Most Important 4 Minutes of Any Appointment
Episode #454 with Tom Viola, R.Ph., C.C.P.
A medical history can change lives, and four minutes is all you need! It’s the most important part of any dental appointment, and Kirk Behrendt brings back Tom Viola, “Mr. Pharmacology” and founder of Pharmacology Declassified, to help make the documenting process easier, more efficient, and as accurate as possible. You can't know everything, but you can ask the right questions and learn to read between the medical history lines. For everything you need to know about the four critical minutes, listen to Episode 454 of The Best Practices Show!
Patients today are more medically complex than ever.
Always make time to review medical histories.
Learn the three questions to always ask.
Document everything you possibly can.
Listen to your patients.
“Your patients have never been more medically complex than they are today. People take more drugs today, more medications today, more substances today, so they're evermore complex. And that means you've got to be an expert in pharmacology. Even if it wasn't your favorite subject, or even if it’s not top priority on your list of everyday things, it has to be because you've got to maintain the patient’s oral health, but also their systemic health at the same time.” (5:46—6:12)
“The greatest blessing ever bestowed upon dentistry was that you could take the patient’s medical history directly from the patient. They're sitting right in your chair, they're right there in front of you. But the greatest curse ever inflicted upon dentistry was that you could take the patient’s medical history directly from the patient themselves, because they're not their own best reporter of their own medical history. And if they don't know, you won't know. If they don't want you to know, you're not going to know.” (7:03—7:26)
“It’s so important to be a sleuth, to be able to read a medical history and read between the lines and know what questions you need to ask the patient to get all of the information, not just necessarily the information they know or want you to know.” (7:34—7:48)
“The most important four minutes of any dental appointment are the four minutes you take to look at that medical history.” (9:02—9:09)
“Some things are important. Some things aren’t. This is important. This is going to make or break your day. It’s going to make or break your patients’ trust in you. It’s going to make or break your career, perhaps. You've got to be able to make the time to take a look at that medical history. Now, if you don't have the time and you can't make it yourself, then delegate. You've got a valuable resource in your hygienist.” (10:15—10:36)
“Especially for patients who take medications that can cause suicidal ideation, a lot of times, if they’ve gotten thoughts of suicide, they may not tell their clergyperson. They might not tell their medical doctor, their nurse practitioner. But they might tell somebody who’s easy to talk to, who listens to them, and who’s actually generally concerned about them. And that's usually their dental professional.” (11:54—12:16)
“I made my way through college being a bartender. And I could tell you, one thing you learn as a bartender is you learn how to listen, and you learn how to speak. That's what I offer up to you guys: listen. Listen to your patients. Listen to what they say.” (12:28—12:40)
“The first thing I'd like to recommend is that you have a medical history form the patient can fill out in advance. A lot of offices do. They have them online now. Get a lot of that done in advance and out of the way so that doesn't waste any of our four minutes.” (13:51—14:02)
“If you can't do [medical histories] online, then maybe work your workflow so that you can delegate that to someone who can visit with the patient before you. Typically, that's the assistant. Sometimes, it’s the hygienist. But get them to do that information intake for you so that when you walk in, if you're the dentist or the hygienist, you've got a lot of that information already down.” (14:12—14:33)
“The next thing you must do is look at their medications. And the reason for that is because, as I said, maybe people don't want to tell you everything that's wrong with them. Maybe they don't know. Maybe they're embarrassed — whatever the situation is. But I've often said if you have a good list of medications, an accurate list of their medications and a working knowledge of pharmacology, that's all you need. You put those two things together, and that equals the complete medical history. If you know what drugs people take and you know why people would take those drugs, what conditions they're treating, you know all the conditions. So, now, you can fill in the blanks.” (15:33—16:09)
“Medications can be used for a variety of different things. So, whenever I take a medical history and I'm trying to get the list of medications from the patient, I often ask the same three questions. And I ask them over and over again, ad nauseam, until they're ready to vomit. I ask them, ‘What do you take?’ I don't say the word, drug. I don't say the word, medication. I say, ‘What do you take?’ and let them tell me everything.” (20:02—20:23)
“Realizing that drugs will be used for different things, the next question I ask them is, ‘Why do you take them? Why do you take this medication?’ Now, my students say, ‘Why do I need to know that? They think I should know that. I'm the professional.’ But you don't know. A drug like amlodipine, which is a calcium channel blocker, could be used for everything from arrhythmia to angina to hypertension. I have no idea why you're taking it, so you have to tell me. But when I ask you, ‘Why do you take it?’ that helps reinforce the conditions you listed at the medical history level, like what did you say you have, what are your systemic conditions.” (20:24—20:57)
“The last question I ask them is the obvious one, but no one seems to ask it every time, which is, ‘Did you take it today? Did you take your medication today?’ Because I know a lot of people who take blood pressure medications that don't take blood pressure medications.” (20:58—21:11)
“I want to know why the patient takes the medications because I want to know if they know why they take it. Because otherwise, ‘Oh, yeah. Sometimes, I take that for my hypertension.’ ‘Sometimes? It’s not a thing you could take as-needed.’ And that helps me jog them into saying, ‘Really, you should be taking this every day,’ or, ‘Really, this medication should be taken this way.’ It’s little pearls like that that you give your patient that, believe me, add to the value of the dental experience, because they walk out like, ‘I didn't just learn about my teeth today. I learned about my medical conditions. I learned about my drugs. Wow, I learned a lot today.’ That's value that's going to keep that patient coming back to see you.” (22:31—23:07)
“We love them, but sometimes our patients make poor choices. And we’re there to save them from themselves because they're not medical experts. They're not dental experts. We are the medical and dental experts, so let's act like it.” (24:02—24:13)
“If you're not taking the patient’s blood pressure and pulse, you're missing a vital sign. That's why they call them vital signs. You're missing something vital that you need to be able to make good decisions, whether or not you're going to treat the patient, whether or not they're taking their medications the way they're supposed to. If you're not taking their blood pressure and pulse, then you're missing out on a lot. I know people who are listening say, ‘I don't have time for that.’ I know. I completely empathize with you. But make the time. Delegate it. Train someone to do it or get a cuff. Wrist cuff, arm cuff — automate it. I'd rather have a wrist cuff that may not be 100% accurate versus nothing in the chart every day of the week.” (24:18—24:56)
“When it comes to cannabis, a lot of our patients use cannabis to take the edge off. As I said, fear is the greatest enemy we have in dentistry. People fear us because, why? Everyone in their life has told them, ‘You're going to the dentist? You're going to be in pain!’ And then, they get there, you cause them pain, and you fulfill the prophecy. So, they know dentistry equals pain. So, if they take a dose of cannabis, they're taking the edge off. But it leads to medical, ethical, and legal considerations.” (25:38—26:05)
“After you've got the medical history down halfway, the next thing is to ask about what kind of substances do they use. And just blurt it out. You're not the police. You've got to encourage them to say it. ‘I'm not the police. I'm not here to report you in any way. I just want to know. I need to know this to make sure that there aren't any complications with what I might use during our appointment today.’ So, you just lay it out there like that. Ask them about alcohol, cannabis, other substances, street drugs, whatever they use. Ask them about that.” (27:52—28:23)
“Circle back to the medications real quick and say, ‘Do you use anything over the counter? Do you use any supplements?’ The reason I do that is because when I'm asking patients, ‘What do you take, and why do you take it?’ they still think I'm talking about medications. And they don't consider over-the-counter drugs like Nexium and Prilosec or substances like cannabis as a thing to talk about, or they don't think of a supplement like St. John’s wort or something to talk about because they don't need a prescription for that. They don't even get it at a pharmacy. They go to buy it at a supermarket. So, I tie that back in to make sure that I get every possible medication and other substance and supplement they're taking.” (28:28—29:09)
“The last thing I ask them is, ‘Why are you here today?’ I want to get it from them. ‘What's going on? I know that when you booked your appointment you told us what was happening. But really, today, what's going on?’ And that gives me a bird’s eye view back now as to, okay, they said they have dry mouth. Well, what medications do they take that cause dry mouth? They said they have jaw pain. Okay. Jaw pain could be, what? It could be odontogenic pain. It could be a side effect of their statin medication because statins cause muscle pain. Heck, it could be angina.” (29:13—29:46)
“We’re very nice to our patients. We try to be. And sometimes, we let them lead the conversation. We can't let that happen. We have to lead the conversation because it’s our four minutes.” (30:35—30:45)
“You've got to document everything — even the things you don't think are important. You've got to document everything that went on in that conversation to the best of your ability. And I'm going to go one step further. And I know a lot of people are going to probably chuckle about this, and it’s okay. I still insist on an ASA for every patient.” (32:29—32:48)
“If you don't document the ASA, then you really can't say later on, whether it’s a week, a month, or three years later, under cross-examination from some plaintiff’s attorney, ‘What was the patient’s suitability for treatment on that day?’ You have to try — and I know this because I serve as an expert witness quite often — to convince anyone in that courtroom that you can remember that patient, on that day, three years ago, when you've seen a thousand patients since. It’s not going to happen. So, documentation is critical.” (33:08—33:37)
“Everyone listening right now is saying, ‘Man, I wish I had the time. I wish I had the time. I wish I had the time.’ Make the time. It’s not all pie in the sky. You can do this. Maybe you can't record every minute of everything that's been said. But do the best you can, because those four minutes really count.” (34:53—35:08)
2:54 Tom’s background.
4:45 Today’s patients are more medically complex.
7:48 The most important four minutes of any appointment.
9:30 Make time for reviewing the medical history.
11:38 Learn to listen to your patients.
13:37 Where to start.
16:17 One shortcut for learning what some drugs do.
19:43 Three questions to always ask your patients.
23:07 Always take patients’ vital signs.
25:05 Ask patients about cannabis use.
27:14 Ask patients about substance use.
30:18 What most people get wrong about the four minutes.
31:41 Document everything you possibly can.
34:45 Last thoughts on the most important four minutes.
35:49 More about Tom and how to get in touch.
Reach Out to Tom:
Tom’s website: https://www.tomviola.com/
Tom’s podcasts: https://www.tomviola.com/category/podcasts/
Tom’s email: email@example.com
Tom’s Facebook: https://www.facebook.com/tomviolarph
Tom’s social media: @pharmacologydeclassified
Tom A. Viola, R.Ph., C.C.P. Bio:
With over 30 years of experience as a pharmacist, educator, speaker, and author, Tom Viola, R.Ph., C.C.P., has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative, engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.
As a clinical educator, Tom is a member of the faculty of 12 dental professional degree programs and has received several awards for Outstanding Teacher of the Year. Tom instructs dental hygiene students and practice dental hygienists in pharmacology and local anesthesia in preparation for national board exams. As a published writer, Tom is well-known internationally for his contributions to several professional journals in the areas of pharmacology, pain management, and local anesthesia. In addition, Tom has served as a contributor, chapter author, and peer reviewer for several pharmacology textbooks. As a professional speaker, Tom has presented continuing education courses to dental professionals internationally since 2001. Meeting planners agree that Tom is their choice to educate audiences within this specialty.