“You need to get here. Fast.”
That’s not a message one likes to receive prior to clinic, but I had one of those messages this week—correction, several messages.
“There is a patient that is very upset and I don’t think the resident is going to survive.”
I received three variations of the same text from different people. I employed my breathing techniques STAT.
“Exhales longer than the inhales,” I said to myself before my vagus nerve got the best of me. I have had two ulcers in my practicing life, and I endeavor to avoid a third.
I then arrived at the chronic facial pain clinic I co-direct, having missed the colorful language and loud complaints about trying to find the correct office, and joined the resident and the very stressed patient.
Fight or Flight
I have learned about the fight or flight state of hyperarousal where people only hear predatory sounds—high pitch, low pitch, and nothing in between. By the way, Disney engineers its music to rest in that zone in between to keep everyone in the Magic Kingdom calm and happy.
Within that window of tolerance, our parasympathetic nervous system allows for pleasant social engagement. Our sympathetic nervous system, on the other hand, is responsible for the terrifying feelings of fight-or-flight.
I got in close, employing all the techniques I learned from Danielle Ofri, who has changed how I speak with patients after all these years in practice. I kept a laser focus, acknowledged the patient’s concerns, and gave her time to tell her story. I flat out said that she was in such a state of hyperarousal that I wanted her to focus carefully on my words, breathe with me, and watch what happens.
“Inhale, one, two, three, hold, exhale, one, two, three, four, five, six,” I told her.
The exhale part is tricky at first when you’re in that one-foot-on-the-brake, one-foot-on-the-gas state. Almost immediately, her demeanor changed.
“I know I am so stressed,” she said. The reasons why started to come forth.
“Who isn’t?” I replied, whereupon she smiled widely.
I reviewed her concerns, asked permission to complete the exam, and drew a flowchart of the proposed treatment. I then had her teach it back to me to ensure she understood it and ended by asking, “Does this make sense to you?”
I inquired if I had missed anything and shook her hand firmly, thanking her for letting us look after her. Several hugs later, she informed me that she was putting me in her will and adopting me. A fine end to the proceedings. My resident simply uttered, “Teach me your ways.”
Communication Is Key
I only wish someone had taught me many years ago to interact with patients the way I have now learned to do. I did a lot of the right things but did not understand why they worked. When the patient is in a state of hyperarousal and the practitioner enters in a similar state, the result is never good. Everyone has to understand how their own minds work before they can help their patients.
Seth Porges has a wonderful talk on the Polyvagal Theory, as espoused by his father, Dr. Stephen Porges. It is something all healthcare team members should watch!
We all have stress. In my lecture on the patient experience, I always ask the people in the audience to raise their hands if they have stress in their lives. I then tell them that if they didn’t raise their hand, then they must by lying or dead.
Communication issues drive a large proportion of medical-legal complaints. An outstanding research study by the amazing Dr. Carlos Quiñonez, an associate professor at the Faculty of Dentistry at the University of Toronto, found that 59% of all complaints were related to clinical care and treatment. Meanwhile, 56% involved interpersonal relationships and conduct, such as how the patient was treated, and issues with informed consent. (Since there often was more than one issue in a single complaint, the numbers did not add up to 100%.)
Digging deeper into the clinical complaints, there is often a component of a communication breakdown, whether it was how the treatment options were presented, the risks and benefits, or myriad other factors. The two greatest fears that patients experience in the healthcare environment, I heave learned from my reading, are whether or not someone is going to hear them and if they will get the right care. Concerns about the cost of treatment or the potential for pain are not primary.
We all need to be mindful of this need to communicate effectively when we’re talking with patients and go back to our “beginner minds.” I find this so crucial when I occasionally hear a resident discussing the condyle with a patient. I ask these residents, when reviewing their cases privately, if they knew what a condyle was before dental school. They sheepishly smile and utter “no.” I then remind them that the patient unlikely knows either.
This is why I draw the anatomy, label each part, and translate all the jargon for the patient, using relatable analogies. A TMJ displacement with limited opening is like a carpet stuck in front of a door. I even draw a door with a squiggle representing the carpet, given that my artistic skills are sorely lacking. All of this brings a bit of lightness to the discussion, and the visual sticks.
You need to take these ideas and make them your own and personalize them. Some things will work, some will fall flat, but you have to keep trying. I have even said to patients who become aggressive, “You know, we are on the same team here.”
When they’re in that state of hyperarousal, patients can lose sight that we too are human and have emotions and fears like they do. The goal is to keep each other within our own window of tolerance so that the best care can be delivered and we can endeavor to lessen the inevitable stress in our lives.
Please never hesitate to reach out to me if you have a question or want to learn more—or possibly even vent a little.
Dr. Freeman is co-director of the TMD-Facial Pain Unit at Mount Sinai Hospital in Toronto. He is an honours graduate of the Faculty of Dentistry at the University of Toronto and completed the Advanced Education in General Dentistry program at the Eastman Dental Center in Rochester, New York. Dr. Freeman then returned to the University of Toronto, where he received his diploma in orthodontics and taught in the undergraduate dental clinic. Subsequently, he completed his master’s degree in temporomandibular disorders and orofacial pain. He lectures internationally on the topics of patient experience, facial pain, and virtual surgical planning. He is a certified yoga instructor with additional training in breathwork, meditation, and trauma informed movement. He runs a wellness program for the hospital dental residents at Mount Sinai Hospital in Toronto, where he teaches yoga and mindful communication. He can be reached at bruce@drbvf.com.
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