Managing fearful patients during the pandemic

We are at a point in the evolution of living through a pandemic where those who have gone back in the operatory are becoming more accustomed to providing patient care within the confines of what I call “the new landscape.” Depending on beliefs, comfort level, and local regulations, some of our patients are coming back with a “business as usual” attitude. Others are cautious but comfortable, and then there are those who are not ready to come back at all. 

 A group that has been the subject of many conversations among dental professionals are those patients who are coming in, but doing so with fear, anxiety, reservations, and a lot of questions.  Dental colleagues are sharing excerpts from interactions that sound like …

Do I have to take my mask off for this dental appointment? 

Is the chair clean? Can I wipe this down myself with my hand sanitizer?

Did you wear a mask before COVID? Do you change gloves between patients? Do you replace the barriers?

Are these instruments sterilized?

These questions can make it sound to us like our rigorous infection control practices did not warrant consideration before in the eyes of some of our patients. With our knowledge, training, and experience, we know what we know, and it can be especially frustrating to be questioned by an audience that doesn’t understand these matters the way we do.

We are garbed up in layers of hot, heavy, and uncomfortable PPE. We are working through additional constraints, challenges, new engineering controls and revised practice protocols as we deliver care while working to keep our patients and ourselves safe.

Regardless of beliefs, individual situations, office adaptations, and comfort level, I think we can all agree that providing care at this time has added a new level of stress for many. This line of questioning by our patients, and what can feel like a lack of trust can be especially off-putting, particularly during current times.  

What can we do to anticipate these conversations proactively to make for a better visit for both the patient and for ourselves? Before we delve into that, I would like to share a concept that once I really understood it, helped make my interactions more effective in all aspects of patient care.     

It’s been said that knowledge is power. Did you also know that it can be a curse? The curse of knowledge is a cognitive bias where we unintentionally assume that others have a level of knowledge to understand something and relate to it the way we do.¹ I’m referring to those things that are so engrained in us that we cannot recall a time we did not know them, and it’s a challenge to try to see them with fresh eyes. 

Have you ever had a conversation with an expert (whether it be your tax accountant, a repair person, a landscaper, sometimes even a friend or family member) where they are speaking about something that to them is seemingly obvious, but in reality you are lost in the words? You may walk away from those interactions disinterested or not hearing what the expert thought you heard, which leads to frustration from both parties. Similarly, the expert may leave pieces of information out that they assume you know, while not having that information affects your feelings, decisions or outcomes negatively. This can lend itself to conflict or lack of trust.  

We can inadvertently demonstrate this curse with our patients. Anyone who has made it through school, boards, practice, and so forth has amassed such a vast knowledge base that it is nearly impossible to go back and remember that you once struggled with the difference between terms like mesial and distal, and now it can be challenging to find a way to explain the difference to a layperson in a way that they understand. Further, we may omit sharing pieces of information because we assume it is obvious, but to our patient it is not.

Let’s take a trip in the way back machine to first year clinic. Do you remember the feeling you had when you received what was likely a document about the size of phone book (for those who remember phone books!) with painfully detailed procedures involved in proper infection control for operatory set up and break down? Can you recall spending entire clinical sessions just on setting up and breaking down? Do you remember the feeling you had trying to decide what to do first and why? There was that feeling of overwhelm just hearing someone tearing off a piece of barrier wrap, and subsequently asking yourself what you may have forgotten to do. Think back on the times an item would fall to the floor and the sheer panic and cold sweat that would ensue as you worked through how to properly remedy the situation.

It is funny now when we think back, but I have witnessed that scene playing out for the past 15 years in which I have taught in first year clinic. Every year, the same thing happens—at some point during the first semester (without realization), the stressful and painfully slow process becomes intuitive, seamless, and something that doesn’t take all kinds of concentration and note checking to accomplish. At this point, you might even be wondering what that lengthy school document even said that took up that many pages for something that now seems as natural to you as breathing. That is an example of the curse of knowledge that relates so well to this topic.

It can be easy to become frustrated with patients, but they do not know what we do and in the way we know it. Additionally, the changes to normal routine living, quarantining, loss of income, isolation, uncertainty about the future, and fear of illness are only a few of the many psychological implications that our patients may be facing in the wake of a pandemic where information changes frequently, differences of opinion vary widely, and conversations can become heated.² According to The Lancet Psychiatry, there is a rise in adverse health effects in both patients with pre-existing mental health disorders as well as in those who were previously healthy.³

So, what can we do to “reverse the curse” to find effective ways to address our patients’ concerns reasonably within the parameters of a career that has gotten a lot more challenging and complex?

Set the stage

In our practice, we have a strict and consistent protocol for patient appointments during the time of COVID-19, and we review this with each patient when scheduling. This is mostly done by our administrative team, under the direction of an RDH or treatment coordinator, but all clinical team members are cross-trained and assist when scheduling allows.

We summarize the potential risks of receiving treatment at this time and balance it with what we are doing to mitigate risks, promoting patient awareness. We also review specific treatment needs to help patients understand the benefits of receiving care against the possible risks of delaying; this is done on an individualized basis so that patients may make their own informed decisions before scheduling. This conversation takes approximately five minutes and results in patients who we find empowered with information and prepared when they enter, saving time for the necessary patient care and decreasing perceived anxiety levels.

Shift your perspective

I understand that we do not always work in environments that are open to “setting the stage,” but we do have the power to shift our thinking. Instead of seeing someone in the chair questioning your infection control practices as you wonder why they didn’t elect to postpone the appointment instead, you can look through a different lens.

You have a patient who came in because they value their oral health. Isn’t this what we have always wanted and worked toward? Perhaps they have listened to you when you explained risk factors and the importance of regular and consistent care. Perhaps they have pain or a situation that they fear may become a painful dental emergency if they hold off. They are trying to balance the need and desire for care against fear and uncertainty in a world that continues to change information by the day. We also have patients who may feel that although it is not ideal, now seems to be a better time to receive treatment than to wait for the fall and winter when things could be back to limited access or a situation with no care available. 

See it as an opportunity to promote all we do now—and did before—to help keep them safe.  The more we can reverse the curse and share the value of what we do and why, the better the likelihood you have a patient in your chair who understands and appreciates your efforts. 

Patients sometimes need to know we care before they are ready to hear what we know. For example, dialogue may sound like, “I am hearing that you have some questions and I would like to help. May I ask you something that might help me to best address your questions? What prompted you to come in today and what are your main concerns receiving care at this time?” This simple opening can allow us to identify and narrow down the specific issue, address it with relevant facts, and bridge the gap quickly and efficiently in an individualized way. By doing so, we allow the patient to make decisions while weighing the risks versus the benefits. 

Approaching conversations from a place of curiosity, listening, and guidance versus instructing or offering unsolicited advice empowers patients in a more impactful way and promotes conversations that foster mutual understanding and change. This is a communication style that is a subject for an article in and of itself; motivational interviewing techniques in health care are game-changing in patient-provider relationships. Conversations become less of a lecture and more of a two-way conversation. Patients come to their own conclusions with your guidance, often resulting in better informed, more committed, and engaged patients. This can also result in less clinician frustration over the long term of the relationship.⁴ 

I often say we need to “meet patients where they are at that moment, not where we want them to be.” Sometimes that can mean reappointing if appropriate. Other times it might mean that if the patient wants to cover the chair in their own paper towels, drape themselves in a homemade plastic poncho, and wear a cap to cover their hair (or some of the other unexpected events we may have witnessed recently) let them! If what they are suggesting will make them comfortable and not interfere with safety or infection control, applaud their efforts (and creativity!) for making a choice they feel comfortable with and doing so in a way that helps them to feel more secure.

Patience for patients

I know it can be a challenge, but remember that you are the expert and every time you have a patient interaction, you have the power to help inform and provide information and education that promotes healthier outcomes or increases patient dental literacy. During these times especially, people can be scared or may be fighting a battle we know nothing about that skews their perspective or even their personality. According to a 2017 study in the Journal of Dental Hygiene, 50-80% of patients present with mild to moderate dental anxiety.⁵ Now add to that our current crisis of COVID-19 and that we are living amidst times of confusion, conflicting opinions and a lot of added stresses.⁶ It is a perfect time for more empathy.

When we attempt to step into a patient’s shoes, it can help us approach conflicts with compassion, which often is a faster path to resolution and mutual understanding. Before you hold a grudge about beliefs or behavior that may be frustrating, hold a conversation. “I am hearing this is a really challenging time for you. On the one hand you value your dental care and on the other you have some concerns. Do you mind if I share with you some information that may help?”

One cannot discuss patience without discussing the knee jerk reaction we can get from improper use of personal protective equipment (PPE) worn by our patients.  Remember the curse of knowledge? It can be so hard to go back to a time where we weren’t experts on PPE.  I go back to my clinical teaching experience. For the first several weeks of first-year hygiene school, students struggle with proper donning and doffing of PPE. Remember when you felt you couldn’t breathe under just a surgical mask and your safety glasses would be fogged to the point you felt you were wearing a blindfold? Do you recall getting spoken to for touching surfaces, such as your pants, your face, or your glasses that would be sliding off your sweaty nose, with treatment gloves? Even something as simple as when and how to wash your hands was something that involved a new set of rules and new way of thinking. 

Our patients are trying to navigate a new world that they didn’t sign up for like we signed up for careers in health care, and they are not trained on proper use of PPE. We have the power to share what we know in this area by respectfully addressing what we see in an effort to help spread important knowledge. One of my most asked questions is simple, “Do you mind if I share something with you that you might find helpful?” I cannot recall a time where someone has answered with a hard no. Most have been receptive and appreciative, and the next time you see them you won’t be having chest pains looking improperly used PPE. Better still, you have a patient using practices that can decrease transmission. 

There is no denying these are complicated times for us and for our patients. We are in a unique position as prevention and infection control experts to assist our patients in new and different ways. It can be helpful if your team comes together to discuss verbiage and consistent messages to be shared with patients. Even in the absence of an environment that supports the team approach to patient care, however, we as individual providers have the opportunity to set the tone in our operatory when performing patient care. 

Stay safe, stay informed, advocate for yourself and your patients, and continue to stay connected to why you chose this career path.  If no one has told you today, thank you for all you are doing to care for your patients; they need you.

References

1. Rosenbaum L. Cursed by knowledge - building a culture of psychological safety. N Engl J Med. 2019;380(8):786-790. doi:10.1056/NEJMms1813429
2. Ahmed MA, Jouhar R, Ahmed N, et al. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. Int J Environ Res Public Health. 2020;17(8):2821. Published 2020 Apr 19. doi:10.3390/ijerph17082821
   
3. Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 2020;7(9):813-824. doi:10.1016/S2215-0366(20)30307-2
4. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Guilford Press; 2013.
5. White AM, Giblin L, Boyd LD. The Prevalence of Dental Anxiety in Dental Practice Settings. J Dent Hyg. 2017;91(1):30-34.
   
6. Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic. N Engl J Med. 2020;383(6):510-512. doi:10.1056/NEJMp2008

Julie Whiteley, BS, RDH, is certified in human resources. She holds degrees in business administration and dental hygiene and has worked extensively in both fields. She is on the faculty of Massachusetts College of Pharmacy and Health Sciences University in Boston. Julie bridges her knowledge and experience from business, clinical hygiene, and teaching to deliver information and programs that enhance dental practices. Contact her at [email protected].