Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
Communicati
o...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
2.2. Practica...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
Differences b...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
Listening and...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
professional ...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
Patients some...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
worries. “The...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
Most dental p...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
2.2.1.3. Comm...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
the physician...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
“greets” the ...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
This is a non...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
close-fitting...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
may refuse to...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
any examinati...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
This particul...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
 Body’s func...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
 If you expe...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
Both groups o...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
next, particu...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ
medical terms...
Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr
AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ

 Check whe...
Prochain SlideShare
Chargement dans…5
×

Communication in dental medicine

In order to succeed in medical profession, every healthcare professional including dentists must be competent at least in two areas – in medicine (to be able to absorb knowledge, master the decision-making process, and have practical skills) and communication (communication skills to deal with people – patients, their family members, colleagues, administrative workers, laymen and other medical staff).
family members, colleagues, administrative workers, always obtained medical knowledge and skills in schools. However, they learn communication skills once they are in practice using a trial-and-error method. This is because some senior colleagues used to think that the best way of learning is to put a medical student into the real-world situation where they will find out what is good and what is wrong when dealing with patients. The key idea behind this is that man will learn to swim quickly if he is thrown into deep water.

  • Soyez le premier à commenter

Communication in dental medicine

  1. 1. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ Communicati on in dental medicine 2.1. Introduction In order to succeed in medical profession, every healthcare professional including dentists must be competent at least in two areas – in medicine (to be able to absorb knowledge, master the decision-making process, and have practical skills) and communication (communication skills to deal with people – patients, their family members, colleagues, administrative workers, laymen and other medical staff). Historically, dentists always obtained medical knowledge and skills in schools. However, they learn communication skills once they are in practice using a trial-and-error method. This is because some senior colleagues used to think that the best way of learning is to put a medical student into the real- world situation where they will find out what is good and what is wrong when dealing with patients. The key idea behind this is that man will learn to swim quickly if he is thrown into deep water. If we consider that every analogy limps a bit, it is obvious that learning by shock can be risky. Not only for swimmers (i.e. medical students), but particularly for a patient who is not taken into account in this analogy. It is not surprising that communication skills are taught in all developed countries, becoming part of pre- graduate courses of dental medicine and postgraduate education. Particularly private dentists need to have good communication skills to deal with their patients, otherwise their patients will go to other dentist who will be able to calm them down, encourage them, explain procedures to them, give them advice, so that they will leave the dental surgery satisfied. The dentist communicates with his/her patients not only through what he is saying or not saying but also through the way of delivering the information to the patient, i.e. what words he/she chooses, what expression is in his/her face, etc. Besides verbal communication, non-verbal communication also plays an important role. A medical student is usually able to deal with common patients but the dentist also meets children, elderly people, patients with disabilities, seriously ill people who expect correct professional handling and behaviour from him/her. It is therefore worth taking a close look at communication in dental medicine.
  2. 2. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ 2.2. Practical aspects of communication 2.2.1. Communication in the dental surgery The dental surgery is a place where professional communication usually takes place. The dentist’s profession requires that the dentist will communicate in a specific manner, i.e. taking interest in patients, respecting their individual specific properties and needs, being helpful and decisive, being able to explain the problem and tell the patient what is the most suitable treatment in a particular case, being able to cooperate effectively with other medical staff (for example nurses) and his/her colleagues. Let us take a more detailed look at four different communication partners of a dentist. 2.2.1.1. Communication with a patient Communication between a dentist and his/her patient looks different from a point of view of either participant. The dentist is in the environment with which he/she is familiar. It is common for him/her that patients come to him/her with their problems. The range of diagnoses is not too wide, examinations and treatments (except for some individuals with specific problems) are routine. The physician understands the nature of diseases which he/she is treating and is able to speak about it using medical terms. He/she comes to work (with some exceptions) well balanced, his/her mental state varies within the norm. He/she usually manages the course of his/her work himself/herself, he/she will decide which of the patients will come next, how long he/she will deal with a patient, etc. His/her relationship with most patients is emotionally neutral. However, problems may occur when a patient is not cooperating, when the dental problem is more complicated than originally anticipated, when the dentist is under time stress, etc. Although the dentist treats dental problems, his/her major role should be in prevention. On the opposite site is the patient who comes to the environment which is foreign to him, sometimes he feels being endangered. The fact that he should see a dentist is something strange, unusual. It takes him a long time to decide to see his dentist. Problems are unpleasant to him, they are something exceptional, he is often unable to describe exactly his problems, where he feels pain, what is the nature of his problems. He hardly understands the nature of his disease, he cannot speak about it in medical terms. As he does not know medical terms, he does not understand exactly what his physician is telling him using complicated medical terms. He is ashamed to ask, he interprets the sentences in his own manner. He comes to the dental surgery in the mental state that is usually at the limit of the norm or sometimes outside this limit. He is worried, sometimes he suffers from pain; waiting in a waiting room usually intensifies his uncertainty, he has also fear. He is preparing mentally for unpleasant experiences. He does not control the course of events, he must wait for what the nurse will tell him, what the physician will ask him to do. He feels being manipulated. His relationship to the physician is ambivalent: he expects help and relief from the physician, he assumes that the procedures performed by the physician will expose him to stress which he may not bear and does not know in advance how intensive it will be. This is why the patients try “to win the physician’s favour”, deflect the physician from the emotionally neutral relationship and develop a more personal relationship with him. The main focus of the dentist’s work lies – according to the patient – in therapy; the patient does not know much about prevention in the dentist’s work and usually does care much about it.
  3. 3. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ Differences between the dentist and his patient also stem from different motivations. L. Stroud (1985) clearly showed the differences between their needs. Let’s take a look at the communication between the dentist and his patient in the dental surgery. The activity of the dentist appears very simple: he/she invites the patient, writes down relevant particulars, puts the patient in a chair, leads a diagnostic talk, examines the dentition, performs dental treatment, tells the patient conclusions, writes down relevant particulars, says goodbye to the patient, and invites the next patient, etc. In fact, communication between the dentist and the patient (with regard to the above-mentioned patient’s characteristics) should be much richer. Let’s remember the main types of dentist’s activities. Inviting a patient “Good morning, Mrs. Jones. Good afternoon, Mr Black. Hello Peter!" A greeting is an introductory element of communication, but it is very often omitted. Sensitive individuals will perceive very negatively if they are not greeted, invited. The dentist should also introduce himself to the patient who has come for the first time and shake his hand. The absence of a proper greeting is an inexcusable social offence. Calming down “What has bloomed in your garden? Have you already made a trip to England? It is a really beautiful day today. Is it still raining? Did you get wet?” The purpose of these seemingly irrelevant, casual topics is to distract the patient’s attention from fear or worries, and open the space for having a chat about general topics in order to help ease accumulated tension. At the same time, it is necessary to consider which topic is the most suitable for a talk. In paediatric patients, the following questions may not work: What was your school report? Is your school teacher nice to you? Doing paper work "Could you please give me your health insurance card. We will also write down your address. Maybe, it would be useful if you tell us your telephone number. Encouraging Now, I am going to examine you. I will look what kind of troubles you have. Today it won’t be very demanding as last time. John, I will take a look at your filling we made last time. Putting, positioning a patient in a chair So please make yourself comfortable. Do you have your head supported well? Is it ok for you? If not, tell me, I will adjust it. Does the headrest hurt? John, sit on your mummy’s lap and rest your head. Dentist’s needs Patient’s needs To run dental practice at a standard quality level To get rid of problems, relieve pain To achieve economically adequate reward for the work done To pay affordable price for dental care To fulfil the aims of preventive care To improve his own appearance To involve a patient in decision-making on further procedures, treatments To transfer responsibility for the condition of the mouth to the dentist Asking questions Have you come for the examination of your teeth? Do you have any problems? How long have you had these problems? Have you been examined for the same problems somewhere else? What is your general health? Are you currently undergoing any treatment? Do you suffer from any heart disease, kidney disease, hypertension? Are you using any medication?
  4. 4. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ Listening and observing This stage of communication is very valuable for succeeding in work with a patient. The patient’s way of expressing himself, the terms which he is using and which he is trying to avoid, ranking the pieces of information, voice intonation will give us an exact picture about to which extent we can rely on the information, what questions we should ask and how great is the patient’s fear of treatment and how much he trusts us. Selecting relevant information Physician: “So you had a toothache? All the night?” Patient: “Yes, doc. It hurt terribly. I could not bear the pain. I had to take some pills. Otherwise, I couldn’t sleep. You know. I take those pills every night. It is too much for me. My wife is in hospital, I visit her every other day. When the doc from the hospital ward saw me how desperate I was about the situation, he said: “I will prescribe you some sleeping pills so that you can have a rest at night at least.” So I have been taking those tablets for three weeks already. He is a very nice doc and very considerate too. The flow of information about which the patient thinks that are important and must be said, contains completely useless information with regard to the disease to be treated. (However, such information is not useless at all from a general point of view to make an opinion on the patient's personality and behaviour.) Otherwise, it is necessary to ask for a relevant answer directly and give a reason for asking such a question since the patient may consider such information useless. Physician: "Mr. Brown, what is your blood pressure?” Patient: “Doc, I did not come here because of my blood pressure but because of my tooth. It hurts so much I would not wish anyone else to have such a terrible pain. I am not treated for hypertension. You know, I am an old man. But I see my doc regularly. He has all papers about me. But this has nothing to do with my tooth.” Examining the patient and asking additional questions We start the examination by asking additional, targeted questions and say many instructions. “Is this swelling painful? Does it hurt when you open your mouth? Did the wound bleed? Does the tooth hurt on percussion? Does (nečitelné) hurt here in this place?? Besides considerate, careful examination, which is a typical requirement, we have to realize the following two things: 1. During certain examination procedures, the patient may answer the question immediately (for example the question whether the swelling in the face hurts on percussion), other time we have to give him some time to answer the question (for example the question whether the swelling in the hard palate hurts upon percussion). If we want to hear the answer, we have to give the patient a chance to answer the question, by removing tools, tampons, fingers, etc. from the patient’s mouth. Otherwise, the patient will say to himself: “He kept on asking me so many questions but I could not speak, he did not allow me to speak.” 2. We have to ask the questions in such a way that the patient will understand the words and terms we are saying. It is better to ask the question “Does the swelling hurt when I press it here?” rather than: “And what about lateral palpation, does it hurt?” Establishing trust The physician will win the patient’s trust and get relevant answers through a truly
  5. 5. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ professional approach. It must be obvious to the patient at first sight that the physician is paying attention to him and is making any efforts to help him. In this sense, relevant communication with other medical staff and the general psychosocial atmosphere in the dental surgery are absolutely necessary. Here are the most common mistakes which diminish patient’s trust in his physician:  A talk between the physician and nurse about matters that do not concern the patient and his disease (“Did you watch that new series on the TV yesterday? I do not know where they found him. I did not know who was who even when half of the film was gone. Anyway, it was so unlikely to happen ... I went for shopping yesterday to buy shoes. I went to four shops and bought nothing. You are right. All shoes look awful with that thick soles, only crazy teenagers like them. Tell me, would you buy it at such a price?  Searching for tools and other aids (“Where is that handy probe? I saw it here a minute ago and now it is gone.”).  Speaking up and having an argument with other members of the team (“Stop it! This is not the way of doing it. I have told you one thousand times how to do it and you haven’t done it properly. I cannot work here any more!”  Repeating questions that have already been asked and answered (“Well, where have we finished? Now, what kind of pain do you have? As I have told you it is convulsive pain and it hurts at night. Yes, yes...”)  Keeping running away from a patient (due to phone calls: “Yes, Charles, I am happy you are calling. I have been looking for you three days, man. I need to do something with my car. It seems unstable in turns.”)  Mistakes in non-verbal communication (appearance that is not well-kept, unsuitable facial expressions, gestures, not keeping an adequate distance at work). Explaining the finding and further procedures in plain language, patient activation and involving the patient into decision making This stage is closely related to the establishing of trust. It is sometime very difficult to provide clear and lucid explanation and we usually search for suitable synonyms of our familiar medical terms. For example, the sentence “we will do extraction in anaesthesia” is not very suitable. The following sentence sounds better: “your problem can be cured by pulling out the tooth. Of course, we will first give you an anaesthetic so you will feel no pain.” For a patient, not only for our own sake, it is necessary to make a plan of treatments which may have several variants. The patient has the right to know all these variants and decide on one of the variants. One should take into account that besides medical indications, economic aspects also have to be considered in dental medicine. If we are going to require payment for a procedure, we will have to inform the patient about it (before the beginning of the procedure). The patient must be informed about the sum and provide an informed consent. If the sum is high, the patient should give his consent in writing. We will win the patient’s favour for active co-participation in the whole treatment, if we give him a chance to make decisions on his own treatment. Convincing the patient Medical indications for a certain procedure are of primary importance. In the majority of cases, it is not possible to leave only the patient to make all decisions.
  6. 6. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ Patients sometimes try to delay unpleasant procedures, trying to persuade their dentist that the procedure is not yet necessary. This strategy was very nicely described by K. Čapek: "In the stage of excruciating pain, the sufferer muttering something horrible puts his hat on and dashes to the dentist. There are only a few moments when man is able to make such heroic decisions. In spite of all expectations, your dentist will not offer any noisy sympathy to you, saying to you in attenuated voice: “Well, we will look at it.” He is knocking on your teeth with a strange instrument, taking no notice of your protests. Then he pauses for a while and says gloomily: “You know, your tooth would like to go out.” At that moment, you feel a kind of generosity: you are a father who is showing endless patience with his naughty blood son before he disowns him. “Perhaps, we can still wait,” you suggest immediately. “Look, it may get settled, and we can save the tooth, don't you think?" At that moment, that naughty tooth hurts a little bit less. It may take a turn for the better. “Well,” says the dentist. “we can wait for a day.” And he let you go with a prescription for ointments and compresses. On the way home, your tooth changes his mind and starts to carry on like a madman. You are hurrying home looking forward to resuming rescue operations. Making superhuman efforts, you are then trying to save that poor tooth (because you are doing it for the tooth itself not for yourself) ... (Čapek, 1991, page 322). Convincing the patient is not therefore always easy. Success depends very much on the clarity of information. A typical reply used by a patient to successful convincing is: “Well, until now, nobody has ever explained the procedure to me so clearly. If I had known it earlier, I would have had my tooth pulled out.” Treating the patient, overcoming fear and relieving pain Generally, people are afraid of all dental procedures, which is a peculiar feature of dental treatment. Dispelling the patient’s fears can only be achieved through a general calm approach, transparent communication (explaining and convincing). If the psychological approach does not suffice, it is possible to use medication, for example a local anaesthetic during cavity preparation. In the majority of cases, the patient does not need to feel pain in the dental surgery. There may be complicated cases such as patients suffering from anxiety, untreatable paediatric and adult patients. Such patients should be given care in specialized clinics, resistance against fear and pain should be systematically trained in these patients. In developed countries, the physician delegates such activities to clinical psychologists that work in the area of dental medicine (Sack, Butler, 1997). Psychosomatic links to patient’s problems The dentist is trained to primarily consider the somatic causes of the patient’s problems. He/she is taking these causes into account during the examination and treatment of his/her patients. However, he/she should not forget that a toothache, facial pain, headache may also indicate some complicated disorders. They may be linked with somatic psychogenic or psychosocial disorders. In such cases, routine dental therapy will usually fail. The patient’s problems are persistent or may even deteriorate. If somatogenic causes of problems have not been confirmed, it is necessary to consider psychological and psychiatric help (Feinmann, Harrison, 1997). Quick reaction to changes During dental treatment, complications may occur on the patient’s side or on the physician’s side. The dentist should react quickly to persistent fears (he should keep observing the patient's facial expressions, his grasping the arm-supports, gripping a handkerchief). “Now, it may hurt a bit, but just for a short while.” If the type of treatment has to be changed (the tooth has broken – the preparation for complicated extraction), the dentist should not forget to provide clear explanation, he/she should stay calm and should not show his/her own fears and
  7. 7. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ worries. “There is a little piece of the root still in there, we will remove it in a while after our nurse prepares tools. This usually happens when the tooth root is too bent.” Informing about the result and referring for further tests The result of the examination is usually expected with great fear (even announcing simply the number of caries found is accompanied with great tension). Where a serious diagnosis was established or a serious finding is suspected, the patient should be referred for further examination or treatment. In such cases it is necessary to be very careful: it is necessary to convince the patient to undergo further tests but we must not scare him with unclear expressions which would strengthen his assumption that he is seriously ill. “You know, it looks a bit strange to me. This might be something more complicated. You’d rather drop in at hospital with this. We should not neglect this. Compare with the laconic sentence: “Go to hospital with this!” Instructing the patient When the examination has been completed, it is necessary to instruct the patient what he should do next, for example how he should do irrigation, what compresses he should use, whether he should take any care at home, what he should do when the prosthetic replacement will hurt, how he should take medication and why. Giving instructions to the patient is very important. Failure to do so will markedly diminish everything that has been done up to now, although it has been done at high quality. The quality of the procedure can hardly be assessed by the patient but the patient can easily assess our way of dealing with him and our care. As already mentioned, dental treatment causes stress in the majority of patients, it is therefore necessary to make sure that the patient understands our instructions properly. It is reported that the patient will forget approximately 60 % of information when he leaves the surgery room. We should not assume that some information is generally known, it can be so for us but not for patients. Parting Parting with children: “We have managed to repair your tooth. It won’t hurt any more. John, the nurse will give you some pictures. I am looking forward to seeing you here on your next visit.” Parting with adults: “Goodbye, Mr Newman. Please do not forget to come for a follow-up in 6 months. Goodbye Mrs Newman, I will see you tomorrow morning or tomorrow afternoon. I have to look at you again to be sure that you are all right and the wound is healing properly. If child’s parents have not been present in the surgery during treatment, we will invite them at the end and inform them about procedures before parting. All information and instructions are said in the surgery room rather than in the waiting room if there are patients there. An exception is when a young child is praised: “Come in, Mrs Newman. John was very brave today, we have managed to pull out the tooth. His lower lip is still numb. So please take care of him for about one hour to prevent him to bite into the lip and make harm to himself. In the case of any problems, please come. What has been said for greeting also applies for parting with a patient. If the act of parting is missing, it is not only improper but it also makes the patient feel that we wanted to get rid of him as soon as possible. Maybe, he wanted to ask about something but he suddenly found himself back in the waiting room. This would also deprive us of the possibility to remind the patient of the next scheduled follow-up. It is also suitable to shake hands with the patient during parting. 2.2.1.2. Communication with people accompanying the patient
  8. 8. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ Most dental patients come to the surgery room alone. However, there are groups of patients who are accompanied with family members or nurses or friends. The dentist must also communicate with these people in an efficient way. Children are usually accompanied with their parents or grandparents. It is not easy to give a single instruction how to deal with parents or grandparents. There is an opinion that they should not be in the surgery room with the patient and we should not therefore invite them in the surgery room. Other authors recommend the presence of accompanying persons so that they can see what is happening with their child or grandchild in the surgery room. If the child is very young, we should allow the accompanying person to come to the surgery room. This is the only way to obtain relevant information from them and the presence of the familiar face, or the close person will give the child confidence, mental and social support, and dispel the child’s fears. The important prerequisite is that such persons are able to calm down the child, encourage him/her and make fun. Such parents and grandparents are of invaluable help and make work for the dentist much easier. However, there are also parents and grandparents who complicate work in the dental surgery:  hysterical and hyperprotective: “It is terrible what they have been doing to him. I can’t watch it any more. I can’t bear it anymore. It will fail again. I will complain!” etc.  impatient and aggressive: “Hurry up, doc! We don't have time to spend the whole day here! Why are you hesitating? Don’t you know what to do? We will go somewhere else!”  mentally unstable who have problems with themselves: “I can’t look at it any more! I also went through it and it was horrible! I leave him here and you do what you want with him!” The above-mentioned cases show that one should consider carefully whether or not to ask such accompanying person politely but decisively to wait in the waiting room. The absence of such an accompanying person is advantageous because the treatment proceeds smoothly. However, the main disadvantage is that the parent has no direct information about what is going on in the surgery room and may come to wrong conclusions. In principle, the presence of parents in the surgery room is recommended and we should try to bring them in the surgery room. It will help greatly, for example for the performance and effectiveness of preventive measures. Mentally disabled individuals are usually accompanied with guides who are of invaluable help to the dentist. The guide knows well the mentally disabled person and is able to interpret his/her behaviour and his/her verbal and non-verbal expressions quickly and adequately. He knows what works on the mentally disabled person. The dentist must therefore divide communication between the mentally disabled person and his guide whereas he/she makes principal decisions after consultation with the guide of the mentally disabled patient. The dentist should speak to the mentally disabled person in a calm voice, using short, simple sentences, showing openness, not hurrying, being patient and kind. The mentally disabled patient is very sensitive and perceives the whole surrounding atmosphere although he cannot understand the details. The atmosphere of cooperation and kindness is the basic condition that enables the dentist to perform examination and treatment of a mentally disabled person.
  9. 9. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ 2.2.1.3. Communication with the nurse – theatre nurse The nurse or theatre nurse is the closest co- worker of the dentist. The dentist could not be able to run his/her practice without a nurse. If he/she has more options, he/she should choose such a nurse whose professional and human qualities match his/her own. The nurse should be competent and should also be able to deal with people. It is clear that the nurse is the person who organizes most contacts with patients. Starting from the management of the waiting room through dealing with waiting patients helping them to feel comfortable to creating pleasant social atmosphere in the dental surgery. The physician and nurse or theatre nurse should clarify their mutual relationship right from the beginning, for example the way of addressing each other, the performance of required work activities, priorities, etc. The patient should always feel in communication between the physician and the nurse or theatre nurse that they both focus on him and his problems. It is strange when the nurse (theatre nurse) and physician are too much friendly one with the other in front of a patient. The same applies to hasty and inconsistent instructions or an argument about who made a mistake. The course and the result of high- quality examination and treatment is completely lost if there is a discussion about a TV programme going on between the dentist and nurse during examination and treatment. On the other hand, a purposeful talk about a distant topic is something else as it helps distract the patient’s attention but it should involve the patient actively into the discussion. The nurse or theatre nurse is of great help in dealing with elderly patients and children: thanks to her communication skills she can save a lot of work and time of the physician. 2.2.2 Communication in a waiting room The dental waiting room is a place where patients gather and wait before they are invited for examination and treatment. As mentioned above, the patients are not always in a good mental mood. The place itself, illumination, furniture, decorations and general layout of the waiting room should therefore diminish patients’ fears, make them feel comfortable, distract their attention from noise coming out of the dental surgery, laboratory. Through the design of the waiting room, the dentist is telling his/her patients whether he/she cares of them, looks forward to their visit, wants the patients to feel comfortable in his/her dental surgery. Another seemingly unimportant factor is greeting the patients in the waiting room. When passing the waiting room and seeing new patients, the physician should always say hello and look at the patients with a friendly face rather than with an indifferent, angry or even annoyed expression in his/her face. Waiting patients have only a few new impulses, as they are preoccupied with their health problems and therefore seeing their physician is a pleasant distraction, and of course, it gives them an opportunity to find out in what mood their physician is and what they can expect behind the doors of his/her dental surgery. Most communication with patients in the waiting room is managed by the nurse or theatre nurse. She finds out who has or has not come for a scheduled visit. She also organizes some administrative things, passes patients’ messages to the physician inside the dental surgery and the dentist’s messages to the patients in the waiting room. It is up to her to assess whether the problem of an unscheduled patient is urgent and requires immediate attention. It is up to her to settle minor arguments between waiting patients. She also apologizes to the patients for delays,
  10. 10. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ the physician's absence caused by urgent matters, his/her present absence etc. Basically, there are two types of waiting rooms in dental medicine: hospitals and clinics still have quite large waiting rooms which are difficult to make cosy. A large number of patients usually gather here, none of the patients is scheduled for a particular hour, they were only referred for a treatment on that particular day. Although some conflicts may occur here they can be managed or even prevented by effective communication. As mentioned above, the kind, patient nurse who invites the patients into the dental surgery means much. Patients do not usually understand why some patients are called earlier than the other despite they came later. Sometimes, the situation becomes critical that the physician has to come out from the dental surgery and sorted it out. No matter how much the dentist is busy with providing treatments to his/her patients, he/she should sometimes take time to look into the waiting room and briefly speak to his patients. When inviting patients from the waiting room to the dental surgery, the nurse or the dentist should always come out of the door rather than call the patient’s name through a slightly open door behind which nobody will see them. When addressing the patients, we use proper names, for example Mr., Mrs., Miss for adult patients and first names for children, or we can also use the title if the patient has some. Names such as grandma or grandpa or madam are not usually suitable except for some rare cases. Waiting rooms in private dental practices differ by design. They are usually designed with good taste so that they resemble living rooms, with friendly atmosphere being created by means of various accessories (paintings, vases, flowers, magazines). They have one thing in common that is that they are usually small in size as the organization of work of a private dentist must respect the patient’s time. The patient who has been scheduled for a particular hour also wishes to be treated at that hour and does not want to loose time by waiting in the waiting room although it is nicely equipped. If we cannot keep the scheduled time for any reason (the previous treatment was delayed due to unexpected complications, emergency, bleeding after tooth extraction), it should be taken for granted that we have to apologize to the waiting patients and explain the reasons. While passing through the waiting room, we have to realize that the environment which is familiar to us and does not stress us may be felt by our patients as the complete opposite. Let’s recall our feelings we used to have while waiting in the waiting room for a clinical, surgical, or gynaecological or paediatric examination or treatment. Or just try to recall your own patient experiences from the waiting room where nobody knew you were a physician. 2.3. Non-verbal communication As it follows from the title, this kind of communication does not use words. Most laymen think that non-verbal communication means facial expressions, i.e. the expression of ideas and feelings through the face (joy, sadness, anger, etc.). Some people identify non-verbal communication with sign language (conventionally settled set of gestures), i.e. the language used by deaf people. However, non-verbal communication is much broader because it includes at least eight different possibilities. They cannot be taken separately since they supplement each other, clarify what it is communicated without words. Communication through eye contact When a dentist meets his/her patient, intensive communication is going on between them through eye contact. He/she
  11. 11. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ “greets” the patient looking at him the entry to the dental surgery, he/she is watching the patient along his/her way to the chair, or he/she does not even “lift up his/her head” off the papers, he does not look at the patient since he/she is making a telephone call, etc. The duration of a single look and the frequency of looks devoted to the patient are important. The patient (although subconsciously) records how frequently the physician looks into his/her eyes; if the physician only follows the inside of the mouth, instrumentation, tools, nurse’s work, and ignores patient’s looks, the patient will have an impression that the physician does not care what he/she feels during the procedure. The experienced physician is able to recognize the current mental state of the patient in patient’s looks, for example uncertainty (the patient looks at the floor, on the wall, he is avoiding eye contact), waiting for a diagnosis (anxious to imploring look), fear (short looks at the physician, blinking, widened pupils), pain (looking at one point in the surgery room, closing eyes, etc.). Eye contact is important in situations when the patient treated in the chair cannot speak but he/she can just reply through his eyes to current questions asked by the dentist. Communication through facial expressions Making oneself understood through facial expression is important and very common in dental medicine. During the examination or treatment, the patient usually uses facial expressions to show his/her current feelings and what he/she is experiencing at a particular moment. A range of feelings, emotions, moods, emotional manifestations and affectionate states which can be expressed in the face is very broad. Fear is usually identified in the region of eyes and eyelids; pain in the area of eyebrow, eyes, and mouth, surprise in the area of the forehead and eyebrow, happiness in facial expression in the lower part of the face and eyes. Only anger has no dominant area and its manifestations can be seen in the whole face. Most people have a good ability to read out the emotions from facial expressions, women are usually better than men. Communication through facial expressions can be used in situations when the physician communicates with the nurse or theatre nurse about next steps of the treatment in the case of a paediatric patient or difficult non-cooperating patient. Communication through movements Movements can communicate many things in a dental surgery. By drawing his/her head away (“manoeuvring” in the chair), the patient may communicate to the physician that he/she is afraid of the procedure, feels pain during the procedure, is not willing to cooperate, etc. The experienced medical professional recognizes the patient’s mental state and personality type from his/her way of entering the surgery room (uncertain, scared, desperate, vigorous entry) and from the movements in the surgery room. Communication through postures The dentist, nurse (theatre nurse) and the patient also communicate through their physical posture. Folded arms, arms akimbo, arms in pockets, slight turn, turning back to the speaker, bent knees, or stretched legs – are just a few examples. It is worth watching patients in the chair: sitting relaxed, curled up, unnatural bodily tension, hands on knees, hands gripping a handkerchief, hands gripping the armrest – all these observations will give the dentist and nurse some clue of how the patient may react to the examination and treatment. When the person is standing and speaking, we distinguish similar to identical postures (indicating a possible agreement) and different postures (indicating reticence to disagreement with what the speaker is saying). Communication through gestures
  12. 12. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ This is a non-verbal communication which has a long cultural tradition, it is a matter of agreement, convention. Here are some culturally determined gestures: nodding means agreement in the Czech Republic, shaking the head means disagreement (for example in Bulgaria this is opposite). Shrugging shoulders means indecisiveness, hesitation, raising the forefinger means strict instructions or criticism, etc. Gestures are often used in the dental surgery. Using gestures with his/her hand, the physician indicates where the patient should sit down, by turning his/her hand he/she tells the nurse that her help is not necessary. A paediatric patient covering his/her face with his/her hands conveys the message that he/she does not want to undergo a treatment, a hyperprotective mother who is covering her eyes in the presence of her child says that she cannot see the suffering of her child. In paediatric dental medicine, the physician can settle gestures with a child through which the child will express his/her feelings and wishes during treatment (when he/she cannot speak). For example, raising his/her left arm means that the pain is too strong and that he/she wants the physician to interrupt the procedure for a while so that he/she can take a rest for a while. Communication through touch This means a direct physical contact between persons, i.e. skin-to-skin contact. Typical examples include handing and pressing a hand, stroking, pushing aside, patting on the shoulder, grasping the hand, etc. In this case, we communicate our mental states (joy, uncertainty, fear, acknowledgment, resistance) through touch. Communication through mutual distance This means both horizontal and vertical distances between two or more persons (one person is sitting, the other is standing). Generally, people as well as other living creatures have their own living zones in which they feel comfortable and are displeased if these zones are disturbed. Science that investigates this area of problems (proxemics) distinguishes four types of zones for man:  intimate distance 0 - 15 (30) cm  personal distance 45 (70) – 100 (120) cm  social distance 150 (200) – 300 (350) cm  public distance from 500 cm When examining and treating a patient, the dentist usually moves in two zones – personal and intimate zones – performing the procedures in the intimate zone which results in unpleasant feelings in a patient. Difference in the vertical distance is also typical in the dental surgery although there are an increasing number of cases where the dentist is sitting during treatment of a patient. Any standing person (usually the physician or nurse) have literally “an edge” on the sitting patient. Modern dental surgeries take into account that the patient will be lying during treatment which may induce a feeling of helplessness in him/her, and particularly children refuse to lie down. If the physician discusses serious things with his/her patient, the distance between them should be around one meter as this induces the feeling of privacy, closeness, seriousness, personal interest. One serious mistake is made when young children come to the dental surgery alone, and neither physician nor nurse will come to meet them and help them to overcome the distance from the door to the dental chair. This strengthens the feeling of loneliness, fear and worries and may complicate cooperation. Communication through outer appearance Both the physician and nurse or theatre nurse (although they wear a “uniform”) communicate a lot to the patients through their outer appearance. Putting aside the fact that the dress is clean, ironed and
  13. 13. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ close-fitting, the patient also observes the hairdo and do not trust those who do not meet his/her expectations: the male physician with long hair, shaved head, or unshaved, with earrings, or rings in the nose, the female physician with extremely short hair, the nurse with provocatively coloured hair, extravagant make-up will arise doubts. Hands that are not well cared for or that are cared for too much will also attract the patient’s attention. Particularly, private dentists must care of their outer appearance since it forms the image of the clinic, affects the mental state of patients and contributes to the reputation of the healthcare professional in a broad public, in both a positive and negative sense. The introductory part of this chapter states that non-verbal communication is part of communication and its individual manifestations combine and enrich each other. Both verbal and non-verbal communications of the dentist form a unit where one helps to interpret the other, giving a complete picture, specifying it, explaining it. However, it may also happen that verbal communication and non-verbal communication will be in conflict. Someone says something but behaves differently. This is usually insincerity, half-truth or lie. In such cases, it is recommended to follow the signals from non-verbal communication because man can check his speech better than his expression. 2.4. Specific features of communication with paediatric patients Correct communication is the basic condition in the examination and treatment of a paediatric patient. Every dentist will recognize this fact when he/she treats the child in a dentist’s chair as if he/she was an adult patient and asks him to open the mouth. It may happen and it is happening that this is the last thing what the physician says to the child because he/she will not get any further. Physician: “Please open the mouth.” Child: “No, I do not want to." The child is then usually referred to another clinic as untreatable. Why does this happen?  Experiences of unpleasant dental examination are shared among people. The child heard that something unpleasant might happen to him/her in the dental surgery.  He/she is scared of the unknown environment of the surgery room and of people in white clothing.  He/she may have traumatic experiences which do not necessarily be associated with dental medicine.  The approach used in adult patients will fail in a child. Since dental examination and treatment uses metal tools in the sensitive part of human body and usually performs the preparation of dental hard tissues which is unpleasant even it is painless, the paediatric dentist (particularly medical student or dentist-beginner) has a very difficult task as:  they should win the child's favour and dispel his/her fears,  they should examine and treat the child correctly and completely,  they should motivate both the child and his/her parents (or the accompanying person) to come for regular visits and care of the dentition at home. It is not easy to fulfil all these requirements and even experienced dentists who do not treat children regularly may have problems to deal with young patients. The first prerequisite to success is to use a proper communication approach to make a contact with a child. Furthermore, the dentist should also be manually skilled and sufficiently quick since the child will get tired much quicker than an adult and
  14. 14. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ may refuse to wait for a long time. Finally, it is also necessary to establish good communication with the child’s parents or guide. Approach of a paediatric and adult patient to dental treatment It should be emphasized that there is a fundamental difference in the approach of a child and adult to dental treatment. This results from different personal characteristics. The intellectual abilities of a child are immature, his/her emotionality is enhanced and unsuppressed, the child has a low ability to control himself/herself, he/she gets tired both mentally and physically very quickly. It is not often easy to understand him/her since the child's active vocabulary may not suffice to describe his/her problems exactly and his/her passive vocabulary may not be sufficient to enable the child to understand what the dentist is saying. Child’s linguistic abilities can be an important mediatory factor in the dental surgery (Pinkham, 1997). In practice, the basic difference between a paediatric and adult patient is that the child does not usually want to undergo examination, let alone treatment. The situation in an adult patient is different, they exactly know why they have come to the dental surgery and understand which procedures they have to undergo. Both young and older children are in a completely different situation. They do not usually come out of their own decision (sporadic exceptions exist), they usually refuse to come, they are often brought to the surgery. We cannot want them to realize and appreciate the benefit of our efforts. Medical students are usually surprised by a seemingly paradoxical situation and wonder how much effort has to be made to win the child’s favour and “get the permission” for dental treatment in him/her. Basic factors for the successful treatment of a child are:  to realize the child’s age,  to consider the influence of the child’s family. If the child’s age is not respected in communication, our efforts will not lead to success and we will never win the child’s favour for permanent cooperation. The following mistakes are still being repeated in our dental surgeries:  Non-empathic, restrained, cold talk with a young child: “So open your mouth, lean your head against the head rest, otherwise I cannot examine your teeth!” (this sentence was said to a three-year-old child).  Improperly chosen words which the child cannot understand: “If you refuse to have your tooth repaired, we will have to extract it. I do it in anaesthesia but it is a pity that you will loose your tooth.”  Addressing the child using his/her surname: “Newman, come here and sit.” or “White, do you have your toothbrush with you?”  The approach and expressions that are childish, too affectionate and too motherly for children of older school age: “Don’t be afraid, darling. Could you please open your lovely mouth?” (speaking to a twelve-year-old boy).  Not respecting specific features in the child’s behaviour at puberty and lowering their personality: “You may be a spark on the playground but stop showing off here.” Besides the patient’s age, one should also take into account the influence of his/her family in order to be able to establish effective communication. This requires some experience which a medical student has not yet gained. We would therefore like to point out that communication with a child can be difficult in the following cases:  Talking back to parents and the physician: “I do not want this. I do not want to sit down. Leave me alone. You should not come here with me, I told you. I do not want
  15. 15. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ any examination. Do not put this into my mouth.” etc.  Unwillingness to answer the questions, grim silence (there are sometimes only non-verbal manifestations such shaking his/her head, protective movements with arms and legs, children often avoid eye contact with the physician).  Improper remarks made by parents: “He had that screwdriver in his mouth once, so now he is afraid. Couldn’t you examine him without those gadgets? Do not bite her (the child biting the physician), otherwise she (the physician) won’t repair it. So he doesn’t open his mouth, does he?”  Problematic relations in the family pointed out by one of the parents or grandparents: “You know, we are getting divorced. So this is why he is so difficult to deal with now. Her mother does not take care of her, so I have to do everything.” (This was said by the grandmother).  References to previous traumatizing dental treatments (the dentist will learn from this talk that the child was calm at his/her previous visit to the dental surgery and willingly came until he/she underwent tooth extraction due to periostitis of the alveolar process without anaesthesia). Both medical students and junior dentists are at a loss in the above-mentioned situations. Aversion can be overcome through explanation and decisive action which clearly will show who must be respected. Of course, this is a matter of experience and social feeling and empathy. Stages of dental treatment Three stages of dental treatment can be distinguished:  the first stage starts at the entry into a waiting room,  the second stage is to putting the child into the chair,  the third stage is when the child is leaving the surgery room, returning to the waiting room. Waiting rooms have already been discussed. At least one part of the waiting room can be adapted to children’s needs (furniture, colours, toys, pictures, etc.). The child is excited by toys and pictures but is able to play with them only for a limited period of time. It is therefore recommended to minimize the period of time the child is in a waiting room. The acoustic separation of the waiting room from the surgery room is also recommended (which will also suit adult patients). After the child enters the surgery, we have to devote all attention to him/her. The arrangement of the surgery room cannot be changed in a manner that works in waiting rooms. If we make any mistake here, we will have to pay for it dearly. The following mistakes are often repeated:  we do not pay attention to a child entering the surgery room,  we talk to other people in his/her presence, usually to the nurse about the things that do not relate to work in the dental surgery or about personal matters, the child is completely excluded from the participation in the talk,  we switch the lamp without realizing that it will shine directly into the child’s eyes,  we make no efforts to explain what we are going to do,  we do not work with the instruments and tools gently in the outside and inside of the mouth,  we diminish or ignore the child’s requests concerning explanation, clarification or making a break. Despite medical students are taught the principles of psychoprophylaxis and know that they should avoid such mistakes, both medical students and junior colleagues often encounter completely opposite and sometimes funny situations which children use skilfully.
  16. 16. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ This particularly concerns the following situations:  The disproportional prolongation of an introductory psychotherapeutic talk: “I would also like to know whether you will be doing it carefully. Please, wait. I have to ask another question. What instruments will you use during the examination, show me.”  The detailed explanation of therapeutic procedures with the description of tools: “And what will you use for extraction? What is extraction? I would rather do it myself. Child: “What do you have in your hand?" Physician: “This is a tool to pull the tooth out.” Child: “What is it? Physician: “It is something like a lever.” Child: “What lever?” Physician: Well, this is the Bein's lever.” Child: “What will you do with it? Show me.” etc.  Calling parents and grandparents in and out: Child: “But I want my mum to be here! Then I will let you do it.” Mother: “So I am here, be a good boy, I will hold your hand.” Child: “I want my dad to be here.” etc.  Trying to escape: Child: “I have to bring my handkerchief. I have to wash my mouth. I have to blow my nose. I have to clear my throat. I have to go to a toilet. I have to say something to my mum. Wait, I have to tell you something. Wait, I do not want you to do it, I want someone else to come and do it.”  Postponing the treatment asking for another visit in the future: “I do not want it today but next time I will let you do it. Not today, we will come tomorrow. It is not possible today, we are in a hurry.” We have already discussed the third stage (i.e. returning to the waiting room, giving the instructions and parting with a patient). It should be pointed out that it is necessary to instruct both the child and his/her guide and make sure that they both have understood our instructions. Paediatric dentistry encounters one specific problem in the area of communication which concerns giving misleading or true information about the treatment that is necessary. Tooth extraction is a typical example. It must be performed in local anaesthesia. If we deceive the child who has willingly opened his/her mouth trusting us that he/she will not be given any injection and suddenly he/she feels the needle, it is no wonder that next communication with him/her will be difficult. Something similar happens when we say: “Open your mouth, I will only take a look at the tooth.” Suddenly, the tooth is extracted without anaesthesia. Interestingly, such tricks are not used in adults as they would be difficult to explain whereas in children we do not bother with explanation and there is no danger that we would be punished after all. We recommend giving the child true information about what we are going to do and adapt the level of information according to the child’s age. 2.5. Communication with elderly The dental surgery is visited not only by people at the productive age but also by the elderly. Diagnosis, treatment and prevention of complications in the elderly are more demanding for a number of reasons. Neuwirth (1998) has summarized the reasons in his illustrative overview:  A number of diseases progress differently than in individuals at the productive age.
  17. 17. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ  Body’s functional reserves and compensation mechanisms are decreasing.  The patient usually suffers from more than one disease and uses many medications.,  Symptoms of a particular disease are not as distinct as the physician may be used to (microsymptomatology).  Symptoms do not necessarily need to be specific.  Chronic pain is more common and results in feelings of exhaustion, despair, depression.  Every disease becomes not only a medical problem but also a mental and social problem. Communication with an elderly patient has its specific features which the dentist must take into account. Old age entails impaired vision, loss of hearing, impaired memory and forgetting, loss of ability to react quickly to changes, problems to cope and manage stress situations. The patient’s mental condition is gradually changing, psychopathology is developing. Old age also decreases patient’s mobility and delicate motor function. Self-sufficiency is lowered and the elderly patient becomes dependent on other people. Communication with the elderly is demanding for the physician (R. Honzák (1998)) since it may cause fear in the physician about his/her own aging, awake the feelings of helplessness if the physician is not able to treat some chronic diseases, it may cause fear from patient’s unexpected reactions, sometimes the physician may even try to avoid “wasting time and energy in very complicated cases”. In spite of this, it is necessary to communicate with elderly patients in the surgery room. Let’s look at the principles that should be respected:  Don’t hurry when treating an elderly patient, don’t be impatient. The visit to the physician is stressful for the elderly and they were preparing for it for a long time.  Speak slowly, pronounce clearly and look into the patient’s eyes. A large number of elderly people are hard of hearing and try to lip-read.  Do not use long complicated sentences and special medical terms.  When asking about the medical history, take into account that the patient’s answer may provide a lengthy description of his/her problems and diverge from the topic.  Ask about other diseases the patients is suffering from.  Write down (in cooperation with family members) the patient’s “pharmacological history”. If you want to prescribe another drug, you should know that any drug that is not vitally necessary in the elderly, is contraindicated.  Examine the patient thoroughly and give him/her a chance to take a break to rest.  Encourage the patient for cooperation and say compliments.  The elderly patient has limited financial sources. Inform him/her clearly and unambiguously about the price of the dental procedure planned so that he/she will decide see if he/she can afford it.  Take into account that it is difficult for the elderly patient to decide on whether or not to undergo radical treatment. Be prepared that it may take a long time to persuade him/her. Your arguments must be brief, clear and positive.  If extensive procedures are necessary, schedule the patient for more visits.  Realize that pain sensation in the elderly is different. Ask your patient carefully on the kind of his/her pain, its intensity, variation in time, how it can be relieved.
  18. 18. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ  If you expect complications during therapy, inform the patient (and his/her family members) in advance about it and tell him/her what he should do if complications occur. This will prevent possible conflicts.  If you have given the patient instructions and recommendations after treatment, check whether he/she have understood them correctly before he/she leaves the surgery room. Don’t ask him for the literal repetition of words but for the meaning expressed in patient’s own words.  Take into account that the elderly patient may forget. Give him a card where all important information such as the dosage of a medication, the date of next visit (day, hour, etc.) is written.  If you prescribe an important medication, make sure at the next visit that the patient has been taking the medication, and check at which intervals and doses he/she has been taking the medication. In dental practice, the physician meets elderly people more often than people with disabilities. However, disabled people also need dental care and professional handling. 2.6. Communication with disabled people The dentist also examines and treats patients whose abilities to communicate and cooperate are limited to some extent. Such patients may suffer from various disorders such as impaired vision, loss of hearing, central nervous system disorders or a combination of both. These specific groups of patients require specific treatment. Physician’s failure to deal with them may have negative consequences such as frustration in both the patient and the physician, the treatment may get complicated or cannot be completed. Patients with hearing impairment Hearing disorders may have different forms: from impaired hearing though more serious hearing disorders up to deafness. For communication with a deaf patient it is important to know whether the defect is congenital (from patient’s birth) or acquired later in life. In the former case (pre-lingual deafness), the flow of stimuli for the development of thinking in a particular person was limited. As result, the primary defect in hearing caused delayed development of thinking. Pre-lingually deaf individuals – although their mental abilities are not affected – have worse start in life. They could not learn to speak, they do not have a tool to get to know the world and themselves, it is difficult for them to recognize the richness of human culture. They learn to speak using sign language. They also learn to make themselves understood with normal people through noises whose intensity, distinctiveness and accuracy they do not perceive (they do not have acoustic feed-back). Their emotional life is rich. They express their feelings about our customs spontaneously and too vigorously as we would expect. Their outer behaviour may cause a layman to make a hasty, mistaken and very dangerous conclusion that besides being deaf they are also mentally ill. Individuals who suffered hearing loss later in life, after they had learned to speak, have more optimistic prospects in both directions. Their development of thinking in early childhood was not affected. Since they were able to hear, they learned to speak correctly. However, unlike pre-lingually deaf people, the loss of hearing is felt by them more intensively because they know the advantages of the kingdom of noises and their meaning for the full-value human life (spoken language, music, singing, acoustic signals, etc.). They are able to lip-read, express what they want and what they feel through spoken language.
  19. 19. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ Both groups of deaf people have one thing in common: they are afraid of medical visits. Besides fear from dental treatment typical of most patients they also have other fears: whether they will be noticed in a waiting room, whether the medical staff will react adequately to their disability, whether they will be able to tell the physician what problems they have, whether the physician will understand them or whether they will be able to understand the physician. Basic recommendations for communication with patients with impaired hearing can be summarized in the following points (Honzák, Pálka, 1995):  Pronounce clearly so that the deaf person can lip-read easily.  If you talk to the patient, your face must be turned towards the patient and illuminated well (to make lip- reading easy). Do not cover your mouth with your hand, do not speak outside the patient’s visual field.  Speak slowly. Realize that the patient has to decipher your words, which is demanding.  Use simple sentences.  Ask the patient about what you have just told him. Make sure that he/she has understood everything that you have told him/her.  Have your non-verbal presentation under control, avoiding impatience, aversion, agitation, anger, etc. Patients with hearing impairment can read your facial expression very well.  Be patient: examination and treatment of the patient with hearing impairment are time- consuming. It is stressful not only for you but also for the patient.  Allow the patient to rest during the examination or treatment, he/she will then cooperate more willingly.  Do not forget to give compliments, encourage the patient to establish good cooperation.  In complicated cases, use a sign language interpreter. The talk will be much quicker and more detailed. It should be pointed out that it is very helpful when the dentist knows the basics of sign language. (the basics of sign language are taught at some universities as an optional subject within the courses of dental medicine). Patient with visual impairment Visual disorders are another group of disabilities which the dentist may encounter in his/her surgery room. They can also have various forms such as impaired vision, blurred vision, vision in a very narrow visual field, differentiation between light and dark, complete blindness. Causes of visual disorders vary; they are congenital, degenerative, or traumatic causes. One advantage as compared to people with hearing impairment is that since childhood the brain of a blind person has been supplied with acoustic stimuli and thus the speech and thinking in such a person has developed without a delay. Visual disorder - particularly congenital visual disorder - can be compensated by hearing, the more sensitive sense of touch and well developed space orientation. Basic rules for communication between health professionals and individuals with visual impairment (Honzák, Pálka, 1995):  Blind people with visual impairment are normal people who are not mentally ill. Some of them have the IQ well above the average.  During your first meeting with the person with visual disorder, introduce yourself and describe your position. Realize that he/she can only hears your voice and that he/she has to link your voice with your name and position.  Use plenty of words to describe the procedures during the examination and treatment of the blind person.  Inform him/her in advance about the procedure you are going to do
  20. 20. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ next, particularly in the case of complicated procedures which may cause pain. Warn the patient with visual disorder in advance that the step you are going to perform may cause pain.  If the blind person is accompanied with a guide, it is usually because he/she needs someone who would help him/her to get familiar in the unknown environment. The guide does not act as an interpreter. You should therefore talk directly to the blind patient since he/she hears you well and understands your spoken words. If you turned with your questions to his/her guide, the blind person would think that you consider him/her disabled or mentally ill. This would be frustrating for him/her and would complicate further cooperation.  Create a suitable acoustic environment for the blind person. Turn down or eliminate interfering noise (noise from other rooms or from the outside, radio, etc.). Interfering noise may complicate communication with the blind person, acting as mist when man with normal vision wants to look around.  Move naturally in your surgery room. Do not try to walk quietly. This may cause fear in the blind person that something tricky is going on there.  Make arrangements in your surgery so that the blind person can walk from the door to the chair without difficulty. Remove all objects that may stand in the way and cause the blind person to fall (chairs, wires, cables, etc.).  Avoid expressing compassion about the patient’s disability. This will not help the patient, it would only hurt the patient’s “ego”, his/her self-confidence, self- consciousness. Patients with mental disabilities Patients with mental disabilities form a specific group of patients, including individuals from the pre-school age to adult age. Due to the nature of their disability, their reaction to examination and treatment resembles that of a child. They usually come with a guide (parents, or nurse). Basic recommendations for communication with mentally ill patients can be summarized in the following points (modified according to Honzák, Pálka, 1995):  Approach mentally ill patients in the same manner as normal individuals. Do not play a role of a parent or nurse, etc.  Adjust the communication to the extent and seriousness of the patient’s mental condition.  Try to obtain all the details from the patient’s guide that are relevant for successful communication with the patient (what the patient is used to, what he/she likes or dislikes, what he/she is scared of, how he/she reacts when he/she feels pain, etc.).  Although the guide is present, try to speak with the mentally ill patient during examination and treatment.  If the patient is an adult, do not address him/her as a child but speak to him/her as if he/she was an adult.  These patients are sensitive to non- verbal manifestations (physician’s voice, facial expressions, gestures, fast or slow movements, etc.). Do not hurry. Be patient and tolerant when dealing with such patients. Emotional wellbeing is important for both sides.  Encourage the patient. Do not hesitate to praise him/her.  Use simple sentences. Do not use foreign words and complicated
  21. 21. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ medical terms which they cannot understand.  If necessary, repeat what you want to tell the patient in other words.  Make sure that the patient understands you and that you understand what he/she wants to tell you;  Treat the patient with respect, it is not his/her fault that they have disability. They just try to live with the help of others and you must not let them down. Somatically disabled patients Somatically disabled patients have difficulties to get to the dental surgery because their mobility is compromised. They have to use orthopaedic aids, crutches, wheelchairs. Some of somatic conditions are characterized by involuntary movements (e.g. of the head) which complicates dental examination and treatment. The outer appearance of somatically ill patients is misleading because the patient’s body is deformed, and typical body shapes may be missing. The expression in the patient’s face may cause the medical professional to draw a wrong conclusion that the patient is mentally ill. This wrong conclusion is sometimes supported by the fact that somatic deformations may also affect speech organs. The patient’s speech is then difficult to understand (there are problems with speech, phrasing; pronunciation is not clear but somewhat “blurred”). Basic rules of communication between health professionals and somatically ill patients (Honzák, Pálka, 1995):  Somatically ill patients are normal people, they are not mentally ill although the outer appearance may be misleading for laymen. There are individuals with high IQs among those people.  Find out the calendar age of those patients. Somatic condition changes their outer appearance. Laymen usually fail to give correct estimates for the age of these patients. Deal with these patients adequately to their current age.  The somatic condition has worsened their mobility but they are used to it and are able to take care of themselves. Do not regret them, do not exaggerate your help when they move from one place to another, want to sit down or get up. This would be degrading for them and may complicate your future cooperation.
  22. 22. Visit Amazon's Haytham Al Fiqi Page http://amzn.to/1Uaf9Mr AUTHOR HAYTHAM AL FIQI BLOG http://bit.ly/1QdhLsZ   Check whether the layout of your surgery room and its placement are not a major obstacle for somatically ill patients (staircase, no lift, narrow doors, etc.).  Do not grumble if the patient brought mud with their crutches or wheelchair to the waiting room. It is not their fault.  Be patient: examination and treatment of somatically ill patients is demanding and time-consuming. It is stressful not only for you but also for the patient.  Do not forget to compliment the patient. It helps further cooperation.  Treat the patient with respect and dignity, it is not their fault that they have disability. They try to live on their own, without being dependent on the help of others and you must not let them down. This is all in brief about the dentist’s work with persons with different disabilities.

×