Head-on with one of those problem patients

Sept. 1, 1999
The chart for my first patient of the day disturbed me a little. Maybe it was all the red ink, the bold letters, and all the underlined words and exclamation points.

The chart for my first patient of the day disturbed me a little. Maybe it was all the red ink, the bold letters, and all the underlined words and exclamation points.

Gwen Krenz, RDH

The standard approach to problem solving is a head-on one - both feet on the floor, eyes straight ahead, chin up, shoulders squared. Face it and solve it. That doesn`t always work, or at least that`s not always the approach used. Over the years, we develop our own technique. Sometimes it`s one that involves procrastination, avoidance, denial, or, an all-time favorite, excuses. But if you happen to be in a small room with no way out and a problem is coming at you, full speed, you`d better do something fast. You can`t put it off; otherwise, you`ll be run over. You can`t duck around the corner; it`s looking you square in the face. It`s impossible to deny it, not something that big. Making excuses about it isn`t going to make it go away. You`d better approach it the best way you can; you`ve got no choice.

It was a new office, an established, busy one. I was the new kid on the block, always a scary situation. I had decided that the standard approach was best. There wouldn`t be any problem to solve that I hadn`t faced before. I had plenty of experience. I had accumulated a great deal of knowledge and had perfected my problem-solving skills through years of work. It`s called self-confidence, and sometimes it works. I had come in early that day to review my charts. Having been hired so recently, I would be seeing these patients for the first time. Getting acquainted with their history before meeting them personally is always a good idea. It`s a way to get a head start, a way to plant your feet more firmly on the ground.

The chart for my first patient of the day disturbed me a little. Maybe it was all the red ink, the bold letters, and all the underlined words and exclamation points. Along with these warnings, my appointment schedule showed that I had been given twice as much time than was normally allowed for this type of appointment. I had already discovered that time was a very precious commodity in this office - not one to be wasted, bartered, or traded. And this man was scheduled to be seen by the doctor immediately after my work was completed.

Talk about pressure and feeling like you`re in a small room with no way out! The doctor walked up to me and went straight to the point. "I see you`re looking at the very chart I wanted to talk to you about."

Not a good sign.

"You do realize that he is to come to me after you`re done with him."

I nodded.

"This patient is always allotted more time. He`s rough to work on and hard to handle."

Oh, great!

"Do the best you can. That`s all I expect. Believe me, I`ve dealt with this guy for years. That`s the only way to approach this job. Good luck!"

With that, I started to mentally prepare myself and physically prepare my room for this appointment. My mental preparation was only made more difficult when one of my fellow employees entered saying, "What a way to start your day. This guy`s a real problem. He`s uncooperative, uncommunicative, and unreasonable. Better you than me. Even with the extra time, you`re gonna run behind. Good luck."

Thanks a lot; I needed that. What about that head-on approach and all of my experience? Even with all the information and "encouragement" I was given, something was really puzzling me. There had been really only one word written continually in the chart to indicate this man`s problem. That word was gagger. Go ahead, laugh. This man had an extremely strong gag reflex. That is a problem, not an uncommon one. I`ve dealt with this problem in my line of work almost daily. It is not a problem that I would red-letter, underscore, or require a "pep talk" for.

I figured that there must be more to it, but neither one of my associates indicated anything else. I started to look at it this way: I knew more about this man than he knew of me. I had dealt with this inconvenience before and so had he. A reflex is not something you can put off, avoid, deny, or make excuses for. You deal with it.

Feet on the floor. Eyes straight ahead. Chin up. Shoulders squared. Meet and greet the patient head-on. He was a big guy. He would fill my chair and make the room seem smaller. Very little eye contact. His eyes were pointed straight ahead all right, but not in the way I`d hoped. His way was a nervous reaction, almost a kind of avoidance - as if he thought by not looking at me I`d disappear. His shoulders were broad and squared; again, not the way I would have liked. His stance indicated an anxiety, as though he was being forced to face a firing squad. His bearded chin was up, but more in an attitude of prayer or supplication, hoping to be spared this punishment. His feet? As slowly as he was moving, I thought he was literally trying to plant them where he stood. That way he wouldn`t be able to be taken to this room of doom.

I began to think that he viewed this appointment as a death sentence handed down by some heartless judge. I started to feel sorry for him. Up to this point, I had been beating my own chest and crying about my own problems. This poor guy thought he was going to die! All I had to do was clean the teeth of this man with a strong gag reflex. Think about it, whose problem was worse?

We made it to my room. I wondered if he thought the chair was electrified or if the suction was really a gas hose. It may seem funny to you, but this guy was scared! His problem was fear. An unreasonable, uncontrollable, and undeniable feeling of fear! Gosh, I could deal with that. You know ... been there, done that. The standard approach would be used. My standard approach is talking. After introducing myself, I admitted to him that I was familiar with his history and his problem, the gagging one. I said nothing about his fear. I briefly explained the physiology involved with this reflex. I then gave him a few pointers on how it can be somewhat controlled. I said nothing about the fact that most reflexes are exaggerated by stress and fear. With that out of the way, I started working and talking. Talking about anything and everything. Cracking a few jokes. Telling a few silly stories. Filling in the time and using up the time without looking at the clock.

He started to make eye contact. His grip on the suction relaxed. His shoulder position softened. His mouth formed a few tentative smiles. Yes, just a few, it`s kind of difficult to talk, let alone smile while getting dental work done. Instead of gagging, he hesitantly, when given a chance, began to talk to me. He told me about his family, his job, and his hobbies. He asked me about how I came to be working here and if I would be there his next time. He even asked me where I had learned to talk so much! I talked. He laughed. I worked. We worked. We faced it head-on.

We got the job done. We made the problems disappear. The gagging never happened, not even once. The fear subsided and went away. You know what else? The entire episode was accomplished by the two of us within the normally designated time allowance. We finished with time to spare. I knew he felt as though he had been granted a reprieve. No, better than that, a full pardon. I felt as though I had been the governor who granted it. It was great. We had both been prepared for the worst, faced it head-on, and came out on top. Our feet weren`t on the ground; we were kicking up our heels. How`s that for problem solving?

I left my room to let the doctor know that I was finished, early. Yes, I earned the right to gloat. I was stopped by the employee who had been so "helpful" to me earlier.

"You`re done already? I don`t believe it. I heard him talking to you. He never does that. What did you do to him? I heard you two laughing. How?d you manage that? How bad was he?O

Maybe I should have said, ONot bad at all. He?s really very nice.O I?m sure that this woman had been introduced to this patient in the same manner that I had. A chart full of red ink and exclamation points. She had undoubtedly received the same verbal warnings and comments from the doctor. She definitely had been given the same amount of extra time. She took it all at face value.

The problem was presented as gagging. In reality, it was fear. I?ve always looked at that as a fact of life in this line of work. It may be irrational. It could be uncontrollable. It might seem ridiculous. But no warnings will alleviate it. Time will not erase it. The only thing that can change it is a new attitude or approach.

My co-worker had been there much longer than I. She?d worked on this man many more times than I. Maybe that was it. She worked on him, not with him. How could I explain that I try to understand how the patient feels? I try to relate to the person, not the problem. I try to be compassionate. I try to be at least sympathetic if I am unable to empathize. How could I tell her that? She and I didn?t have enough time for that. Remember how precious that commodity was in this office? I shrugged and walked on to the doctor?s room.

He looked at me, then at the clock, then back at me. OYou?re done already?O

I nodded.

OWell, that?s a first. Put him in the open room and tell him that I?ll be in as soon as I can. I?m not looking forward to this. I hope I?ve given myself enough time for him. How bad was it? You know you still have more time if you need it?O

I informed him that I didn?t need it.

OI guess it?s my turn now. I?m never ready for this guy.O

You know, it was his turn. It was his problem. A problem that he dealt with for years. A problem that he?d wasted so much OpreciousO time on. A problem that he would continue to deal with and OwasteO even more time on. He had warned me. How could I explain to him that warnings would never alleviate it? He had given us both extra time. How could I explain that time would not erase the problem? How could I tell him that he had to change his attitude? How could I tell him that he needed to change his approach?

I said the only thing that I felt I could, OGood luck!O

Gwen Krenz, RDH, lives and practices in Mendota, Illinois.