Avoiding emotional negligence

AugSept12 - Emotional negligence

Caroline Holland looks at interactions in the dental setting from the patient’s perspective and explains the importance of tuning in to the patient’s needs in the event that they are injured because of a clinical mishap

Jane is an American woman in her mid 40s. She started her online blog (bit.ly/K5YX5M) after a dental appointment went horribly wrong and she became a reluctant authority on lingual nerve damage. Here is the resume of her first entry:

“I went for a routine dental visit to have two fillings. I left with a puzzling injury I’d never heard of, which would end up causing me severe pain all over my face, tongue, mouth, and throat, in addition to migraine headaches and earraches, which caused me to lose my job. It completely obliterated my social life and changed an active, happy, healthy single mom into a chronic pain sufferer who needs to be medicated to get through every day.

“(Lingual nerve) injury can happen any time a dentist or oral surgeon doesn’t take proper care. Everyone’s anatomy is different, so the nerves aren’t always in exactly the same place, but dentists know this, and are taught in dental school how to handle this and to react when a patient complains because something may have occurred to injure the nerve.

“However, in my case, my appointment was on the last day of the year, and it was a packed house, with everyone trying to get their dental work done before the new insurance deductible started for 2010. The dentist rushed the procedure and accidentally injured me, but worst of all was that he ignored my complaints afterward and all my pleading for help with the pain for weeks afterward.’

Not alone

Jane’s story is not an isolated incident, as you can tell if you read the comments from her online followers and visit the other forums and blogs on the internet. While nerve injury is mercifully still unusual, advanced dental procedures, such as implants, have created an additional risk. At a leading clinic in the UK for patients who have suffered a nerve injury, more than 70 per cent suffer neuropathic pain. Unlike other dental injuries which can usually be rectified through restorative treatment, nerve injury can be a life-long affliction.

It’s no surprise that Jane is hurt and angry. What is surprising, however, is that she appears far less upset by the accident itself than by the dentist’s lack of concern after the event. She accepts that mistakes can happen. What she can’t accept is that the dentist ignored her complaints.

Support

In line with the growing recognition that people who have suffered an accident or witnessed terrible events may need therapy to recover emotionally, there is now help available in some countries for patients who have suffered dental nerve damage. One psychiatrist, who runs a clinic for dental patients affected by nerve damage, spoke at a Dental Protection event last year. She commented that patients who are supported by their dentist tend to cope better than those who felt abandoned by the clinician responsible for the injury.

What do we learn from this? Firstly, failure by the healthcare provider to empathise amounts to emotional negligence. Secondly, the betrayal of trust which underpins emotional negligence is harder to bear than clinical negligence. We can deal with an aspect of our care going wrong but it’s much harder to deal with the clinician who doesn’t explain what has gone wrong and fails to express concern and regret.

Trust

Interestingly, surveys have been carried out which show that for the patient, the most important consideration in their choice of dental practice is trust. It’s not price, location, cleanliness, or the waiting room decor; it’s the fact that they trust the dentist and the clinical team.

I have always felt that the patient-dentist relationship, at its best, is a special one. Why is this? Why should a dentist have a fundamentally different role in the lives of their patients than, say, doctors, podiatrists or opticians?

I have some theories. Firstly, a visit to the dentist always involves an internal examination. This is not necessarily true of an appointment with other healthcare providers. For the examination to proceed, the patient must lie back in the chair and surrender themselves to their dentist. (A dental nurse will be on hand, not just to assist, but to act as a chaperone. This too is peculiar to dentistry.)

Secondly, it is extremely difficult for the patient to know if their dentist is providing excellent dental care, so they must trust this is the case. A patient’s relationship with their dentist is often stronger, more enduring and more rooted in trust than the relationship they have with any other healthcare provider.

Anxiety

Certainly, the absence of trust and a phobic response are closely linked. According to Tim Newton, the only professor of psychology as applied to dentistry, one of the most common concerns among the phobic patients he treats is trust. “Patients need to be able to believe and trust that their dentist will listen to them, respect their requests and give them a degree of control over their dental care. Often a lack of trust has arisen because of a traumatic experience in the dental or medical setting.”

Anxiety deters many people from going to the dentist. According to the UK Adult Dental Health survey, 12 per cent of people here suffer from extreme dental anxiety. And only 50 per cent of the population sees a dentist.

Positive feelings

But this article is about those of us who want to have a positive relationship with our healthcare providers. People like me. People like Jane. If her dentist had cared for her, acknowledged the mishap, attempted to put right the problem, referred her for specialist help, it’s possible he would still be her dentist.

One theory has been expounded by Eric Weiner in his book: “The Geography of Bliss.’ He argues that the best predictor of happiness is trust. If people trust the people around them, friends, and family, and if they trust their government, then they will score highest on the happiness surveys.

How do we build trust?

According to Professor Newton: “Building trust takes time and communication skills – most importantly listening and respecting the patient’s concerns, not belittling them, and planning treatment that respects the patient’s wishes. Give patients some sense of control by offering choices, such as what they would like to do first, giving them the suction to hold, a choice of music in the background (or no music), or by teaching them the stop signal.”

Given that dental patients are usually open-mouthed and unable to converse, dentists and hygienists are in a position to control communication. While treatment is under way, you can explain what you are doing, what will happen next and what the outcome will be.

Dental professionals who fail to communicate effectively – especially on cost and about choices – are unlikely to have the full confidence of their patients. My own dentist placed a filling at my last appointment without telling me it was an amalgam. I have no objection to amalgam, but I do mind that I was not informed or offered a choice.

There was no adverse outcome from my treatment, but what if there had been? What would my dentist have done then? I would like to think that she would follow the advice of another blogger, a dentist whose online name is The Curious Dentist.

He describes the “light bulb moment’ when he realised that he should not beat himself up when something went wrong, especially if the mishap was out of his control. The turning point for him was a new epithet: “Every mistake is an opportunity for greatness.”

His blog continues: “Rather than dreading to look our patients in the eye to deliver an apology, we should face them with confidence. Our confidence stems not just from our knowledge that mistakes and complications are bound to happen, but also from the knowledge that we get to show the patient our character and integrity.”

If you can only look into your patients’ mouths and not into their eyes, perhaps it is time for some training in communication and leadership? To have the trust of your patients, whatever might occur, is a privilege. You lose it at your peril.

This article originally appeared in Teamwise 13, one of the regular publications available to DPL members alongside their professional indemnity. http://www.dentalprotection.org

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