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JMI Hero Phobic Patient Care Dr. Louis Siegelman built a practice in New York on the foundations of listening and caring. He is praised for his "excellent sedation dentistry for phobic patients...how he listens and cares about anxiety," by Cathy Jameson, PhD., who has worked with thousands of practices worldwide as president and CEO of Jameson Management, Inc. Below you’ll hear words from Dr. Siegelman himself, who was interviewed for this article shortly after his sister went through cancer surgery. "Health professionals are not focused on pain control. I think that the doctors don't really feel the patient's pain and very often they don't seem like they even care. My sister had her staples removed and was given a cream - EMLA cream – a mixture of local anesthetics that penetrate where other things don't. She got this oily cream two hours in advance. So, she didn't feel a thing when the staples were removed. There are so many ways and strategies to address the patient's discomfort and there are so many tools that can be used. But dentists have to want to have those things in their tool box so they can pull them out when the patients need it. Dentists today don't have a lot of things in their tool box. In dental school, you learn if you give this injection, you get 98% success rates for pain control. But they didn't tell us in dental school what to do with that remaining 2% to feel better.” LISTEN “I tell my patients that I want them to tell me how they feel. If they're not comfortable with plan a, we have other plans. I try to have a lot of different options because people are different. Dentists just aren't trained to have these other adjuncts. A dentist gives local anesthesia and the patient says “I still feel it.” So, the dentist gives more anesthetic. Then, if the patient is still uncomfortable, the doctor gets frustrated and it’s a bad experience for everyone. DON’T PLACE BLAME OR JUDGE “It's not the patient's fault or the dentist’s fault! Don't blame the patient for their disease or be hard on yourself for not having a perfectly smooth visit every time. Instead, focus on helping the patient with their disease. I had a patient who told me that she used to be a high level administrative secretary before she slid into paranoid schizophrenia. She had a fairly severe dental phobia beforehand, but it was now very severe. She would do everything to frustrate your ability to care for her: coming late, no-showing, etc. One night she was really very trying. It was a Friday night and everyone wanted to go home. She was supposed to be in at noon and she came in at 5:30. She said she had pain and I noticed a white powder around her nose, which I thought to be traces of the cocaine she’d used to be able to even walk through the door. When I asked her, she said it was from donuts. When she saw my expression of something like ‘oh, please’, she looked up at me with this sweet expression and said ‘you can't punish the patient for their disease.’ I’ll never forget that moment, but there I stood wondering what to do with this woman. I’ve learned, over the years, that there are so many incredible cases of seemingly impossible circumstances but they all have someone with a need waiting on the other side of the perspective. There are so many different things we could do.” EXPAND YOUR TOOL BOX “So, they gag, have anxiety problems, can't get numb with normal anesthesia treatment? Don't punish them but be a real doctor. You’re not a tooth jockey who can offer them only the tools from your box, but you’re a real doctor focused on truly helping each person. The gratitude of that patient will more than repay you for the time and effort you spend to have those tools. You really have an ability as a dentist to change someone's life and when you can do that, it's really worth getting up in the morning. For instance, I try to speak with phobic patients on the phone before they come in. Making that connection and proving that you’re easy to talk to and anxious to listen and help them get better will prove invaluable to the entire process. People who are really apprehensive have suffered at a dentist’s or dentists’ office before so there’s an embedded lack of trust that results in tremendous avoidance. You have to invest in helping them overcome that avoidance and feel it’s safe to come in. One patient I talked with on the phone recently said her teeth were in terrible shape, but she was so afraid. I told her I would not use a pick like she’d been exposed to before. I told her we could knock off unclean areas using blows of air. I told her ‘I'm going to take a look with my hands and a plastic mirror. I will never criticize and it won't be a hard appointment.’ Many dentists will look inside a patient’s mouth and say ‘Oh, my. And how long has it been since you've been to the dentist?’ and the patient feels so embarrassed. We're more social creatures than we realize. When your teeth really get bad, the fear of what someone would say is overwhelming, even beyond the fear of pain. You may be wondering, how bad can it be? We’re dentists, we’ve seen it all. But there are needs out there beyond most dentists’ imaginations. Since I’ve worked with phobic patients for a while, I’ve seen situations where people try to take out their own teeth, glue their teeth in and virtually go through anything to avoid professional dental treatment. But, that patient I talked to on the phone did keep her appointment. She came in dressed in sweats with her unkept hair falling in every other direction. She was right – her teeth were in terrible shape. She’d been gluing them in, so her teeth were like a rope bridge of different glue types. She works with the blind and didn’t care too much about her appearance, but she needed full upper and full lower work. I saw her seven years ago and she wasn't ready to proceed with the full extend of needed treatment. I told her I could make her some transitional dentures and clean things up for her. Then, we could eventually do the full uppers, in which case I would still make these transitionals. I told her ‘we can do these transitionals and agree to do the full work but we just won't put a date on it. When you're ready to proceed we will.’ She's never proceeded, but I took out the terrible infected teeth and left in what we could. We cleaned her up extensively. The transitionals made her smile look much better. She has since then started her own business, going on dates and living a more full life. She comes in dressed nice with combed hair, quite a difference from our first sight of her. She’s telling me “oh, you have to get tickets to x and y show.” She goes out and has a social life. That's a big change and it’s awesome to know that we helped make that happen. WHAT THEY WANT MAY NOT BE WHAT YOU’D ASSUME THEY WANT Another girl was referred by a psychologist because she'd been molested under anesthetic by a dentist. So, at first, we just met. The patient cried for a half hour and I just sat there. We didn't talk very much. It seemed that she just needed to be clear about her circumstance and learn to get comfortable in the presence of another dentist. At the end of this first meeting, I just gave her a really big hug and left for the day. I was completely floored and had no idea how to respond. Like my previous story, she had also been gluing her teeth in. She said she could not give her teeth to someone because evidently the guy who violated her held on to her teeth and told her that, if she cooperated, he'd give her her teeth. She desperately wanted to be whole and wanted to get her teeth fixed, but she didn't want her teeth pulled. So, I measured the teeth so I can make replacements the same size. She held them while I measured them. So, together, we created a full upper denture in spite of this tricky circumstance. She didn't want a correct denture, but rather just to be restored back to the way she looked before. So, listening to her was the only way her needs would be met. Any dentist would’ve looked at her case and thought upper dentures would be ideal and vastly improve her appearance. But, that’s not what interested her. We must listen and keep in mind that, what we think as dentists may not be what's in the patient's mind. She wanted to feel like ‘this is me’ when I put in the denture. At the end of treatment, I took them out of the room to polish them and she reminded me how huge of a break through this was. We ended up doing full upper implants and she was thrilled not only to regain trust in someone but be restored dentally and cared about as a person.” During this JMI Hero interview, it was clear that Dr. Siegelman could give example after example of phobic, extremely difficult patients. “Patients come to me after having kicked, hit and bit dentists; gone into anaphylactic shock in the dental office; ran out of the office with the bib on, etc. These are actually common notes in my patient files. It's interesting and if someone comes in and is not that way, I'm honestly not as set up for them. I'm really set up for the higher demanding people. I never look for ordinary people, but am completely promoted as the dentist for the apprehensive,” he said. So, how did he get into this niche, you might be wondering. And, even then, how did he grow to be so great at treating such a unique patient family? Dr Siegelman said, “I went into this field with no idea of what it would be. I was interested in anesthesia and I liked being in the hospital. I thought all that was interesting and challenging. I didn't want to be an oral surgeon because everyone who did got divorced and I wanted to stay married. Then, there I was, practicing dentistry for apprehensive patients. I found that I had a lot of former POWs, some of whom had been captured by Kongs or North Koreans, lived in a hole for a year, etc. I started to learn a lot about post-traumatic stress syndrome associated with Vietnam. I broadened that definition to see that people who weren't necessarily in combat still had past stresses that made them behave like post-traumatic stress folks: closed, boxed in, contained, quiet people. I focused on understanding my patients early on. Most had bad experiences as children at dentists. With time, I got better and better and better at tapping into the closed people to find out what makes them tick. A major group was people who were victims of abuse. They grow up with a lot of morbid conditions and end up with any kind anxiety disorder. Dental phobia may not be their main concern, but it's just a sideline of some other type of fear or anxiety disorder. For example, I just treated a woman who has an anal, rectal chronic pain problem. She’s very high strung, doesn't go to sleep, is controlling and obsessive compulsive. So, as you can imagine, everything takes a long time. She has to go to the bathroom for long periods. She gets up and just walks out and we know not to judge her because she has a history of abuse. She’s grown up with anxiety, depression…many issues that are caused by something terrible in the past. Doing this for more than 20 years now, I’ve gotten better at picking out and knowing the root of it all, almost like a math problem. Intuitively, I just listen and in the subconscious of my mind I think there’s a little calculator figuring anxiety level like an 8 out of 10, history adds up to a 4, so I'm missing another 4…what is that?...keep listening. Where does that come from? No, this isn’t a form or anything I actually calculate. I’m just trying to clarify how my brain works as I just sit and listen. I have a feel for when I’ve tapped into all real issues relevant to their treatment. I delve a little bit and delve a little bit and try to understand them. My effort to understand gives us a bond. This person, for example, is a nice woman who’d been divorced three times in addition to her other traumas. To work on anterior crown & bridge, I put her to sleep with no issues. When she woke up, she was really, really mad at me. I was obviously very bothered by that. I’m bothered ten times worse if someone doesn't like me than if they stiff me on the bill. So, I gave her time to cool off and then I called her. She said ‘a dentist's office is not a great place for me. I'm sorry.’ I said ok, no problem but decided not to give her as much anesthesia next time so her anger emotion would not be as easily provoked due to the tranquilizer. I treated her the next time and she woke up at the end mad again. So, again, I gave her a couple days, called her and she gave me the same answer. You see, sometimes my patients have issues they don't even realize are issues. So, back to square one: listen and care! ‘Is it possible that we're touching on an issue related to your teeth that we're not aware of? Did something happen somewhere else in your life that seems unrelated but might be coming into play?’ ‘No.’ Silence for 40 seconds. ‘Well, you know, when I was six, my dad kicked me down the stairs and knocked out my front teeth. After that, I had to lie there and get fixed and then wake up and lie to the dentist about it. He continued beating me up until I was old enough to beat him up.’ This information enabled me to switch gears a little bit and go back to the old tool box to see what might be a better fit for this patient. I gave her a medication called Clonidine which is not a tranquilizer, but a stress-blocker. With that, she was much better. I completed her crown & bridge and, while she did say something argumentative, she didn't leave near as angry. We just smiled at each other because she knew I knew why she had to get that out. There are those that are fine for all visits and then come in angry for an adjustment on a partial. In one case, I adjusted the partial while she was asleep but when she was awake and standing she wouldn't allow me to do any other adjustments. Even though I could do that in my hand, she would not allow it. She took out the partial, threw it in the floor and stomped on it. Andrea, who was a new employee, couldn’t imagine what was going on. In any case, we find that the most bizarre things happen on somebody's first day. I do have such a great team, and I’m sometimes amazed that they come back. I guess, like me, it’s rewarding to make a difference in light of such great challenge. We had a couple come in and write on their health history form that they smoke heroin. They looked like bag people. My partner wanted nothing to do with them. I talked to them and found that they have a child, an auto body business and freely admit to using heroin. I told them that I can't do IV sedation because of this drug history. But, I was willing to try to help. Their teeth were all twisted and sticking out in all different directions. They had multiple cists the size of marbles showing up on x-rays. Their dry, wiry hair was uncombed atop their skinny bodies. They’re Howard Stern fans. I wore three pairs of gloves, used a local anesthetic only and completed extractions even though the root would just fall into the abscesses of the bone. Each time I'd see them, they’d look a little bit better and then they actually cleaned up pretty nice. The wife was able, without going to drug rehab, to get off drugs. The husband went to rehab and got off drugs. She got an upper roundhouse, crown & bridge and then went back to school. She became a teacher and the child has grown up ok. Their life drastically changed and they got a divorce, but he is now remarried. "They didn't know where to start in turning their life around, IN SUMMARY Whether you’re dealing with extreme patients like Dr. Siegelman’s or a more common patient family mix, something makes your patients tick. When he was new at treating phobic patients, he may have spent five visits getting to know his patients and waiting for trust and avoidance barriers to fall. Now, he can usually get to that point during the first meeting. Imagine what you can do if you just listen that closely to your patients. “When all else fails, just put one foot in front of the other and try. Keep trying. They deserve your effort,” said Siegelman. “Listen-don't deny the patient's reality. If they say they feel it, we need to have the tools in our toolbox to change our tactic. Don't just argue and tell them it's pressure. Meet them where they are, accept them for who they are and what they say,” he said. See dentalphobia.com for Dr. Siegelman’s articles and writings including one on “what is dental phobia".
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