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Reflection of a Foundation Trainee: Managing the Difficult Patient

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Reflection of a Foundation Trainee: Managing the Difficult Patient

Katy Martin studied at University of Sheffield and qualified in 2014. She is currently a foundation trainee in London on the UCL Eastman training scheme. Katie is starting a dental core training post in Thames Valley in September 2015.

Katie wanted to write this article to share the hints and tips that she has picked up over her foundation training year and to help other trainees manage the difficult patients that we are not always prepared for.

This article discusses the management of the everyday patients you will encounter as a foundation trainee and some hints and tips I have picked up along the way. Treatment is not always straight forward and we have not always been fully prepared for the 'difficult patient' in our undergraduate studies.

So five years of lectures, OSCE's, exams and coursework are over and you are finally a dentist. What follows is a rollercoaster ride of challenge and excitement, with a sprinkling of frustration and occasional disappointment. Practicing dentistry is like passing your driving test; the real learning begins once you have that BDS after your name. Every patient is unique and each will bring their own blend of expectations, wants and emotions. Here are some tips from my year as a foundation trainee in London which I hope will provide you with some insight into how to manage difficult patients.

The Anxious Child

Undergraduate training provides a broad basis for dealing with difficult patients across all age groups, but perhaps the most challenging is treating the anxious child. Break the appointment down into small steps, rather than panicking about how on earth you are going to restore that cavity on a four year old.

Firstly build a rapport with the child; let them see that you are just a normal person too. By speaking to them on their level, you can establish why they are anxious and use the appropriate distraction techniques; ("Peppa Pig goes to the Dentist" is a lifesaver in this situation). A little research into the latest children's books, TV programmes or online games will not only help you to engage with the patient, but also reassure their apprehensive parent.

Utilise the child's eagerness to learn. I find that children love to be involved in their treatment, whether this be counting to ten whilst waiting for a tooth to be acid etched, or acting as your helper by holding a cotton wool roll and passing it when you need it for that fissure sealant. By turning treatment into a game, the anxious child suddenly becomes a pleasure to treat.

Be realistic with your treatment; if a child is very dentally anxious and requires complex treatment, always consider referring to community or secondary care. This may be in their best interest and will prevent this anxiety continuing into adulthood.

The "You Look Too Young to Do This Job" Patient

You will hear this phrase regularly in your first few years of practicing. Many patients are aware that you are a foundation trainee before they even walk through the door and often question your ability, purely because you look young. Be confident – patients can sense anxiety, particularly if they are nervous themselves. Try not to be defensive when they question your ability; instead politely but more importantly CONFIDENTLY reassure them that despite your age/appearance, you are a fully qualified dentist and capable of carrying out their treatment.

I have found that by the end of treatment, these are the patients that tend to be the most grateful, especially if you spend that extra time explaining treatment options, listening to their concerns and ultimately providing good dental care.

The Dentally Anxious Patient

You will hear the classic line "I hate the dentist" on an almost daily basis and this provides challenges to delivering quality dental care. Firstly try to establish the cause of the anxiety; a previous bad experience, a phobia of needles, fear of the unknown... Once you have established the cause, you can plan your treatment accordingly.

Remember you are treating a person, not just a tooth. Many of these patients appreciate the extra five minutes taken to discuss their anxiety. It helps remind them that you are human too. If patients don't like the noises associated with treatment, advise them to bring their own music to distract them from their surroundings. The use of topical anaesthetic is paramount in the needle phobic patient; not only does it make their treatment more comfortable, but the patient remembers their visit being 'not as bad as they thought it would be' and return to you with a new found trust.

Do not underestimate the power of knowledge; often the biggest fear for patients is that of the unknown. If patients do not understand what is involved, the best visual aid is their own teeth through radiographs and clinical photographs. It is a good talking point for patients whilst drawing them into their own treatment. It is important they are always offered alternative ways of carrying out treatment - not only to manage their anxiety, but to obtain valid consent – for example referring a phobic patient for extractions with the use of conscious sedation. And most importantly, document this discussion.

The Patient who Pays

Discussing costs with patients is difficult (even with NHS treatment) as it is something we have had little exposure to as an undergraduate. Simply asking a patient if they are happy with an amalgam filling or metal crown prior to treatment prevents a huge headache later on; there is nothing more heart sinking than a patient asking for a white filling after you have prepared an amalgam cavity. Always check first, and offer all available options with costs in your treatment planning stage.

Learn from the best. I have found observing my trainer discussing treatments with patients without 'pushing' or 'selling' gave me hints and tips for the best ways to refine my own work. Most importantly, practice makes perfect. Use this year whilst time is on your side.

The Patient with Unrealistic Expectations

It is crucial that before treatment starts, your patient is fully aware of what you can provide for them and the results they can expect to achieve following treatment. A discussion of the patient's expectations in the planning stage is time well spent. It is better they know at this stage what can be achieved and not at the end of treatment when they have spent considerable time and/or money coming to see you for what amounts to unattainable expectations on their part . Treatment is a two way street. If a patient expects their advanced periodontal disease to be cured overnight with no input from themselves at home, you are fighting a losing battle from the offset. This year you have an experienced trainer on your side. If you're unsure - pick their brains.

The Patient Whose Treatment Does Not Go to Plan

There is a reason we have a training year – things do not always go to plan. A perforated molar endodontic treatment, a crown preparation where you just can't get that perfect taper, or a lower complete denture that just won't stay in all contribute to those head in hand moments. Don't worry. Speak to your trainer and most importantly have an honest conversation with your patient. Tell them you are seeking a "second pair of eyes" to ensure they are receiving the best treatment possible.

Make sure your patient is fully aware of the risks and benefits of their treatment before you start, and that this is documented in their records. Identifying risks which ultimately do not occur is a great result in the eyes of the patient and builds their confidence in you as their dentist. Of course things go wrong, but most patients are understanding if they were warned before treatment. More often than not, these patients say "oh yes, you said that might happen". It is all about managing expectations, being honest when things are going wrong, and learning from these experiences.

This year you have the huge advantage of time on your side – it is the perfect opportunity to hone your communication and clinical skills, and get your record keeping up to scratch. We have all read textbooks on how to deal with these difficult situations, but practicing in a clinical setting is very different. Practice makes perfect, and soon you will be doing these everyday things without even thinking (just like driving a car.)

The most important message is to have fun and enjoy this year – it really is a fantastic opportunity and the more you put in, the more you get out.

Katy Martin


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