The Patient’s Perception of the
Doctor Fearful patients require a
specific kind of behavior from doctors. Janis constructed a
blueprint of such behavior based on his results obtained from a five
year study of the psychological stress endured by patients preparing
for and undergoing major and minor surgery, including operative
dentistry.
He explored, in great
depth, the emotions, needs and responses of these patients relative
to the doctors who were caring for them. The behavior of the doctors
was determined to have a powerful influence on the patients’ fear
and stress levels. What they needed from their doctors became
apparent. To begin with, Janis concluded that the patient perceives
his doctor in 2 important ways as:
- A Danger Control
Authority, and
- A Protective
Authority.
Surrounding the
perception of the doctor in these roles were strong feelings and
needs. Janis summarized them as follows:
The doctor controls what
the patient perceives as threatening or dangerous and is the only
one able to protect him from that danger. The patient facing a
threatening situation becomes anxious and looks for emotional
support. The Danger-Control Authority, able to protect him from that
danger, becomes invested with strong emotional significance. His
behavior and communications assume greater importance than would
ordinarily be expected. The patient’s ability to tolerate stress and
learn to cope with this fear depends upon his being able to develop
a sense of trust and maintain high confidence in the Protective
Authority figure. In order to do this and develop a feeling of
safety, there must be a "working through" before the patient is
exposed to what he considers dangerous. This "working through" is
the iatrosedative interview, the first interaction between the
fearful patient and his doctor. Skillfully performed from a base of
knowledge, it ordinarily should not exceed five to ten minutes.
Janis’ findings suggest 2 questions that must be answered in order
to solve the problem. They are:
- What does the patient perceive as
threatening or dangerous?
- What can the doctor do to make the
patient feel safe, that he will be protected from the danger?
The answers to
these questions are the heart of the iatrosedative
process.
The Iatrosedative Interview The
iatrosedative interview has been fashioned after the traditional
open-end interview. It begins with a question such as, "Are you
having any difficulties?" The question provides the patient maximum
opportunity to reveal what is uppermost in his/her mind; it permits
the patient to establish his/her priority of "difficulties." If the
patient elects to begin with a statement about sensitive teeth or
bleeding gingiva or a need for examination because he suspects
caries, the doctor responds to each particular cue. He will go on to
get information about the problem or need until he is satisfied that
he has all that is required to help make a diagnosis and treatment
plan.
Most patients are not
inordinately fearful and manage their anxieties well, hence the
iatrosedative interview is not needed. However, should the patient
respond with any of the many statements of anxiety such as, "I am a
coward about teeth" or "I’m the worst patient you’ll ever have" or
"I’m scared to death, " the interview should be put on an
iatrosedative course imediately.
Strategies of the
Interview Two strategies are involved:
- A verbal,
fact-finding, interpretative strategy, and
- A non-verbal,
empathic strategy
The verbal fact-finding
strategy is divided into 2 major categories:
- gathering information
- giving
information
Gathering information has a Sherlock Holmes
quality about it. The objective is to ferret out pertinent
information quickly and concisely. The first question, as suggested
from Janis’ findings, the doctor (Danger Control Authority) must
have answered is, "What is it that the patient perceives as
threatening or dangerous?" Once the patient’s fear is
determined, the second step is to determine how the fear was
learned.
Knowledge of the
learning paradigms mentioned above can be helpful at this point.
Again, this information can be elicited quickly and concisely in a
matter of four or five minutes, or less. This is not meant to be an
in-depth, prolonged inquiry.
Good information
gathering requires an adroit questioning technique, the ability to
listen and "hear" what is central in the patient’s communication and
to respond in a way that will facilitate the unfolding of the
story.
After gathering
information, the doctor switches to giving information. It is his
turn to talk and the patient’s turn to listen. In giving
information, the doctor (Protective Authority) answers Janis second
question, "What can the doctor do to make the patient feel safe,
protected from danger?"
The gathered information
is valueless unless it is sorted out and interpreted. It is then fed
back to the patient in a way that will give him insight into the
specifics of the fear, how is/was this learned and how it can be
unlearned. The doctor then states his commitment as to how he will
behave and what effect he expects his behavior to have on the
patient’s ability to relearn.
This verbal
communication, coupled with empathic non-verbal communication will
initiate a feeling of trust. If the trust is maintained and
subsequently deepened by the Iatrosedative clinical encounters, the
fear may be eliminated because fear is soluble in
trust.
Model of the
Iatrosedative Interview A simple four step
model of the above strategy is:
Gathering Information
1. Recognizing and acknowledging the
problem
2. Exploring and identifying the
problem
Giving Information
3. Explaining (your interpretation of) the
problem
4. Offering a solution to the
problem (commitment)
The following is a brief
explanation of each of these steps:
1. Recognizing and
acknowledging the problem: To respond both non-verbally and
verbally to the expression of fear. In a way as to communicate
understanding and acceptance of the fear and the intent to explore
the problem in order to help. The dentist may say, "I’m sorry,
this must be difficult for you. Let’s look at this first because
we can do something about it." This is a crucial point – a sort of
"moment of truth".
Once a patient responds to the opening
question with a statement of anxiety or fear such as, "I'm petrified
of dentists, " a simple but precise tactical design should be
operative. The doctor must progress from the general statement
of fear to the determination of what the patient specifically
fears. Eliminating or reducing the fear level is thereby made
much easier; it is virtually impossible to make a commitment
of behavior if the specific fear is unknown. Once the specific
fear is known, the next step is to learn the circumstances of its
origin.
Graphically
stated: General statement -->
specific statement--> origin of fear
The most economical and expeditious technique
of moving from the general to the specific to the origin is by the
use of brief, highly specialized questions in responding to the
patient's statements. We will label these questions as:
These "on target" questions are
succinct. The doctor at this stage of the interview does a
minimum of talking and a maximum of listening and responding.
This will be reversed when the time comes for him to give
information. Examples of these "what" and "can you tell me"
questions can be illustrated briefly as follows: