Y. Cathy Hung, DDS, DIP. ABOMS

Managing your goals and busy life doesn't have to be put on hold when you go away for a business trip. 

Do you wish you had more hours in the day? Time away from the office as a business owner is common and expected.  First, I want to say that if you choose to take some shut eye and rest while you’re away, it may be the healthiest thing you could do for yourself.  We all need to unwind! 

Upon arriving a new town, touring and perhaps venturing into a new restaurant can be therapeutic at the end of a business conference.  Business lunches and dinners help to extend your network and broaden your horizons. Aside from the “main goals” of the business trips, there are multiple different ways we can utilize time to tie loose ends.

I take car services to the airport.  During this one-hour drive, I like to pre-schedule short phone calls with different business contacts.  This could be a new vendor you are trying to establish a relationship with, or a colleague you wish to connect with.  I find this quiet one hour extremely productive without distraction. 

Or, call your mother or your best friend just to say hello. Catching up is also good for you too.

This is also a great time to take care of business or personal finances.  Be sure you are in an isolated and safe environment, such as your hotel room, and have a connection that you know is secure.

I was in the midst of upgrading my office phone system while away on a business trip. There was a lot of paperwork that needed to be signed and returned, as well as follow up phone calls to schedule for installation.  Utilize the business center in the hotel to print your documents. Download apps on your phone that have scanning capabilities.  My Tiny Scanner app on my iPhone has saved me hours of time scanning and e-mailing documents right from my phone, in turn, allowing me to get projects done without missing a beat.

Time away allows me to clear my head to refocus on my short term and long-term goals. Each person should employ a system that works for them to keep track of personal and professional goals. I personally prefer the traditional notebook planner.  I find this to be the best way for me to keep track of my goals for the rest of the year.  Ten to twenty minutes spent on my personal planner allows me to gain clarity and refocus on my next steps for the months ahead. 

I have a personal knack for traditional planners because as I look back to the previous months in my own writing, I see how many goals I have achieved within that time line. So, find the system that work for you and utilize the down time away from your hectic home life to plan out these goals and assess where you stand with them.

Reading, writing, and listening to audiobooks or podcast

If you also love to read, the time spent on the airplane is excellent reading time in my opinion.  I prefer reading business books, especially if the topics are relevant to that particular business trip. If you have a preference for audiobooks or podcast, the waiting time in the airport is also a perfect time to be plugged-in (but don’t miss your flight!)

As I am sitting in the boarding area writing this article, I hope that these little tips will help you to utilize your time away from the office. Take advantage of the time difference when scheduling for phone calls so that you could be the most efficient while away.

Articles

It's hard to find time to sit down and manage your goals and take time to address ongoing projects, but you can do all this and more in the most unlikely of places, on a business trip. 

How to Maximize Time Away on a Business Trip

Rational or irrational, patient fears and concerns need to be properly addressed before you can begin treatment.

Today is just like any other working day, you walk into the treatment room to greet the patient but before you can continue the conversation, the patient says something like this to you:

	“Don’t take this personally but I hate dentists.”

	“I had a very bad experience and now I am scared of the dentist.”

	“No offense but I don’t like coming here.”

	“I have not seen a dentist in twenty years.”

	“You are not going to hurt me, are you?”

	“I went on YouTube last night to watch wisdom teeth taken out and now I can’t sleep.”

I am sure these statements are not foreign to you. If you’ve heard one or more of these statements at least one time in your career, you are probably dealing with an anxious patient.  An anxious patient may or may not be on anxiolytic medications.

Therefore, it is important to pick up these cues prior to treating anxious patients.  Some of these initial statements may serve to raise a flag for the providers to take some extra measures in order to make the procedures go more smoothly.

Anxiety can also manifest as fear or anger, and physical signs and symptoms. The patient’s anxiety may be masked during the initial encounter, only to be revealed later at the time of the treatment. So, you may have experienced the following scenarios:

		Mrs. Smith keeps on asking how much pain and swelling she will be experiencing and if she might die from extraction sites bleeding.  You keep reassuring her, but she keeps on asking the same questions over and over again. Her husband also called asking the same questions. She had called ten times between Tuesday and Thursday. Her husband another ten. Your staff members were dreading who should be picking up the next phone call from this patient.

		Mr. McDonald told you he used to have a school dentist who was mean and took out his tooth while he was “feeling everything”. He sat there quietly but he started to tremble and sweat. You took his blood pressure and it was 180/100.

		College Junior Michael came with his mom.  Michael was on the wrestling team. He’s 6 feet and 220 lbs. He acted non-chalantly about the procedure saying, “it’s not a big deal, I can handle it.”  On the day of the procedure, his eyes rolled backwards and went into syncope as soon as you started venipuncture on him.

		Seventeen-year-old Megan said to you she didn’t do well with needles and passed out last year when someone did bloodwork on her.  As you started to work on her, she hyperventilated, coughed, and retched.  She was weeping and her heart rate was 128. 

		Mr. Ramsey had a heart attack and triple bypass three months ago. He was also a heavy smoker with a history of severe COPD. His doctor did not clear him for the procedure.  He told you “the only way I could have this done is to be put to sleep completely.” When you told him you couldn’t put him to sleep completely, he started getting abrasive and started to curse at you.

All these different scenarios reflect different ways anxious patients may express themselves.  Most people feel somewhat nervous going to dentists or doctors. Is the person’s anxiety within normal limits?  How do we determine whether it’s within normal limits or not?  Many people may not be clinically diagnosed as having generalized anxiety disorder; some may be dental-phobic. Others may be already on anxiety medications but still feel anxious about the procedure. 

I recommend a 6-step approach in treating the anxious patients in your dental office. Ask the patient to take a deep B-R-E-A-T-H with you.

Step 1. B for Body language/non-verbal cues

Someone who may be anxious may be touching or holding themselves in the chair, crossing their arms, sitting forward, moving back and forth, looking around, or moving away from you. You may notice the patient looking pale or possibly diaphoretic. The patient’s blood pressure and heart rate may be elevated, and hyperventilation may be present. A Fight-or-flight response is triggered making an anxious patient excessively talkative, or excessively quiet. 

There are different coping mechanisms to anxiety for each and every person. As a provider, keep your voice low, speak slowly and reassure the patient that you are only talking. Ask the patient to try to take a deep breath and sit back. Continue to reassure the patient throughout the procedure as you keep track of their body language throughout the process.

Step 2. R for Review of Systems or History of Present Illness (HPI)

During your initial consultation with the patient, ask the following questions:

		What exactly bothers you about the procedure? (Sounds, vibration, not getting numb easily)

		Have you had any unusual situations or bad experiences with dental treatment in the past?

		When was your last dental visit? What was done?

		How did you do with your last procedure?

		Are you currently taking any medications to help with your anxiety?

		Do you want to talk to a provider about your anxiety?

Knowing about what happened with the previous visit helps to navigate the root of the cause for the patient’s anxiety. Many times, I find that just by talking it through, I bond with my patient and develop an initial trust.

I once had a patient who was very nervous about being reclined too far back. He simply told me “I went into a panic attack when my dentist dropped the chair all the way.” So, I kept him in more or less of an upright position and he responded well to the positioning.

The key to a successful outcome will be to establish healthy expectations as close to the reality of what you can achieve and what you can’t. If this patient is very anxious but his or her medical conditions do not support deep sedation or general anesthesia in the office, state so. Offer alternatives with lighter anesthesia options and shorter procedures. Very anxious patients should be scheduled for shorter visits. Gag reflex may be more pronounced and exaggerated with anxiety. Avoid aspiration by sitting patients in a slightly reclined position.

Step 4. A for Anesthesia or other adjuncts to reduce anxiety

Enteral sedation and/or nitrous oxide, if not contraindicated, are good adjuncts to local anesthesia to help manage very anxious patients. I perform intravenous sedations in my office.  Many patients are in fear of venipuncture. I will put the patient in the Trendelenberg position to avoid decrease of blood flow to the brain which can cause syncope or seizure activities in an anxious patient who has been NPO (nothing by mouth) for 8 hours prior to procedure.

I may decide to use 100% oxygen delivered via mask or nasal cannula, or to give nitrous/oxygen mixture to shift the patient’s focal point. Various anesthesia modalities are means to help manage anxiety but should not be relied on as the only way to manage anxiety. 

In some other patients, having something to squeeze during the procedure helps.  It could be as simple as a pillow or a stuffed animal. Some patients bring in their own stuffed animals from home. Some offices utilize sunglasses. I allow earphone in one ear for some patients as long as they can hear me as well. Some offices will even offer massage chair and hot towels to achieve a spa experience. All these measures will help to reduce anxiety.

Take your time during the procedure. Schedule shorter procedures and take small breaks in between if possible. Many anxious patients also gag easily. I use a smaller biteblock and take some small breaks in between each step of the procedure.

Distract the patient a bit by using humor. I might ask about the patient’s occupation, field of study, or a trip that a patient just took. I might decide to throw a story in or to talk about something my patient and I have in common. For example, I saw a patient who had my same birthday and also was a fellow piano player as I noticed his cell phone cover being a piano keyboard.

This little conversation carried a long way. Use humor to relate to your patient on a personal level, in addition to telling them “you are in good hands”, can really help to make the patient feel comfortable, and trusting, with you personally.

I hope you find this 6-step process helpful. Let’s take a deep breath and get through this together!

For more insight on addressing patient concerns, read on 

In order to properly care for all of your patients, you need to address their concerns, especially their fears. This simple 6 step process can help you talk to your patients through their treatment and get them to trust you for future visits. 

Take a Deep BREATH: A 6-Step Process to Management of Anxious Patients in the Dental Office

Elderly patients require extra care and consideration when crafting a treatment plan for them, so listen to what they have to say. 

As life expectancy increases, it is important to know how to manage geriatric patients, especially the very old (80 years old and up) in the office. In my own practice, it is not uncommon to see elderly patients as I have quite a handful of 100-year-old patients walking in my office for treatment with a set of natural dentition and very little health problems!

In order to keep these patients healthy, and keep them coming back to your practice, it is important to listen and respond to what they are saying. Here are 6 of the most common remarks I hear and how to handle them.

Many geriatric patients wear hearing aids.  When I examine the patient, I position myself at eye-level with the patient in a sitting position and speak clearly and slowly when delivering my message. Many elderly patients are accustomed to reading lips, so remove the mask you are wearing and sit closer. Use simple words when speaking to make lip-reading easier. Repeat your messages and write down instructions for them regarding their treatment or next visit.

2. “I take a lot of medications and I can’t remember what I am taking.”

Patients may be accompanied by family members or a nursing aid to help answer questions. When making an appointment over the phone, have the receptionist indicate that you would need a complete list of medications to be brought to the office for the initial visit. Any recent hospitalizations need to be noted as elective procedures may need to be delayed. 

Ask additional guiding questions when reviewing history, for example, many patients put down Coumadin on the paper without specifying the reason why they are on it in the first place; whether Coumadin was prescribed for atrial fibrillation or mechanical heart valve placement. Asking additional questions can help establish risk factors in the overall medical picture. For example, INR of patients with atrial fibrillation are maintained between 2 to 3, versus 3 to 4 in patients with mechanical heart valve placement. Often times, someone with mechanical valve placement needs to continue coumadin throughout the peri-surgical period. Risk for bleeding is therefore increased. Request a medical evaluation if the history is not clear or if medical clearance is needed.

3. “I have arthritis and I can’t move my neck.”

Osteoarthritis and the presence of cervical hump can make positioning of X-rays difficult. Postural reflexes are weaker, making falling more likely. Elderly patients often have decreased GI tone which also makes swallowing more difficult.  Xerostomia is common. The combination of these factors translates into longer time getting in and out of chair. It is imperative to have a staff member standing by the patient for fall prevention.

I typically like to sit the patient in a slightly reclined position when performing a procedure and prop their neck with a small roll. As swallowing is usually more difficult in elderly patients, aspiration and coughing would be more likely during the procedure. Therefore, a nearly supine position is not recommended. Airway protection is paramount.  Use of mouth props and throat pack can prevent aspiration and stabilize the jaw especially for those who have essential tremor or Parkinson’s disease. Watch for orthostatic hypotension when getting them up from the chair.

Patients who are wheelchair-bound should stay in their own wheelchair during examinations and X-rays if mobility is an issue.  In our office, we always ask our patients if they can stand, and how long they can stand holding themselves, to determine whether this patient should be moved to dental chair.  Use of headlights, tracking lights, and portable x-ray devices such as 

 are useful to aid examining these patients. If the patient is to be transported to dental chair have one person standing on either side of the chair when transporting the patient from the wheelchair to the dental chair to prevent them from falling.

I prefer to schedule elderly patients early or midweek. In my office I perform sedation in the morning; therefore, geriatric patients are often scheduled in the early afternoon. When certain comorbidities exist, such as renal failure patients receiving hemodialysis on a Monday-Wednesday-Friday schedule, I find that Tuesday early afternoon is the best day to schedule such patients for surgery in my office. For those who are on anticoagulants for various reasons such as atrial fibrillation or coronary artery disease status post stent placement, I prefer to schedule these patients earlier in the week and earlier in the day.

In rare instances where delayed bleeding occurs after surgery, the patient will have a chance to return to the office before the end of the day. Even just supportive care like offering more gauze packs and reinforcing post-op instructions gives an additional layer of security. After-hours phone numbers should also be available to these patients. 

Schedule and perform shorter procedures if possible. Due to increasing time in communication and transportation, a half an hour procedure might turn into 45 minutes or an hour of your office time. Make sure to schedule these appointments at a time where you have enough flexibility to deal with any changes.

Elderly patients have decreased cardiac and pulmonary reserve and increased sensitivity to local anesthesia and other medications. Many are on various different home medications.  The presence of comorbid factors can make anesthesia riskier. In my office, very old patients (80 and up) usually receive local anesthesia only for their procedure. From time to time I receive requests for full-mouth extractions under general anesthesia on an elderly patient. I typically break up the treatment plan into multiple visits without deep anesthesia.

As a general rule, the patient’s age should be inversely proportional with the number of anesthetics used per procedure due to physiologic changes.  I perform more infiltrations instead of IAN blocks on elderly patients to avoid palpitations from inadvertent intraarterial injections. So, inject slowly and allow breaks in between.

One time, I saw an elderly gentleman with a history of labile hypertension with systolic as high as 200 and as low as 40 at unexpected times. He was sent to be treated in the hospital setting as it would be safer for this particular patient. For management of anxious patients consider enteral sedation and/or nitrous oxide, but reduce the dosage on the anxiolytics to avoid over-sedation.

6. “Can you have the prescriptions delivered?”

Often times, geriatric patients in my area have home medications delivered by a local pharmacy. There is a “routine” and the pharmacy know these patients well.  It is important to find out the delivery time schedule. For example, I treated a patient who needed anbiotics and pain medications to be delivered. When the pharmacy was called we were told that the delivery of medications wouldn’t happen until the next day. Under those circumstances, I would dispense a limited amount of medications from my office to get them through the night until medications are delivered.

Many geriatric patients are taking multiple home medications, so be sure to check for drug interactions.  Choose medications with a wide margin of safety, and the least frequency, to ensure patient’s safety and compliance.  For example, Amoxicillin 500mg TID may be favored over Penicillin VK 500mg QID because patients may forget a dose here and there. Z-pack is a great alternative for its once-a-day dosing. Medications with wide safety margin should be written in such a way that they are taken during waking hours. 

For example, Amoxicillin 500mg may be divided up to be taken with three meals (TID), rather than every 8 hours (Q8H).  It is not necessary to have patients wake up in the middle of the night to take medications with wide safety margins. I had an elderly woman with severe osteoporosis showing me a Q8H antibiotic prescription. She was waking up in the middle of the night to take the medication in fear of developing the infection. If she falls, the consequences are far greater than the possibility of getting a dental infection.

Taking care of geriatric patients require us to take extra steps. Many seniors live alone. Some have part-time or full-time aids. Others might live in a nursing home or assisted living facility. Knowing their social disposition ahead of time helps treating them safely and efficiently without major delay, confusions, frustrations and interruptions to your daily flow. Asking patients to fill out office forms ahead of time and to bring in a list of medications will save you time. Ask guiding questions during health history review and allow more chair time to position the patients. Most importantly, all of your office team needs to be trained on how to adapt to these specific needs.

For more practice management tips and insight, read on 

Elderly patients require you to make extra considerations when treating them, and they will also surprise you with what they might say. Here are 6 of the most common requests you may hear from these patients and how best to handle them.   