The Elephant in the Operatory: Understanding the Psychosocial Impact of Covid-19

by Pat Mc Bride, PhD, CCSH

As we reopen practices and return to the business of providing care for our patients, no one has a clear view of how the Covid-19 pandemic will play out. Mandated closures of many practices across the country have led to unprecedented revenue declines, stress, and anxiety across the field. Dental Sleep Medicine providers, regardless of economic concerns, must focus on the changed emotional and psychological well-being of each patient.

Providers and their staffs are presenting care paradigms that include expanded safety precautions and changes in care provision e.g. possibly not polishing at hygiene appointments and no contact billing/front office policies. Patients who have been waiting for months to see you are intrinsically different from their last appointments. You are, too. They are eager to reconnect now and share their experiences of the last few months with you. Remember, many people, especially those who have been distancing from others alone, will be eager to engage. It will be a sound investment for you and your practice if you deliver a sincere connection that confers a high level of care and understanding of the struggles individuals have experienced in recent months.

While it may take some time, most practices can recover and even thrive in the post-pandemic world. Covid-19 cannot stop dental decay, periodontal disease, or sleep and breathing disorders from affecting our patients health and wellbeing. However, you can. Unfortunately, while patients need you, many providers must deal with numerous attendant anxieties related to reopening offices – PPE shortages and price gouging by suppliers, patient inability to return to the clinic due to economic reasons or out of fear, and staffing constraints as employees decline to return to work. On top of these urgent concerns, it will be imperative that providers critically evaluate how they are coping as well as assessing how patients and staff are faring psychologically, physically, and emotionally during these turbulent times. No one sees the world as they once did, and it behooves providers to acknowledge this elephant in the operatory.

Mandated quarantining meant that every person had to suppress profoundly human and evolutionarily hard-wired impulses for connection and touch. Never in our collective experience have we been forced to forgo basic social interactions such as weddings, school, graduations, funerals, sporting events, and worship and replace them with online substitutes. While physical distancing is intended to protect our physical health and slow the spread of disease, the unintended emotional, relational, and spiritual consequences on individuals and communities is largly unseen. But it is present.

Prolonged periods of enforced physical separation are sorely testing our collective capacity for cooperation as evidenced by the “busting out” behaviors observed across the country. The concept of social distancing suggests social isolation which is why we should be mindful to shift the term to “physical distancing.” When we must be physically distanced from others it is imperative that we remain accesible and socially available to them. This is true of patients, staff members, and others in our social spheres. Segerstrom (2010) noted that when faced with illness or infection, human beings and other animals naturally withdraw as an adaptive response to conserve energy. This natural withdrawal is not the same as prescriptive distancing in the absence of symptoms or disease which can actually increase the likelihood that individuals may become ill – not from coronavirus, but from something else like depression or heart disease. A meta-analysis by Julianne Holt-Lunstad (2015) determined that chronic social isolation increases the risk of mortality by 29%. She also noted that there is a connection between perceived social connectedness and stress responses. As providers reengaging with our patients, we will need to understand that there is an enormous variation in individuals’ abilities to handle the isolation and its related stress. We can begin doing this by recognizing the aforementioned elephant. It’s real.

Heather Servaty-Seib’s (2014) loss gains framework may be a means by which we can conceptualize the unique impact of specific life events such as coronavirus on our own lives and those of our patients. As we reach out and reconnect with patients to reschedule appointments, we should be particularly attuned to tone. Schedulers trained to get people on the book and off the phone in two minutes or less will need to stop and truly listen to the patient. We must remember that grief is not only connected with death. It is a multi-dimensional emotional, cognitive, physiological, social, and spiritual response to myriad types of loss. There has been a loss of community and established routines accompanied by inhibited freedom of movement. Other tangible impacts include access to resources such as food and meal programs for underprvileged kids in schools that are now closed, planned activities and celebrations, increased marital discord, inability to see primary care physicians and dentists in person, and child care disruptions. The occurrences and their severity run the gamut. Postponement of a long-awaited DMV appointment for one 16 year-old aspiring driver was cause for more than a few bouts of hysteria in our neighborhood. As providers, we must be cognizant that any and all of these losses are real.

Fortunately, dental providers typically spend more minutes per patient than any other healthcare provider which uniquely positions us to help patients identify gains as well. Recognizing that many professionals work long hours and yearn for more time with their kids, this mandated hiatus can be considered a huge positive. Okay, home schooling your teenager may be exasperating – and had you Googling the Pythagorean Theorem caluculator on your phone in the other room, but in the greater scheme of things, it’ll be totally worth the time spent together. As a new normal emerges, it’s unlikely we’ll have these opportunities again. We will all become “too busy” again. It is vital that we seize these opportunities and reap the benefits while we can. And it is important that we reflect this positive mindset to our patients.

Next to touch, the human voice comes second in importance for our well-being. People long for connection right now. Don’t make the mistake of having text or computer appointment confirmations for the foreseeable future. While texting is expedient and asynchronous, nothing can replace the hormonal responses we get from hearing the human voice. Hearing the familiar voice of your scheduling staff may be a healing balm and set the tone for the next visit when you can reconnect in a truly meaningful way. During this initial conversation, provide clear expectations as to what the patient will experience during the visit. Eliminate trepidation and assuage concerns while building trust and confidence.

In advance of appointments, prepare patients by sending forms for medical history updates that they can complete ahead of time as they will no longer be allowed to sit in the waiting room. Even if the chart shows that the medical history is current, it isn’t. Every single patient has been exposed to many Covid-related psychological and emotional (if not physical) traumas, and their health status may reflect it. Raised sympathetic tone and autonomic nervous system dysregulation are potentially present. Be prepared to talk with patients about how they are actually “feeling.” Medication doses previously effective for their hypertension, depression, and or thyroid disorders may not seem to be working as well, and they may not be able to articulate why. This may be a manifestation of the autonomic nervous system being thrown off by raised sympathetic tone. If an oral appliance patient says they’re not sleeping well anymore, consider whether it is from stress-related insomnia or other manifestation of anxiety before simply adjusting the device. Be ready to connect with their physician with any concerns you may have regarding your patients’ medical or mental health status. And if you haven’t been screening all of your patients for sleep disordered breathing due to time constraints, now is the time to implement this ADA-recommended guideline.

Finally, enjoy the additional time you have with patients. You cannot pop out of the operatory and do a few hygiene checks while waiting for a restoration to set anymore. Taking off all that PPE, putting on new equipment, and then going back into the room you just came out of is a costly and impractical venture. Appreciate that the restrictions placed on your movements to conserve PPE may actually work in your favor as you spend time connecting with your patients. Once they get used to seeing you looking like an extra from Contagion, flip up your loupes and let them see how much you care. Honor their effort, reconnect, talk to them, and let them know you are there to support them in any way you can. You will turn the recent months’ losses to gains, connect in a meaningful way, build rapport, and retain patients for many years to come.