Iatrosedative Clinical Behavior
The clinical encounter begins the moment you pick up an instrument, whether it be a mirror or a probe. An important commitment should be made at this time, to wit: the quality of your tactile behavior. How delicately or roughly you use your instrument tells the patient something of your involvement with him; your awareness, concern and skill. The more threatening an instrument is, the more significant is your manner of wielding it and the more important are the verbal communications made in conjunction with its use. What you are about to do with it and what you anticipate the effects on the patient will be are two important happenings that should be shared with him/her. In short, you should communicate in a way that will prepare your patient for what is about to occur. Skill in the use of such preparatory communications is essential in iatrosedation.
Let us consider preparatory communications in relation to the “normal” patient first. The non-fearful patient is subject to normal anxiety which is an anticipatory state of expecting threat or danger and preparing for it.
We all tend to be apprehensive when dependent on another whose actions hold the threat of pain and /or body damage. We have no control and are helpless. The unknown is disturbing: that disquieting sense of not knowing what the other person is going to do, the threatening silence when the “needle” or other potentially painful or cutting instrument is picked up. All of these feelings are exaggerated when the person in control gives us no information with which to brace ourselves psychologically, no assurance that he is aware or concerned about us.
Preparatory communications are brief communications made to the patient prior to using an instrument or performing an action which could be perceived as threatening. The communication is intended to prepare the patient for what is about to happen or may be experienced; such as discomfort, pain, noise, pressure, etc. Such preparatory communications tend to dispel the fear of the unknown and the sense of helplessness through the simple act of foretelling. The patient receives an additional sense of control over his situation because he knows what to expect.
Control through knowing (cognitive control) tends to increase with the use of preparatory communications. When the Danger Control and Protective Authority shares knowledge with the patient, it tends to reduce anxiety significantly. Egbert’s studies clearly demonstrate this.
Egbert and his colleagues demonstrated the effects of preparatory communications on the anxiety level of patients scheduled for major surgery. A number of clinical experiments were performed by his group of anesthesiologists to determine the effects of the doctor’s behavior and communication on the anxiety level of surgical patients. One such study measured the effect of the anesthesiologist’s pre-operative visit with his patients in producing calmness versus the effect of pentobarbital for preanesthetic medication. They summarized their findings this way:
Patients who had received a visit by an anesthetist before the operation were not drowsy but were more likely to be calm on the day of the operation. Patients receiving pentobarbital one hour before an operation became drowsy but it could not be shown that they became calm. If the purpose of pre-anesthetic medication is to allay anxiety, our data suggest that pentobarbital, causing drowsiness does not achieve the desired result alone.
Their data also suggested that the psychological impact of the pre-operative visit made the effects of the pentobarbital seem inconsequential. In their comment, Egbert et al stated:
At first sight it would seem surprising that an anesthetist, in a 5-10 minute interview, would be able to exert a psychological effect demonstrable the following day. The patient’s interest in knowing about anesthesia would not seem to be an adequate explanation. A better explanation is provided by Janis. He found that persons facing a frightening situation became anxious and looked for emotional support … an authority supposedly able to modify the dangers, becomes invested with strong emotional significance. The statements made by this authority assume greater importance than would ordinarily be expected.