by Sandy Roth
In part four of her series, the author discusses doctor's obligations to their patients as clinical advisors.
When I began this series last February, I promised to alternate each installment between staff/team-focused issues and patient-focused issues. In this issue, we will build upon those points from Chapter Two.
Let's review the four principles I outlined. These guidelines emphasize important concepts that impact your ability to serve your patients well.
Patients must feel understood and respected before you can influence them with your clinical opinion. If your patients don't believe you understand and respect them, your opinion will have little weight. Thus, your first job is to understand your patients' issues, concerns, wants, and needs from their perspective.
When patients seek dental care, they are buying quality of life changes, not dental hardware. No one comes to your practice wanting crowns, or bridges, or even veneers or bleaching for their own sake. Rather, they come for a combination of quality-of-life issues such as appearance, comfort, function, and peace of mind. The clinical recommendations are merely the means to attain something the patient values or wants.
Education rarely comes before listening and learning. This concept is essential for dentists to understand - for their own sakes as well as for their patients. If you get into a "telling" frame of mind before you ask and learn from your patients, you run the risk of manipulating, misunderstanding, or, frankly, annoying your patients. When they feel "spoken at" rather than listened to, they will resist and disengage. Neither situation enhances the relationship and almost always causes problems that are difficult to remedy.
Your patients are entitled to your clearly conveyed clinical opinion. Indeed, they are paying for it, if nothing else. Frankly, whether patients like what they hear is not your issue; you are obligated - legally, morally, and ethically - to convey your findings, diagnosis, prognosis, and treatment recommendations under any circumstances.
So, how do all of those principles work together? On the surface, they can look almost mutually exclusive, particularly when you consider the fourth principle - clearly conveying information to patients about their condition and its implications. Many dentists resist total disclosure with patients for fear of overwhelming and driving them away. I often hear things like: "This patient has a lot of dental problems and it will take a lot to fix them. I am afraid he is unprepared to handle it all and I don't want to overwhelm him. If I break the news in manageable chunks, I won't blow him away and I'm likely to keep him as a patient."
This way of thinking presumes that you have only two choices - good consequences or disastrous ones. You either blast forth with the whole truth and overwhelm the patient, or disclose only what you assume he can handle so as not to overwhelm him, which is a better idea. However, this thinking is laden with fallacies.
Telling the truth does not automatically overwhelm a patient. But you won't know this until you learn enough about the patient to understand what he expects and wants to hear. Simply asking patients what they expect you to discover during an examination gives you a clue about their expectations. If, in reply, the patient suggests that, since he hasn't seen a dentist in some time, he is not expecting "good" news, you can relate your findings within that expectation. "Your guess was right, Mr. Jones, you do have several problems that are asking for attention right away." If, on the other hand, the patient professes to be in superb dental condition, your revelations must fit into that context. "Unlike what you were expecting, Mr. Jones, I am finding several problems of which you were unaware. I'd like to talk with you about them now."
In both examples, the dentist has acknowledged the patient's frame of mind and entered into a discussion of the clinical findings within the context of the patient's expectations. Not only is this respectful, but it demonstrates to a significant degree the understanding mentioned earlier.
Thus, the real question is not how major or minor a patient's dental problems might be, but whether the whole truth - good, bad, or otherwise - is anticipated. You can earn enormous good will by declaring your intention to share what you learn about the patient's condition and promising to convey information clearly. For example, "Mr. Jones, during our examination, I will be learning a great deal about the condition of your mouth. Likely, some of those conditions will be familiar to you and perhaps some will be unfamiliar to you. As I move through my examination, I'll use straightforward language so we can stay on the same page throughout the process."
Withholding information that you believe will overwhelm a patient might seem like a good idea, but piecemeal disclosure can have more serious repercussions. How would you feel if someone treated you as incapable of handling the truth? Revealing only selected bits of information eliminates the patient's right to see the big picture and fully participate. Withholding information can be risky; patients often discover the lack of candor later on. If that happens, a patient understandably might lose all trust and either resent that you co-opted his rightful prerogative or feel that you have run an agenda on him.
You can ameliorate this possibility by learning about the patient's expectations and proactively declaring your intentions. Doing so may be risky , but you must understand the difference between the patient not liking the answer and the patient not liking you.
While I do believe dentists can get caught up in the "kill the messenger" syndrome, it doesn't happen as often as one might fear. Nonetheless, it does not relieve you of your obligation as clinician. Your fees include your professional clinical opinion, which is based on your experience, proficiency, and training. Frankly, you don't have a choice. Dentistry is a profession that demands - indeed, requires - honesty and trust in the relationships you create with your patients. Anything you do that undermines this trust chips away at the integrity of the profession. It hurts dentistry; it hurts the patients; and it hurts you.
So, why do so many dentists withhold information? Because dentists are afraid of their patients! Many fear rejection; others are afraid of being challenged or questioned. A significant number fear losing patients. Many are afraid that people will not like them. Still others worry they will get a bad reputation in the community. A significant majority of dentists are afraid of conflict. Young and old alike fear that patients will reject proper examinations, so they agree to "just a cleaning." And many believe their patients expect answers "right now," so they diagnose and treatment-plan on the fly. And finally, many who long to provide comprehensive and planned care are afraid patients won't participate, so they package recommendations in bite-sized pieces.
Patients can't pay the price for your fear. They're entitled to better than that. This series of workshop installments is designed to help you learn how to address rather than succumb to these issues. So, let's learn how to do things better - by looking at how you can do it poorly.
What gets in the way of truthful discussions?
•A dentist who shares limited amounts of information and serves up modest treatment plans because they are most likely to be accepted.
•The dentist's ignorance about the patient's understanding of his own condition and what he is expecting to hear.
•"Dental-ese." A dentist who keeps clinical findings secret or so heavily couched in "dental-ese" that patients learn nothing of their condition impedes successful communication. It might make you feel important, or you may think it enhances the patient's trust in your clinical acumen. Instead, it has the opposite effect. "Dental-ese" drives a wedge between you and the patient.
Dentists don't have to talk down to their patients or staff, and should avoid patronizing language such as, "I'll try to explain this so you can understand." "The top side," "the back side," "the tongue side" and other functional, everyday terms work just fine. Your assistants can even chart from this language.
Information bombardment. Dentists who blind-side patients with huge amounts of complicated information also destroy any chance of truthful discussion. I often hear dentists attempt to convey, for example, the principles of occlusion to patients, with disastrous results. I say forget the clinical lecture and simply let the patient know that you've discovered what is contributing to his problems.
Inadequate support staff. Failing to have the support staff, time, and privacy that patients need to work through these sometimes complicated decisions also impedes the process. This is one of the biggest philosophical and structural problems in most dental practices. Dentists place a huge emphasis on getting administrative work done, and an equally large emphasis on delivering care. But there is not enough emphasis on behavioral dynamics with patients. Patients too often are forced to discuss treatment recommendations either in the clinical chair or in public at the front desk, often with staff who are constantly pulled away for other duties. Behavioral support - facilitation - is as important as having competent administrative support and clinical staff. In most cases, talented, trained, and focused staffs don't exist. In other cases, they are asked to do so much paperwork and routine tasks that they lose their focus on patient care. While most practices have utilized the expertise of a professional hygienist, few seek out the expertise of a professional communicator to focus on this essential element of patient care. The presence or absence of a professional facilitator has huge implications on the dentist's ability to connect and work well with patients.
Incomplete examination, diagnosis and treatment-planning. Each dentist must determine what falls within his or her standard of care. Most clinicians agree (off the record) that proper treatment can be rendered only with a thorough examination, diagnosis, and treatment plan. However, too many dentists diagnose and treatment-plan on the fly after a cursory examination and hygiene appointment. Most dentists who do this argue that their patients want their teeth cleaned and won't tolerate an exam. I have found the opposite to be true. No one wants you to rush, take short cuts with their health, overlook important clues, or make recommendations based on incomplete information. Patients want things to be easier, more convenient, and less expensive, but that doesn't mean they won't allow you to do your job. People can have their teeth cleaned but that doesn't mean you can't do a proper examination as well. And patients needn't jump through an endless array of hoops to qualify as a good enough to "fit" into your practice.
Patients may ask for your recommendations once they have learned about their conditions, but that doesn't mean you must give them an answer prematurely. When you sincerely ask for their patience while you study the diagnostic information, patients usually will agree. Most often, they want assurance that you can help them, which is easy enough to provide. Telling the truth is essential under all of these circumstances.
Building Blocks: a guided practice
So what can you do to ensure that patients will allow you the time and focus to do your job and that they will take your recommendations seriously? Here are some ideas to consider for your workshop assignment this month.
Learn in advance how the patient perceives his condition. This is best done by interview, but can also be learned through a written questionnaire. If you don't have a reference point, you will not know when you have discovered something unexpected.
Ask for permission to be completely honest about your findings, their implications, and your recommendations. It may seem like an unnecessary or an assumed step, but it prepares patients, at least in theory, if they are inclined to mistrust trust or denial.
Be deliberate and thorough. Use a standard sequence for your examination, but be ready to divert and respond to items of patient interest. Wear loupes. This emphasizes that you are both serious and professional.
Make your findings known as you discover them, and use lay language. This is the essence of co-discovery. Don't just call out dental conditions to your assistant without involving the patient, and certainly don't do treatment planning on the fly the first time you look in a patient's mouth.
Don't use minimizing words like "a little" or "just a bit of." Dentists often underspeak and therefore underrate dental conditions. Patients interpret these words to mean there is no problem, only to be surprised later when they learn treatment will be required.
Empathize with your patients. "I'll bet this is not what you expected - how do you feel about all this?," is an appropriate expression that allows patients to go beyond the detachment of clinical findings. It acknowledges their feelings and generates good will.
Summarize your findings at the conclusion of the examination and as you make your recommendations.
Make a written report your findings and explain their significance. Patients will forget much of what you say during the examination, and it's important to have something to refresh their memory.
Charge a proper fee for your examination. When it's done right-with an in-depth preclinical interview and health history, thorough examination and charting, photographic or intraoral video documentation, appropriate radiographs and time to interpret them, study casts, cause-oriented diagnosis, and thoughtful treatment planning-it's the most valuable service you provide.
The level at which your patient's are overwhelmed is directly related to the size of the discrepancy between what they were expecting and what they learn is real. Your efforts to make that gap smaller by preparing the patient for the complete truth will serve both of you well. Every patient-contact team member can play a part in this - a magnificent form of customer service.
To learn more about how to develop communication skills, call Sandy Roth at (800) 848-8326 or email her at firstname.lastname@example.org for a catalogue of learning resources.