A question about those connections

Aug. 1, 1998
To provide competent and responsible dental care, the dental team must develop a connected, supportive relationship with each patient. Successful relationships provide the basis for greater patient satisfaction for the services received from the dentist and, in turn, offer significant personal and financial rewards for the dentist.

The objective on both sides is to be understood.

Marvin Mansky, DDS

To provide competent and responsible dental care, the dental team must develop a connected, supportive relationship with each patient. Successful relationships provide the basis for greater patient satisfaction for the services received from the dentist and, in turn, offer significant personal and financial rewards for the dentist.

Some of the benefits of successful relationships are less anxiety for both patient and dentist, more new-patient referrals, improved patient retention, and more successful treatment acceptance needed for private, fee-for-service practice growth.

Conversely, unsatisfactory dentist-patient interactions lead to increased anxiety and stress for both patient and dentist. Patients accept less treatment, patient turnover is high, and patient referrals are low. In addition, practices with poor dentist-patient relationships help foster a belief by patients that managed-care practices can provide dental care equal to care provided by fee-for-service practices.

To build a successful dentist-patient relationship, four patient needs must be fulfilled. The patient needs to:

- Feel connected with the dentist and know that his or her best interest is the dentist`s main concern.

- Know the dentist can focus attention on each moment of the treatment and interaction.

- Feel relaxed and anxiety-free in the dental environment.

- Know that his or her dentist is competent.

The more capable a doctor and staff are in satisfying these interrelated requirements, the more enriched the doctor-patient relationship will be. Multiple technical, administrative, and business functions compete for a dentist`s time. Therefore, requirements for developing successful relationships are simple, easy-to-repeat techniques that consistently are effective.

What is a connected relationship?

Many years ago, Dr. Bob Barkley, the early missionary for preventive dentistry, taught that the quality of a relationship with a patient is more important than the treatment provided at any point in time.

An emphatic connection - or connected relationship - develops from the willingness of people to be in a close relationship with each other. Understanding what another person thinks and feels characterizes connected relationships. Other relationship-building blocks are mutual awareness, concern, respect, and honesty. The communication must be empathetic, convey attentiveness, and have a common language.

Basic to understanding the patient`s need to feel connected to the dentist is the need to understand the underlying significance of the mouth. Leon Lefer, DDS, MD, a psychiatrist and former practicing dentist, speaks about this importance.

At birth, the tongue, needed for nursing, is the only fully developed organ. The infant`s survival, the pleasure derived from nursing, the ability to communicate, and the infant`s first explorations of the surrounding world depend on the mouth`s proper functioning. During the same developmental period, infants are helpless, cannot adequately express themselves, can be hurt, and are dependent on others. Therefore, it`s easy to see that the mouth becomes profoundly important in the development of the unconscious.

This brings up some questions about how the developmental importance of the mouth, in conjunction with the infant`s helplessness, affects how a person deals with dental situations:

- How do both a person`s unconscious, emotional memories of early helplessness and the early significance of the mouth affect him or her in a dental situation later in life?

- How do differing degrees of control needed by different people affect anxiety levels?

- How does the dentist as an authority figure, with power to cause pain to a patient who feels helpless, influence the patient`s perception of dental treatment? If significant people in a person`s early life were abusive, dishonest, or uncaring, how does this affect his or her relationship with the dentist?

- How does a person who has difficulty with intimacy deal with the physical closeness and contact integral to most dentist-patient interactions?

Patients come to us with unique personalities and histories. They often feel vulnerable and anxious. They frequently express frustration because they do not feel understood. When new patients are queried about previous dental experiences, they frequently recount experiences of not being heard, being talked at, and of being ignored. Frequently expressed patient comments include:

- "The doctor rushed from room to room."

- "He would take calls from his stockbroker in the middle of my treatment."

- "She did not pay attention to my concerns."

- "She got upset when I asked questions."

- "He talked about subjects I had no interest in. It made me very angry."

- "He hurt me and did not seem to care."

- "The doctor clearly did not respect my time."

From these comments, it is easy to see why some patients say their previous experiences have been difficult.

Why is a connected relationship important?

Both patient and health-care provider benefit from sharing in a connected relationship. Each person feels understood. The patient feels safe and protected. The treating professional wants to do the best he or she can for the patient.

When connected, the health-care professional can better perceive and react to moment-to-moment changes in a patient`s attitude and awareness. Moreover, the dentist and staff can provide a more competent service that reflects each patient`s unique personality.

Understanding what another person thinks and feels strengthens connections between people. Two main roadblocks prevent our understanding what others think or feel: 1) we do not think of asking, and 2), we do not know what to ask.

A dental school curriculum is intensively technique-oriented. Unfortunately, students often do not receive adequate training in understanding the complex interactions that characterize the dentist-patient interchange.

This occurs because of curricula time restraints and a lack of faculty interest. After graduation, the dentist`s conversation with a patient is mostly one-way, with the dentist speaking to a person whose filled mouth does not allow effective responses.

In essence, the doctor talks at the patient. Because of this, the dentist generally does not learn the patient`s thoughts or feelings. Consequently, the dentist frequently speaks to the patient based on his or her own assumptions and frame of reference. The expectation is that a patient will understand, agree, and comply with what the dentist thinks the patient should understand, agree to, and comply with.

Effective, empathetic listening and communication approaches for eliciting responses from patients are not part of the dentist`s training. Because of this, the dentist generally accepts a patient`s "yes" or positive-looking nods as acceptance of or acquiesence to his or her recommendations and ideas. Moreover, when the dentist later discovers that the patient did not accept the recommendations, he or she frequently becomes upset and anxious. The dentist feels misunderstood and eventually becomes "burned out."

Dentistry is a difficult profession. Excellence in business, staff management, patient management, and systems development is critical and time-consuming, yet peripheral to providing dental care. The burden of difficult relationships accounts for much of the stress experienced by dentists. With improved doctor-patient interactions, decreased stress levels, personal growth, and practice development, the quality of care dramatically improves.

Simple questions, thoughtful answers

A simple question that can dramatically change the traditional one-way line of communication, so frequently characteristic of dentist-patient relationships, is, "When you think about xxxxxx, what are you thinking?"

The underline in the previous sentence is for asking about any of the patient`s thoughts or feelings the dentist is interested in understanding. This question elicits immediate and honest responses from almost everyone. This question seems to eliminate any barrier between what a person thinks and what he or she says.

The following are a few examples using this structure, with some variations that are pertinent to a dental practice:

- When you think about seeing a new dentist, what thoughts come to your mind?

- When you think about the problems you have, what are you saying to yourself?

- When you think about the treatment I am proposing, what thoughts come to mind?

- When you think about the fees for your treatment, what are you thinking?

- When you think about sitting in the dental chair, what comes to mind?

- When you think about how you would like your teeth to look, what are you thinking?

What is significant is that the patient`s answer is the start of a conversation relating directly to what the patient is interested in and concerned about. Knowing the patient`s thoughts and feelings allows the dentist to respond in a meaningful way to the patient. Because the dentist`s response pertains to the patient`s concerns, it is easier for the patient to assimilate concepts and recommendations. In addition, the dentist can customize the treatment presentation appropriately for each patient.

Another variation of the question used to elicit a patient`s thoughts can reveal what the patient is feeling. For example:

- When you think about the treatment I am proposing, what are your feelings?

- When you thought about making this first appointment with our office, what were your feelings?

It is surprising how open people will be if you give them a chance. Questions by a dentist who searches for understanding allows people to explain themselves. Questions are more appreciated by the patient than inaccurate or even reasonably accurate assumptions the dentist might make.

Be aware, however, that many people are not comfortable expressing feelings, or are not sure what they are feeling.

Knowing the patient`s thoughts about his or her problems, recommended treatment, fees, and dental health is very valuable. It also is very valuable to know how the patient feels about office service. These issues are easier to explore if the dentist is comfortable with and interested in the patients. It also is helpful if the dentist feels comfortable occasionally sharing information about his or her own life.

An attitude of warmth

- Recognize that it is heroic for highly fearful people to visit a dental office.

- Be committed to making every interaction with a patient a positive one.

- Be convinced that the treatment you provide is in your patient`s best interest and fits in with his/her preferences and lifestyle.

- Respect and acknowledge the patient`s concerns.

- Offer a full explanation before and during treatment.

- Warn the patient if pain is anticipated.

- Coach the patient in coping with pain and anxiety.

- Don`t appear rushed.

- Offer the patient an opportunity to take breaks or stop treatment at any time.

- Demonstrate personal warmth toward the patient.

- Make it comfortable for the patient to discuss any problem he or she has with the office.

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