Communication skills for successful relationships

In this first article of an 11-part series, consultant Sandy Roth shows you how making assumptions about patients can damage a potentially good relationship.

by Sandy Roth

Chapter 1 - The skill of staying out of judgment

For over 18 years, Julia Cayson had been working with Dr. Nygaard and had just about seen it all. She was highly competent at handling the actual tasks of her position, which involved responding to incoming telephone calls, greeting patients, helping them with appointments, making financial arrangements, and collecting fees. Julia also possessed a great deal of natural intuition and insights about patient behavior, which she viewed as highly valuable to the practice.

The practice had developed a coding system identifying its best patients as "A" patients, and the tougher ones as "B's." The lowest designation, "C," was reserved for the most problematic group. "A" patients showed up on time, didn't cancel or fail appointments, paid their bills without a fuss, and generally accepted the doctor's treatment recommendations. Julia's people skills as well as her tenure in the practice gave her a key role in determining how patients were categorized. She had learned the signs which indicated what type of patient a person would become.

Julia could always tell which patients were insurance-dependent, for example. These patients usually wanted a predetermination before agreeing to treatment. She also observed that patients who didn't value dentistry very highly always wanted the least expensive choice. Julia also became very skilled at handling new patient calls, possessing an innate ability to weed out emergency-only patients and shoppers. In identifying certain patterns of behavior, Julia had developed her own arsenal of standard responses to recurring patient comments and frequently asked questions. She could almost put her brain on autopilot as she conveyed the importance of regular examinations or reminded patients that dental insurance was a contract between their employer and the carrier.

Because Julia was so confident, she responded routinely one day when a new patient, Sarah King, approached the front desk to make an appointment at the end of her initial visit. Julia's antenna activated at the first sign of trouble: The patient immediately began to complain about the treatment Dr. Nygaard had proposed. "I can't believe I have to have a crown," said Sarah, frustration in her voice. Julia calmly responded, "Well, you know Dr. Nygaard wouldn't recommend anything that wasn't necessary." She was attempting to instill confidence in what she assumed was a doubting patient. The patient retorted, "So, how much is this going to cost me?" "A crown is five-hundred," replied Julia, careful not to use the word "dollars" as she had been coached. "Five hundred dollars? For a crown? Are you serious?" responded the incredulous Sarah.

Believing herself in all-too familiar territory, Julia shifted into one of her patented routines. She began by explaining that the doctor used only the finest labs and materials, took extra time to check the bite and margins, and that he had attended numerous continuing education courses far above and beyond what was required to maintain his license. His skills, Julia argued, surely justified his fee. Sarah listened patiently. When Julia appeared to be finished, she calmly responded, "I don't think you understand, my dear. My husband had a tooth crowned before we moved and he was charged $735. I'm wondering if this one will be good enough."

Julia, though a fictional composite, is not unlike many of us. She is competent, well-meaning, and sincerely wants to do her job well. She is intent on helping patients while supporting her dentist and the practice. In her attempt to become more proficient in her position, however, she developed some habits that are likely to contribute to relationship breakdown. Although her instincts are good, she makes many assumptions about what initial signs and signals mean. Thus, her inclination to judge and incorporate a pattern of judgmental responses may overcome her positive abilities. Because she is unaware of the negative potential of these patterns, she is not likely to change them. And, by the way, Julia is probably not alone: Her entire team is likely to exhibit similar behaviors and attitudes.

In this installment of Communication Skills for Successful Relationships, we will explore three basic and critically important communication skills to help you free yourselves from judgments. First, I'll help you look at how certain erroneous beliefs and attitudes can easily lead to damaging behaviors. Then, I will introduce some important skills to begin using in place of those you may have adopted.

Relationship damager No. 1:

Stereotypes and judgments. Reconsider the following comments from our case study:

She saw herself as highly valuable to the practice because of her natural intuition and insights about patient behavior.

Many people believe they have the gift of intuition. Intuition is generally defined as the ability to perceive the truth without engaging directly in the process of discovering that truth. Although a great deal of research has been conducted on this issue, there is no data that suggests people can actually discern the truth by intuition alone. People who describe themselves as intuitive mean that they often get a feeling that leads to a guess that is eventually confirmed. I suspect that given a certain set of circumstances, most of us could make a reasonable and potentially accurate guess at what is going on.

Let's try an experiment. See if you get any "intuition" about what is going on from the following fictitious news report: "Anna Maria Mansfield, a 22-year-old aspiring actress, today wed 97-year-old Howard Houston in a private civil ceremony on the ailing multi-billionaire's private island in the Caribbean."

Now, what went through your mind? Perhaps an idea that the former Ms. Mansfield had married the man for his money - right? I bet you would not be surprised if the next line in the article read: "The new Mrs. Houston immediately issued a statement rejecting any implication that she was motivated by financial gain, adding, 'Howie and I are deeply in love.'"

If you did guess what came next, was it intuition? More likely, it was stereotyping, which is a judgment raised to an art form. In this example, it is easy to find a pattern commonly repeated in movies, jokes, and even in real life. But the whole truth is unknown about this particular situation. Because we have only the scantiest details, it is improper to conclude that we understand the entire truth about them or their circumstances. Applying this to our dental scenario, "Julia" simply adopted the habit of applying stereotypes. If so, how many times is the stereotype misapplied? How frequently is she wrong?

As easy as it is to judge by stereotype, it is equally difficult to resist the temptation to do so. But resist we must. Stereotyping is a damaging, hurtful, and unfair practice. Even worse, stereotyping gives us bad information. We presume more widely than we should and treat people according to patterns that may have nothing to do with them. So Julia's "intuition" is, at best, stereotyped guessing. It isn't a skill at all - it is a liability.

She had learned the signs which indicated what type of patient a person would become. Julia could always tell which patients were insurance dependent, for example, because they wanted a predetermination before they agreed to treatment. Patients who didn't value dentistry very highly always wanted the least expensive choice, she observed. And she had become very skilled at handling new patient calls, possessing an innate ability to weed out emergency-oriented patients and shoppers.

If we return to our case study, we find that stereotyping is a tool Julia often employs. She believes a few signs and signals provide enough insight to predict how a person will behave or react. But she can just as easily be wrong about a person's behavior. Although Julia may hear patients report feeling limited by their insurance coverage, it is too big a leap to suggest that those who ask for predeterminations are all "insurance dependent." Unless we specifically hear otherwise, such a request only indicates a desire to know how much help will be provided by an employment benefit. A small number of patients believe that if they really need a service, it will be paid for in full by their dental benefit; however, it is not true for the vast majority. Some people ask for a predetermination to make personal financial plans. If you want your patients to be responsible financially, this is a good thing. The "insurance dependent" judgment is a serious error.

Certainly, some patients seek the least costly option without regard to other variables, but that says nothing about their values. It only says something about their pocketbook. It is wrong to suggest that patients with large amounts of disposable income have good dental values and equally wrong to assume the opposite about those with limited funds. Exploring less costly options may indicate nothing more than financial concerns. Judging a patient via such superficial means eliminates the likelihood that any team member will learn more about the unique individual. It may be easier to put people into these boxes, but it is significantly less effective.

Finally, a patient with an urgent need may or may not be emergency-only oriented. Just because a new patient is experiencing discomfort doesn't mean he or she chronically neglects seeking care or seeks that care only when required by pain. Patients are often prompted by a condition to seek a new dentist when they have become displeased with their previous care. What many would call a "shopper," a friend of mine calls "32 teeth looking for a home." In another situation, many of us might inquire of other providers (swimming pool servicers, hair stylists, and even accountants) in the same way. Forgive callers for not knowing the "right" way to begin a conversation and avoid judging them when they initially ask about fees.

Relationship damager No. 2:Libeling by label

The practice had developed a coding system to identify its patients.

This practice is mostly inaccurate, misleading, and incomplete, with no real tangible benefit for the practice or the patient. It is a form of judgment more relationship-damaging than enhancing. Certainly it makes sense to use caution in determining who might be a financial risk, especially if you finance dental fees for your patients. But the harm this practice causes far outweighs any gain.

There are two serious implications of this practice. First, it locks patients into a category with a label that will likely stick for a long time. This "libeling by label" depresses the quality of the relationship and profoundly diminishes its potential. If you believe, as I do, that each patient has a right to our full respect and understanding, you also believe that this labeling system must be eliminated.

Secondly, it has a direct impact on how each team member views and treats each patient. This phenomenon is called a "self-fulfilling prophecy." Educational research has determined that teachers who were told a child was a poor student treated that child accordingly, thereby negatively influencing that child's learning. This occurred whether the child was a slow learner or actually quite competent. The opposite was true as well. Slow learners who were labeled "gifted" performed at higher levels based on the teacher's perception of that child's ability. There is strong evidence that suggests these labels contribute significantly to how a patient's behavior is interpreted by the members of the team. Thus, thinking well of people is more likely to contribute to a more positive and successful relationship than thinking ill of them.

Relationship damager No. 3: Using scripted responses

In identifying certain patterns of behavior, Julia had developed her own arsenal of standard responses to recurring patient comments and frequently asked questions.

Julia may have had similar conversations with many people, but it is the first time she has had it with Sarah. One reason I reject scripts and canned responses is that they fail to take into account the uniqueness of each situation. Every patient is different, and although the question or comment may sound the same, it isn't. Scripts are easier, but they are much less effective. Without a script, Julia would have to abandon her preconceived notions, listen more fully, and modify her response to fit each person in each specific situation. Thinking and responding at this level is more work, without a doubt. But all successful relationships are work.

Ask yourself how you feel when you are being treated to a scripted response or a company's party line. How do you respond when you know the person isn't listening or doesn't care about what you are saying? How likely are you to want to encourage others to patronize that business or engage in more business with this company yourself?

Relationship enhancing skill No.1:Replace judgment with curiosity.

When you begin to judge, you lose the ability to help. Judgment locks you into a way of thinking that eliminates other options and other possibilities. Once you believe you know the answer, all of your efforts are naturally directed toward making that a reality. Those who hold a different perspective or have not yet determined their own answer will likely experience your efforts as manipulative and self-serving.

Curiosity, however, comes from an entirely different frame of reference. It focuses your attention more on what you don't yet know. If judgment is based on presuming to know the whole from only a few parts, then curiosity is exactly the opposite - realizing that the picture is incomplete and that more information is necessary. Curiosity is wonderful because it forces you to stay open to hearing something so unique that it changes how you provide help. The process of helping people make choices in dentistry requires curiosity and must specifically exclude manipulation.

Wondering what a patient meant by a comment, or how a patient is thinking, or what variables will impact his choices, or what causes him concern, and thousands of other questions is the stuff of which curiosity is made. Believing that there is always more to learn leads to curiosity about what remains unknown. In that unknown space is the right answer - give yourself the opportunity to find it.

Relationship enhancing skill No. 2: Say it out loud.

It is easy to stay out of judgment when you establish a simple rule to guide your behavior: If you cannot properly state your perspective out loud, directly to the person, you are likely in judgment. Perhaps it is time to make an important distinction. As a dentist, you are an expert on clinical dentistry. Thus, you are entitled to a clinical opinion, and you are obligated to state that opinion to the patient. You are not entitled, however, to an opinion about the patient's life, an area where you have no expertise and insufficient knowledge. In this arena, the patient is the only expert. You are responsible for determining whether the patient's clinical conditions call for a certain procedure, but you are not entitled to an opinion about whether an octogenarian is too old for an implant. The significant distinction between an opinion and a judgment involves jurisdiction. A judgment openly stated in an area in which you have jurisdiction is an opinion. An opinion that remains undisclosed in an area in which you do not have jurisdiction is a judgment. Share your opinions freely. Withhold and check your judgments.

To learn more about how you can develop your communication skills, call Sandy Roth at (800) 848-8326 or send her an e-mail atsandy@prosynergy.com for a catalog of learning resources.


Guided personal exercise

Skill-building requires awareness, discipline and practice. This month, I'd like to help you become aware of how often you may be judging unfairly.

For this exercise, you will need a journal or log book with at least one page for each day you are in the practice. Keep it handy so you can write notations throughout each day. If possible, set an unobtrusive alarm or establish a signal that will prompt your attention once each hour. The alarm asks you to think carefully over the events of the past hour to consider what judgments you may have formed.

The next step is to consider the part those judgments played in your patient interactions. Of course, you needn't wait an hour to make notations once you begin to become more aware of them. At the end of each day, gather with your fellow team members for a few moments and share what you have written. For each notation, determine whether you have jurisdiction. If so, you are entitled to an opinion and must share that opinion with the patient in the future. Determine how you will accomplish this. If you do not have jurisdiction, determine what questions would replace your judgment with curiosity. Make a note to ask those questions at the next patient contact.

Staying away from judgment requires discipline - and the support of your fellow team members. Listen to each other and help one another become more aware of times when relationships are put at risk. And support one another as you learn to include these two important skills in your arsenal.

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