Communication skills for successful relationships

By Sandy Roth

Chapter 4 - Delivering bad news

This month, Sandy offers some tips on how to give the bitter with the sweet - without overwhelming your patients.

Dr. Randy Shumer had a knot in the pit of his stomach from thinking about his afternoon consultation. He still hadn't decided what to tell her. Even he was a bit overwhelmed by the extent of her problems - and the size of the treatment plan he had put together. He knew she had financial problems, or at least he suspected she did from a few hints she had dropped. And she had already implied that the last dentist had tried to "rip her off." He certainly didn't want her to think that about him. Maybe he should just focus on the most serious problems and leave the rest for later.

These situations were always perplexing for Dr. Shumer, and he never felt confident about how to handle them. It seemed that a lot of his new patients were clueless about the extent of their problems. When he did his job, they were more likely to "kill the messenger" than thank him for his thoroughness and professionalism.

It was almost as if they blamed him for their problems. Good grief! It wasn't his fault. They simply needed to face the truth and learn how to handle their own problems.

On second thought, he decided, he would tell her everything and let the chips fall where they may. This meant he'd have to present entire the treatment plan to her, and he dreaded her response. He often worried that patients thought he was out to rob them blind. Didn't they understand that good dentistry costs money? He was tired of the snide remarks about putting his kids through college or buying his new car. Little did patients know how tight things really were.

Maybe he should just skim over the expensive option, even though he knew it was the best choice. Truth be told, he was a bit afraid of scaring this patient and losing her altogether, which had happened before with several patients.

Against his better judgment, he decided to play it safe. Better to do that than overwhelm her.

To overwhelm or to withhold? Is that the question? Many dentists struggle with situations like that faced by our hypothetical Dr. Shumer. Dentists tire of being seen as the bad guy. No one likes telling people things they would rather not hear. But informing patients of their condition, the implications of those findings, and treatment options are three important responsibilities a dentist has. Because these responsibilities cannot be avoided, dentists must develop skills to deliver information so their patients can interpret it. They must also support those patients in making choices.

Let's first outline the some of the givens in these types of situations.

Reality No. 1: No one ever hopes you will find something wrong. Patients hope that they are "healthy" and that they will not have to use their resources (time, money, and energy) to solve a problem. If a problem is small, most patients will wish it were nonexistent. If it's a medium-sized problem, a small one would be preferable.

Even fully discretionary issues like cosmetic dentistry are impacted by this reality. A patient seeking esthetic care would always prefer the solution to be less complicated, costly, or time-consuming. They might be able to accept the final answer, but they almost always hope for something a bit better.

Reality No. 2: Patients must assimilate information when it is counter to their hope or wish. The new information must displace the mental wish that preceded it. The gap that exists between a patient's initial expectation and the new reality determines the degree of conflict or disappointment. If the gap is huge, the resolution will take time; the patient will likely require some major support. If the gap is small, the patient may be able to handle everything on his or her own. Either way, the process happens in a predictable series of stages.

Dr. Elizabeth Kubler-Ross, a physician who worked with the terminally ill, wrote On Death and Dying to describe the cognitive and emotional stages people go through before accepting their fate. Although dental disease and damage doesn't come close to the issues of death, the stages she identified have a direct application for dental patients receiving unwanted information. The common thread is loss - loss of health or bodily integrity. Although patients go through these stages in the same order, they don't necessarily devote the same amount of time or energy progressing through each stage.

Stage one: shock and denial

People who learn that they have an unwanted problem react universally with feelings of denial. We hear this when the dentist leaves the treatment area; the patient asks the assistant, "Do I really need this treatment?" This stage is psychologically important because it provides a buffer between the undesired news (something is wrong.) and the pain. During this stage, patients may not want to face the fact (they have periodontal disease) or discuss the problem.

The dentist and team must understand that attempting to make patients "face the facts" before they can talk about their feelings is a mistake. Asking questions and allowing patients to address emotional reactions is the key. Questions such as, "Was that different than what you had expected?" keep the focus on the patient and directly address the emotional responses.

Stage two: anger and resentment

As denial dissipates and the patient begins to accept the fact that his first choice (nothing wrong) isn't the case, a usual reaction is anger and resentment. "Why me?" or "I did everything you told me to do, Doctor." Patients will often direct their anger at their health- care providers; it may seem as if they are blaming the dentist - aka "kill the messenger."

Under these circumstances, patients are not always pleasant to be around. However, it is very important to be with them during this stage and allow them to vent their feelings. Defensiveness from the dentist and team won't help. If your response is primarily to protect yourself, you will not be in a position to help the patient work through this stage. It is natural for people to look for someone or something to blame when faced with unwanted news. Personalizing it by saying things like, "Look, it's not my fault" is insensitive to the patient's process.

Stage Three: bargaining

As the patient begins to realize that anger won't change things and that the situation won't go away on its own, he or she may often shift into a bargaining process. This can often be seen as an attempt to modify the treatment recommended by the dentist. "How long will it wait, Doc?" or "Can't you just patch it up?" Your honest, yet supportive answers to these questions are imperative to help the patient move through this stage and on to the next. What is the patient waiting on? How much time is necessary? What will have to be different to address the problem? If there are less costly (in any currency - time, money, energy, etc.) options that fall within your standard of care, by all means offer them. If not, simply tell the truth. A patch is ineffective. The patient needs your direct and truthful answers, and your professional recommendations.

Stage Four: depression

Mild depression may set in when the patient realizes the problem can no longer be denied. This depression can be about what has been lost (a tooth) or what will be lost (perhaps a vacation is no longer affordable due to the money spent on dentistry). It is important for dentists and team members to be actively supportive during this stage. Do not patronize by saying things like, "We all have to go through things like this." Acknowledge the patient's feelings and stay connected.

Stage Five: acceptance

At this point, the patient has experienced a range of emotions and is ready to accept the reality of the situation. Often, when the patient has been helped through the previous stages, relief and the ability to commit to specific actions accompany acceptance.

Reality No. 3: If patients feel supported while assimilating new information, they will more likely engage in treatment. If there is no such system in place, patients can get stuck in one stage or will recycle to another practice hoping to hear an answer more to their liking. If you truly want to help your patients, support them as they go through the assimilation process. Doing so helps patients make better choices for themselves.

Failing to understand this natural process means missing the opportunity to help people as they go through it. You may label patients "problematic," "disagreeable," or "stubborn," or leave them to negotiate the emotional maze on their own. You may create new patient and consultation systems that push people to agree to proposed treatment when they may not have dealt with these stages. Many dentists resist total disclosure with patients for fear of overwhelming and driving them away. "I know there's a lot wrong and it will take a lot to fix it, but I don't want to overwhelm them. If I break the news in manageable chunks, I won't blow them away." There is something universal about this strategy, because I hear almost exactly the same thing, whether I am in the United States, Canada, England, or Australia. This way of thinking presumes there are only two choices:

1. Tell the whole truth and overwhelm the patient (bad)
2. Disclose only what you think (guess, assume) the patient can handle and not overwhelm him (good)

This thinking contains a number of fallacies. Telling the truth does not necessarily mean it will overwhelm a patient. The real question is whether the whole truth - good, bad, or otherwise - is expected. Moreover, piecemeal disclosure can have more serious repercussions than simply being forthcoming. How would you feel if someone treated you as incapable of handling the truth and only revealed selected portions, eliminating your ability to fully participate? Sharing only bits and pieces contains the risk that your lack of forthrightness will be discovered. If that happens, a patient may understandably lose trust and either resent that you co-opted his rightful prerogative or feel that you have run an agenda on him.

And here is the clincher: You are legally, morally, and ethically obligated to tell your patient the truth about your findings, their significance and prognosis, treatment choices, and the implications of those choices. Patients pay dentists for their professional clinical opinions based on experience, expertise, and training. Dentistry is a profession that demands - indeed, requires - honesty and trust in the relationships created with patients. Anything that might undermine this trust chips away at the integrity of the profession. It hurts dentistry; it hurts the patients; and it hurts you.

Why do dentists withhold the truth?

Collectively, dentists are afraid of their patients. A strong statement, but true. Many are afraid of rejection, while others are afraid of being challenged or questioned. Almost all are afraid of losing patients. A significant number are afraid that people will not like them. Still others are afraid they will get a bad reputation in the community. Quite a few are afraid of conflict. Young and old alike are afraid patients will reject comprehensive examinations, so they agree to "just a cleaning." And many believe their patients expect and insist on having 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.

What variables get in the way of truthful discussions?

• A dentist and/or team member who avoids conflict by serving up limited treatment plans or making clear financial arrangements
• Keeping individual findings secret (or couched in dental-ese) as they are discovered
• Blind-siding the patient with huge amounts of information he or she cannot understand or assimilate
• A lack of knowledge about the patient's estimation of his or her condition and what the patient expects to hear
• Lack of skills and resources to support patients as they work through sometimes tricky and complicated decisions about their care
• Shortcuts taken through the garden of proper examination, diagnosis, and treatment planning.

This chapter of our series on Communication Skills for Successful Relationships will provide an array of ideas about how to honor your professional obligation without overwhelming your patients.

1. Learn about the patient's perception of his own health at the first appointment. This is best done during an interview, but can also be assessed through a written questionnaire. If you don't have a reference point, you will not know when you have discovered something unexpected.(For more information on how to do this, refer to the August 2000 issue of Dental Economics for my eighth installment in the series, "Mastering the Art of Communication" or contact me directly.)
2. Ask for permission to be completely honest and upfront about your findings. It may seem unnecessary, but it prepares patients if they are inclined toward lack of trust or denial.It is a simple step, often accomplished by saying, "Mrs. Jones, since this is the first time we've worked together, I'd like your permission to be totally honest with you about what I find during our examination. I say that because sometimes patients are not receptive to hearing what a dentist has to say, and I'd like to remove that barrier if I can."
3. Be thorough. Use a standard sequence for your examination, but be ready to divert and respond to items of patient interest. Wear loupes. Chart everything on your paper chart or on the computer. Be precise. Each of these strategies has a practical result, and they also make the point that you are both serious and professional.
4. Make your findings known as you discover them. Use lay language understandable to the patient. This is the essence of codiscovery. 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.If your examination sounds something like, "No. 2, onlay; No. 3, PVC; No. 4, MOD composite," etc., you are not giving the patient any chance to get involved and own the problems, which probably guarantees that he will feel overwhelmed.

5. Don't use minimizing words like "a little" or "just a bit of." Dentists often "underspeak" and therefore underrate dental conditions. Patients hear these words as an indication that there is no problem, which magnifies their surprise when they learn treatment will be required. Don't rush to make the patient feel better by comparing him to someone else. It doesn't matter that you have "seen worse in other patients."
6. Don't be reluctant to offer your emotional reactions. "This breaks my heart to see so much decay in your mouth." "This must be quite a disappointment for you." "I'll bet this is not what you expected." "How do you feel about all this?" These are all appropriate expressions that allow patients to go beyond the sterility and detachment of clinical findings. It acknowledges that feelings and significance may well be generated as an upshot of a clinical examination.
7. Summarize your findings. It's important at the conclusion of the examination to summarize your findings, especially if it's a complex case. If you tell your patients you'd like some time to think carefully about everything you have learned, they will know they're not alone in feeling uncomfortable about unanticipated disease. The period of psychological discomfort that follow's for the patient may be important in solidifying your relationship, particularly when you lend your support and skill.

8. Commit your findings to a written report. Explain the significance of those findings. Patients will forget much of what you say at the time of the examination, and it's important to have something to refresh their memory. Bob Barkley's concept of written diagnosis was beautifully captured in the little-known companion workbook to his now out-of-print masterpiece, Successful Preventive Dental Practices. In it, he offers about five stunning but down-to-earth examples of reports he banged out on a typewriter back in the late 1960s. Now it's possible for such a report, with the help of specialized software, to virtually leap out of the computer - created for that patient alone!(For additional information about this software, contact me directly.)
9. Understand the Kubler-Ross stages of loss. You and your staff must be as supportive as possible when there is a major gap between expectation and reality. Remember, expectation minus reality equals disappointment.If your patient is demonstrating signs of shock, denial, or bargaining, you must be prepared to support him through this process. A patient's inability to manage these stages triggers most dentists' fear of overwhelming their patients.Since you can never know when it will happen, a staff member trained in facilitation must be available to support the patient appropriately.
10. Charge a proper fee for your examination. When it's done right - with 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.

How overwhelmed a patient may be is directly related to the size of the discrepancy between what the patient was expecting and reality. Your efforts to make that gap smaller by preparing the patient to hear the full truth in advance will serve both you and the patient well. Every team member can play a part in this, a magnificent form of customer service.

To learn more about how you and your team can develop stronger and more effective communication skills, call Sandy Roth at (800) 848-8326 or send her an e-mail at [email protected] to request a catalog of learning resources.

Guided personal exercise

This month, I challenge you and your team to a self-assessment of your skills and resources in this area. In a team meeting, answer and discuss the following questions:

• How often do patients experience distress when hearing information for which they are not prepared?
• How can we better prepare them for new and unexpected information?
• How do each of us respond when patients express denial, anger, bargaining, and depression?
• Are we more inclined to defend ourselves and personalize our patient's reactions than keep a healthy boundary between their feelings and our egos?
• What skills do we not yet have but need to help patients when they hear bad news?
• What opportunities are we losing because we are not prepared to support patients through this type of distress?
• How will we go about developing these skills? What is our plan?