by Jeffrey Ganeles, DMD
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Patients often know that they need dental treatment, even before they are told of their problems during a dental appointment. They can look in the mirror and see missing, discolored, or broken teeth without an advanced degree. It doesn’t take years of specialized training to recognize bad breath or diagnose chewing problems. So why don’t patients come to our offices demanding the services they want or need? In one of her practice management newsletters, Cathy Jameson wrote that patients do not accept treatment recommendations for four basic reasons: lack of knowledge, fear, money, and time.
Combinations of these factors can paralyze an individual, which can prevent him or her from inquiring about needed services or listening to factual responses. Once a patient’s unique circumstances are appreciated and analyzed, a consultation occurs with the goal of case acceptance.
The patient consultation
Patient consultations should be structured as deliberate conversations between the dental professional(s) and patient, which addresses the patient’s dental condition, relevant medical condition(s), obstacles to treatment, treatment options, risks, and relevant details including time and cost. It should be recognized that it is almost impossible to provide the patient with an exhaustive understanding of all treatment options and details. The dentist needs to identify, educate, inform, and advise the patient about all relevant information in layman’s terms.
Heaping on all permutations of treatment will likely create confusion rather than clarity. Once the patient becomes perplexed, his or her ability to accept treatment virtually disappears.
Since it is clearly not in the patient’s or dentist’s best interest to have appropriate options refused, each professional eventually develops his or her own style of communication for consultations. This article suggests adhering to a formula that accounts for the patient’s condition, history, psychology, expectations, and requirements to communicate appropriate information in a logical sequence. This formula is known as the “4 Consultation Questions” —
- What will I look like when I am done?
- How long will it take?
- Will it hurt?
- What will it cost?
It is particularly important to answer Question 1 first and Question 4 last to preserve the integrity of the presentation. The second and third questions may be addressed in whichever order is most appropriate to the situation. It is not recommended that a consultation be started with a patient unless all of the questions can be adequately answered.
Scheduling time for a complete consultation is usually more effective than giving fragmented or incomplete information, and reduces the likelihood of patient misunderstanding or misinterpretation.
What will I look like when I am done?
This question is the primary focus of the consultation and encompasses the patient’s current condition and possible treatment outcomes. It is much more important for patients to first understand the results of treatment rather than the methods used. Also, discussing healing, surgical risks, restorative materials, or provisional options at this time can be confusing and irrelevant. Once a treatment outcome is identified, other considerations become more relevant because the patient can recognize that he or she is working toward a specific treatment goal.
In dentistry, this process is called “backwards planning,” where concrete treatment objectives are articulated before a treatment schedule is discussed. This process requires realistic predictions of results for the sake of treatment planning, recognizing that there may be variations beyond the dentist’s or patient’s control.
Obstacles to treatment should be ignored during the initial conversation. Complicating factors and risks need to be discussed once the patient agrees on the treatment objective. However, until the treatment goal is established, the discussion of methods and treatment sequence are not important and may be distracting.
The “backwards planning” philosophy somewhat contradicts methods taught in most dental schools. Traditionally, patients are brought through different standardized, prescribed phases of treatment, then “reevaluated” to identify the final treatment objective. As a result, patients can become exhausted and frustrated by the process and do not understand their goals. They lose their enthusiasm and patience, and sometimes question the value of the services.
Therefore it is important to describe the transition process from the patient’s current condition to the completion of treatment. Patients need to know what they will look like and how they will function during the treatment process. They need to be reassured they will not be incapacitated or disfigured during treatment. Questions include the type of provisional restoration to be used and when esthetics and function will improve.
How long will it take?
This question can only be answered accurately after concrete treatment objectives have been identified. Time questions include duration of treatment from beginning to end, number of appointments, duration of appointments, and flexibility of appointments. Sensitivity to patients’ work, travel, and personal commitments tend to reduce objections based on time. Organizing the sequence of treatment to optimize appointment utilization is an excellent strategy to minimize time commitments for busy patients.
Will it hurt?
Stated or not, this is an important issue for almost all patients. For some, it is a paralyzing issue. It is a concern that requires more than a casual reassurance about local anesthetic. Include a conversation about how the patient will feel following appointments and at the completion of treatment. Discussion of anxiety management and the use of sedatives is appropriate. Thermal sensitivity, bite changes, pressure sensitivity, and any dietary modifications should be included as needed. Patients should be told how long it will take to recover from invasive procedures, including duration and severity of inconvenience.
Provide suggestions for recuperation time and limitations on activities. Patients understand that dental treatment requires adaptation and recovery, but they often don’t ask the correct questions to plan their time.
For some particularly anxious patients, the discussion of anxiety management may need to precede the “what will I look like?” conversation. If not done satisfactorily, patients will not effectively listen to other aspects of treatment. Patients may hear the dentist’s words, but not register the ideas and images conveyed. Of all obstacles to treatment, anxiety about pain and discomfort are the most common “hot button” issues that either emotionally motivate or incapacitate patients.
What will it cost?
This is usually the first question patients ask and the last one that should be answered. Often, patients are overwhelmed with the process, possibilities, and technical information presented. Regardless of the doctor’s bedside manner or relationship to the patient, a certain level of tension usually exists during consultations. The easiest question for a patient to think of in this situation is “How much?”
If it is agreed that consultations should be deliberate, organized, structured conversations, then the cost question should be deferred until the other issues have been addressed. At this time, the patient should have a good idea of what he or she is “buying.” Most important, the dentist will have explained and established the value for the proposed services. Only at this point is the patient ready for the cost discussion.
It is not recommended that the cost be itemized for individual procedures, because this tends to diminish total value and create a “comparison shopping” list. This is analogous to exploding the prices from a price-fixed dinner menu to determine how much the bread costs. Instead, patients should understand that the ultimate outcome of their treatment is the total result, not a sum of its individual parts.
When insurance is involved, clearly fees must be itemized, but this should be accomplished after discussing the total treatment package. If treatment involves different dentists, then it is optimal, but possibly unreasonable, to present them together. Payment options also should be presented during the fee discussion.
Patients are frequently aware of their dental needs, but often avoid treatment for many different reasons, many of which are beyond the control or influence of the dentist. Regardless, dentists have an obligation and opportunity to present appropriate, desirable, and necessary treatment that can improve their patients’ dental health, systemic health, appearance, confidence, and self-image. Appreciating patients’ obstacles to treatment can provide an environment conducive to case acceptance.
Structuring case presentations so that information is presented using the “4 Questions” creates a logical and complete format for discussion. Approaching treatment planning using the principles of “backwards planning” enables both dentists and patients to distinguish between treatment objectives, treatment methods, and treatment sequence.
All information needs to be prepared, analyzed, and communicated for education, disclosure, and informed consent. It should be recognized that both the content and format for patient consultations could influence the success of consultations.
When consultations satisfactorily answer the “4 Questions,” patients often accept treatment and schedule appointments. If not, they either ignore their conditions, return for additional discussion, or move to another office. Insightful, deliberate, structured planning can help ensure patients will want to schedule the treatment they need.
Jeffrey Ganeles, DMD, FACD, a periodontist who practices in Boca Raton with the Florida Institute for Periodontics & Dental Implants, is a clinical professor at Nova Southeastern University. He graduated from Cornell University, Boston University, and the University of Pennsylvania, and is a diplomate of the American Board of Periodontology and a fellow of the ITI and the Academy of Osseointegration. Reach him at firstname.lastname@example.org.