Communication skills

by Sandy Roth

Chapter 3 - Becoming a learner

This month, we present some guidelines to help doctors learn more about their patients and clarify their expectations.

The conversation did not go as Carolyn had envisioned. Eagerly anticipating the new patient, Eugenie Greenlaw, Carolyn reviewed her telephone notes. "Health-conscious. Prevention-oriented. Healthy diet. Avoids fats, sugars, and additives." Eugenie sounded like a perfect patient, at least until she announced that she would not permit radiographs for her children.

Carolyn winced. "Oh, no," she thought, "I was hoping this would be a breeze." Carolyn delivered the carefully rehearsed speech she invoked whenever a patient balked at X-rays. "Mrs. Greenlaw, the doctor insists on necessary X-rays and would not be comfortable treating you without them. You needn't worry; the radiation dosage is much lower than what you would receive from a single day in the sun. And your insurance will pay for them," Carolyn stated. Eugenie remained unmoved. Having exhausted her arguments, Carolyn excused herself and returned with Dr. Shoemaker. "Time for the big guns," she thought.

"Mrs. Greenlaw, I'm so glad to meet you. I'm Ralph Shoemaker. Carolyn has told me that you have some reservations about radiographs. Tell me about them."

Dr. Shoemaker listened as Eugenie outlined her concern relating to something she called buildup of radiation in the myelin tissue. Her mother, she reported, had been told by her naturopathic physician to avoid X-rays for this reason.

"And have you and your children been advised to avoid them as well?" Dr. Shoemaker asked.

"Well, not specifically," Eugenie responded.

"And what is the negative impact of this buildup?" queried Dr. Shoemaker.

"I'm not entirely sure other than it's something my mother was told to avoid wherever possible." Eugenie said.

"You may have to make a hard decision, then," Dr. Shoemaker cautioned. "Carolyn tells me you are a proponent of early diagnosis and prevention, and dental radiographs are tremendously useful for those purposes. Since some conditions are impossible to detect without the advantages of X-rays, you may be faced with choosing to have the information X-rays provide or avoiding a buildup that may or may not be a specific problem for you."

Eugenie replied, "Oh, for finding cavities X-rays are fine - I just don't want them done every time or for no reason!"

Although I have changed the names, this conversation is an accurate recap of one I recently observed in a dental practice. It provides a great example of how important it is for the dentist and other members of the team to shift into the role of learner. I suspect almost every practitioner has had his or her share of patients who expressed reservations about dental X-rays. When this happened to you, how did you respond? Did you assume that the patient's objection was based on radiation concerns and then give him or her a brochure explaining dental radiation in an attempt to allay their fears? Or perhaps you guessed that the patient didn't want to incur the fees for radiographs. If so, you might have become adamant about how important X-rays were to proper diagnosis and treatment planning. I have even heard some dentists report that they no longer have any tolerance for people who resist the diagnostic procedures they are legally, morally, and ethically obligated to perform.

In similar circumstances, many dentists and team members react more like Carolyn than Dr. Shoemaker. Let's look at the difference in their approaches. Upon hearing Eugenie's objection to X-rays, Carolyn, who knows a lot about dentistry and about Dr. Shoemaker's clinical standards, dipped into her knowledge bank, determined to set the patient straight. Her information delivery was professional and cordial, but she made a number of presumptions. Most importantly, her rush to defend her position actually got in the way of a mutually agreeable resolution.

Dr. Shoemaker, on the other hand, approached the new patient with curiosity. He was more concerned with what had influenced Eugenie's thinking than he was vested in the rightness of his position. While Carolyn was the teller, teacher, educator, and informer, Dr. Shoemaker was the "learner." With only a few simple questions, he learned that the patient did not want to have X-rays for "no reason." Since he does not order X-rays without a good reason, he clarified that there really was no problem. He was able to honor her request without violating his standard of care. Carolyn, however, was headed into a impasse with this patient solely because she failed to assume the role of a learner.

What's more, Dr. Shoemaker's questions allowed Eugenie to talk through her position, actually testing it in the open. He never had to tell her she was wrong, and she left this conversation feeling understood and respected. Did Dr. Shoemaker understand or agree with the myelin concern? Not necessarily. He did, however, understand and agree with her perspective: that it is not appropriate to take dental X-rays without a compelling reason. Unlike Carolyn, who was determined to defend her position and quickly drew a line in the sand, Dr. Shoemaker temporarily stepped out of his role as clinician and entered a facilitator role, inviting his patient to share her thinking.

In most practices, the dental staff is knowledgeable and well-informed about conditions and treatments - certainly more so than most patients. Indeed, patients enter practices with ideas that range from sound to laughable. Some believe they developed soft teeth as a result of minerals in their water. Others are convinced that they are destined to lose their teeth because their parents did.

Ideas that sound strange to us creep into patient belief systems for many reasons. Some people remember only snippets of an earlier explanation, opting to fill in the gaps with bits and pieces of half-truths and folk-wisdom. In other cases, people gather ideas from dubious sources, unable to discern their validity, yet compelled by the persuasiveness of the source. Some patients cling to ideas that fit their perspectives on the world - overly optimistic, darkly pessimistic, or Pollyanna-like. Whatever the reason, those ideas will influence your patient's behavior and contribute to the choices he or she makes. You must make it your business to learn about it and understand it if you are to address it effectively.

In most of these cases, however, these perspectives remain untested by patients because they are rarely asked to convey those ideas in full or even analyze the logic of their positions. Rather, dentists and team members alike, having heard a portion of the patient's story, often automatically shift into a practiced telling mode, eager to inform, re-educate, and set the record straight. After all, you all know there is no such thing as "soft teeth" and that tooth loss can be avoided, even for the patient with edentulous parents. You know that X-rays are safe and that hygienists don't loosen previously stable teeth when they remove calculus. But there are many times when you must set aside all that you know to make room for what you do not yet know. This is the skill of becoming a learner.

Of course, dentistry is a profession that requires a tremendous amount of education. In most cases, fortunately, dentists make it their business to pursue clinical continuing education throughout their entire careers. They read journals, attend conferences and meetings, form study clubs, and take courses to increase their base of knowledge. The amount of information dentists have in their brains is staggering, and they develop a habit of telling others what they know, often when it is inappropriate.

Years after dental school, many dentists still tell stories about instructors expecting quick, definitive answers to their questions. "I learned that giving the wrong answer was better than admitting that I wasn't sure," one dentist told me a few years ago. Others have echoed that experience. Demonstrating what they knew was the key to success in dental school. When asked a question, deliver an answer. Be confident, self-assured, and definitive. But this tendency can be just the one that makes it problematic for dentists to learn enough about their patients.

Emulating their dentists, team members often develop a knowledgeable air that borders on arrogance or officiousness, which easily crowds out their own learning. I often wonder if this is a reaction to a general lack of respect they may feel from their dentist, co-workers, and even patients. Of course the only way I'll learn the answer is to ask them directly. The same principle applies to us all.

There is a second type of situation when you must be cautious. Let me give you an example.

The patient, in denial of her condition, had suffered some significant periodontal deterioration. On several occasions, the dentist and hygienist had reviewed the cause of and treatment recommendations for periodontal disease. They used videos, brochures, books, and diagrams to aid their educational approach. When the dentist and team finally got her attention, the patient agreed to a course of root-planing in hopes of arresting the disease and avoiding periodontal surgery. After completing two quadrants, the patient returned for her third treatment. After she was seated, she looked at the hygienist with sad eyes and said, "Tell me again why I am having this done?"

"How many times must we explain this?" thought the hygienist to herself. She again opened her reference book and began the explanation of how periodontal disease progresses. "No," said the patient. "I understand all that stuff you keep telling me. What I mean is, why me? Why is this happening to me? I did everything I was told. I went to the dentist every six months. I brushed regularly. I flossed and had cleanings when I was told to come. What did I do wrong?"

Sometimes we provide the right answer to the wrong question. I often hear patients ask questions, yet suspect that those initial queries are just the tip of the iceberg.

"Do you recommend those tartar control toothpastes?" If you think the "right" answer is either "yes" or "no," you may miss a grand opportunity to learn something more.
"Are implants safe?" This question begs for a deeper understanding of what prompted the patient to ask. What is he or she concerned about, and what is the patient considering?
"What about at-home bleaching kits - do they work?" As simple as this may sound, there may be something more. The question may be an attempt to bring appearance issues into the treatment plan.
"How long can I wait to have this crown done?" Although we often hear this as asking permission to delay treatment, that may not necessarily be the case. One would be advised to inquire further, perhaps with, "What kind of plans are you wanting to make?"

Training yourself to become a learner

Many dentists and team members have become so vested in what they know that shifting into the role of learner is difficult. The following guidelines will help frame your thinking and support you in approaching patient relationships with a different perspective.

You may be an expert on clinical dentistry, but your patient is an expert on herself. Avoid confusing this distinction. In the past, many patients relied almost exclusively on the dentist's opinion, which largely determined the course of action. "You're the dentist - whatever you say!" Times have changed; most patients now weigh the dentist's clinical recommendation against other factors.

Most dentistry is highly discretionary; it competes with other uses for patients' discretionary dollars, time, and energy. Patient choices will almost always be based on the value they place on the services, relative to the value they place on other options. The more you know about what your patients value, the more you will understand their choices. This is one of the most compelling reasons for becoming a learner.

What you don't know or understand is as important as what you already know. It's easy to convince yourself that the little you know about the patient tells the entire story. You can also trick yourself into believing that what you now know about a patient is what will always be, but that is hardly the case. People are complex and they change, for reasons unrelated to you or your influence over them.

If you must presume, presume that each person is different; make this presumption during each patient visit. Make it your business to learn what is new or different about the patient and how it will impact the services you perform. Adopting this perspective will almost always result in new and valuable information about your patients and will help keep your relationships growing and on track.

"Why" may be more important than "what" when it comes to understanding patient belief systems. The things that seem logical to you may not occur to your patient - and vice versa. Because patients are almost always at an educational and informational disadvantage, it's unfair to assume that what makes sense to you makes sense to them. Asking what is behind a belief or perspective is a great learning tool. It demonstrates a genuine interest and respect for the patient's point of view and increases the likelihood that the patient will be honest. Remember, the issue isn't the resistance to X-rays. It's why the patient is resistant.

Forget the notion that asking questions is a sign of ignorance. Questions are the road to insight, wisdom, and knowledge. Avoid answering a question until you are clear about what the patient wants to know.

"Would you restate your question, please? I want to make sure I understand it" is a great way to open the door. I guarantee you will get more insight and be better prepared to provide an answer.

"I'll be happy to answer your question, and I'm curious about why you ask" will yield more details and convey a genuine interest in the patient's perspective. You can even recover from a too-quickly framed answer by returning to the question. "I'm not certain I answered your question. What part did I miss or not understand?"

Patients want your opinion, and they are entitled to it. Your opinion has more influence, however, when the patient feels understood and respected. Patients pay for their dentists' expertise; there is a time and a place for informing and sharing your knowledge. Patients are more open to the recommendations of dentists who take the time to ask questions and learn about what is important to them first. The skilled dentist and team will develop their abilities to learn first - and inform second.

Dentists, unlike attorneys, must only ask those questions for which they do not yet have answers. Attorneys manipulate for a reason: they are charged with framing testimony to make it favorable to their position. Manipulative courtroom tactics are highly unsuitable in the dental practice. Your patient is not your adversary; you must design your questions to discover the best way to collaborate.

Just as your questions about symptoms help you learn enough to discover the correct diagnosis, your questions about how patients think and what they want will help you learn enough to discover the right treatment recommendations.

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

For the next month, I encourage you and your team to work on your learning skills. I have a few questions to help you frame your conversations with patients. You might use these questions to prepare yourselves for new patients, patients who are returning for visits with the hygienist, or even patients who have dropped off your radar screen.

Remember that these questions must be genuine - that is, you must be sincerely interested in the answers. I recommend you post the questions in your lab or staff lounge and refer to them while preparing for the patient workday. It may be helpful to transfer these questions to a checklist laminated for future reference.