Tips from a fellow traveler

Oct. 1, 2000
A good storyteller is not defined by the story he tells, but how he tells the story. This same technique applies to good case presentation.

Part 4

A good storyteller is not defined by the story he tells, but how he tells the story. This same technique applies to good case presentation.

Marvin H. Berman, DDS

As students in dental school, we have all we can do to try to assimilate basic sciences and the rudiments of clinical dentistry. Then, you enter the world of private practice and discover that very little thought has been given to business principles, managing a practice, or patient relations. You enter private practice with a lot of enthusiasm and idealism in terms of providing the best care possible for your patients. But, you must be able to inspire them to understand, accept, and pay you for your efforts ... not an easy task!

Practically speaking, you must identify the patient`s wants and needs and then formulate the ideal treatment plan. I`m not saying you should do what the patient wants. There are wants and there are needs. That means the patient has the ultimate choice when it comes to the treatment, but you are the voice of professional reason.

This is not a restaurant where the patient orders from a menu. "I`ll have the soup and not the salad. I`ll have the rice instead of fries. Can you just do the worst teeth? Can you just do the front teeth?" Don`t get involved with this kind of thinking!

How about a pair of glasses with only one lens? How about removing half of the appendix or one ovary? Remember, when the patient expresses doubt about your diagnosis and treatment plan, it`s rarely ever about intellectual thoughtfulness or scientific knowledge. It`s usually about money.

In some instances, I`ll put it directly to the patient: "If the treatment were free, would you consent to the plan?" I enjoy the unguarded response I get when the patient usually says something like, "Well, sure!" Then I talk to the patient about priorities. A TV set is important. A piece of jewelry is important. But how about your teeth? Why would a guy spend $80,000 on a gray Mercedes, but will not part with a couple of thousand bucks to fix his two gray central incisors? Priorities!

On the other side of the coin, I`m speaking about the patient`s needs and wants - not the dentist`s. "You came just in time, Mrs. Wilson, I have two kids in college. Ha! Ha!" I deplore the tactics of some very aggressive colleagues who specialize in what I call "creative dentistry" - the "let`s look for something to do" school of thought. Why take an impression for one crown? You may as well crown the tooth with the old amalgam behind it. Or, it`s difficult to match the shade for two laminate veneers, so let`s do all six anterior teeth. Are you extracting enough third molars? You`re not recommending enough sealants. You should be taking more X-rays.

Solving your busyness problems by taking advantage of a patient`s vulnerability certainly is not the ethical road to success. When one of those stock salesmen calls me on the phone with a "once-in-a-lifetime stock" deal, I always ask him, "Did you call your mother with this terrific deal? If it`s so terrific, you really should call your mom first!" Invariably, the stock salesman hangs up!

Doctor-patient consultation

You know the story. You are the storyteller, so tell the story. Communication is everything. Keep these four things in mind:

(1) You`re never fully dressed without a smile. No matter what, a smile helps carry the day. So smile - a lot.

(2) Don`t sit behind a desk. The desk is a barrier. It distances you from the patient. The atmosphere should be intimate, but not intrusive.

(3) Focus on the person to whom you`re speaking. "I can see it in your eyes."

(4) The first look, the first word, can make or break the relationship. The initial impression sets the tone.

First the good news, then the bad We`ll be able to save all your teeth. You have very nice teeth, but ..." Or, "She`s a beautiful little girl! There are just a couple of things that we can do to make her smile better." In other words, we can fix everything, but here`s what we have to do. The most important first words are: "We don`t have to do the treatment." What if we don`t do the treatment? There are only two things we must do in life - die and pay taxes.

As soon as the patient hears the magic words, "You don`t have to do the treatment," the pressure is off. The tension drains away. You can almost hear the sigh of relief. Now, your patient is very receptive to the story you`re telling - the story being, of course, why the treatment is really and truly necessary. You`ve given the patient the feeling that he or she is not trapped, not a victim - that the patient is in control of the situation to some extent, even though you`re pulling the strings.

This is the tried and true, low-pressure salesmanship technique. You are not selling a product. You`re selling yourself as a person to be trusted and respected.

In dental school, we were forced to deal with units or requirements - the piecework mentality. Insurance companies attempt to put us into that framework all the time. It`s a mistake to think of ourselves as producers of crowns or fillings or appliances. We provide a professional service, which encompasses a much broader relationship than that of a salesman and customer. The caring aspect of the treatment we provide may be more important than the treatment itself. That is the essence of the patient-doctor relationship.

A word about body language

Even after all these years in practice, I still have a passion for what I do. My enthusiasm is infectious and immediately apparent when I meet a new patient. If this were a "Winnie the Pooh" story, I`d be bouncy Tigger, rather than disconsolate Eyore. The patient - whether an adult or child - can tell that I genuinely like people. My eyes make direct contact with theirs. My handshake is firm and confident. My smile is overt. I convey the feeling that I don`t care about money; I care about you. Patients are more comfortable with a doctor who is confident about himself.

Alternatives and choices

You`re at a wedding and the minister asks the bride, "Do you take this man to be your lawfully wedded husband?" The bride carefully looks around at all of those assembled and answers, "No, I think I like that one over there."

It`s altogether fitting and proper that you inform patients about all of the possibilities and choices that are available to them. However, at some point, you, the professional, must bring all this information together to form a cohesive plan that brings all of these possibilities into a manageable perspective for the patient to consider. Having too many choices sometimes can be very confusing.

Thinking out loud in the presence of the patient and mentally sorting through the possibilities in front of him or her can be very effective. You`re bringing the patient into the intimate workings of your mind as you bring up and reject ideas, almost like doing a monologue in a play like "Hamlet" - "To be or not to be? That is the question."

In the case of a doctor-patient consultation, that translates into: "To crown or not to crown; to do an implant or a bridge? That is the question." The truth is that you`ve probably already made your decision. But it is far better psychologically not to come into the room with the one and only definitive solution. Then, the patient is put in the position of asking, "Well, what about this? Why can`t you do that?" Or - the one we all love to hear - "A friend of mine had the same problem and his dentist did something else."

By exhausting all of the possibilities during the open-thought process, you also minimize the chance that the patient will express the desire to go for a second opinion.

How the process works

A 35-year-old man had a maxillary first molar extracted. His dentition is otherwise intact, but, naturally, we`re concerned about the empty space. The patient says, "It doesn`t show and it doesn`t hurt." You know the consequences of leaving the space open (drifting teeth, arch integrity, supereruption, periodontal considerations, etc.). Explain all of the ramifications and what you would recommend as a remedy, offering a number of choices.

How about a removable partial denture? A 35-year-old, taking teeth in and out of the mouth; the ugly clasps wearing down the abutment teeth? Not my first choice!

How about a Maryland-type bonded bridge? Not a bad idea. It would be easy to do because of the minimal tooth reduction, and it would be relatively inexpensive. Did I tell you that he has a very strong bite and grinds his teeth once in a while? Well, he does! Now what?

How about a conventional three- unit bridge with a pontic and full coverage on the adjacent abutment teeth? Sounds good! But did you know that the would-be abutment teeth are perfect, caries-free, and restoration-free? What now?

Okay, how about an implant? Perfect! But when you look at the X-ray, the maxillary sinus dips down on that side, leaving only 5-6 millimeters of bone. Of course, we could do a bone enhancement, couldn`t we?

All of these possibilities are raised with the patient present. Then it`s up to you, the doctor, to offer the solution that is in the patient`s best interest. What would you do if it were your mouth? Or, your mother`s mouth?

By discussing the choices openly, you`re not really asking the patient`s opinion. You`re merely letting the patient in on your thinking. Most patients want the doctor to be confident with the decision. After all, you`re the doctor. You`re the expert!

By the way, in the example above, I`d probably start with the bonded bridge to make sure we hold the space. That gives us the luxury of exploring any of the other options later.

A timely tip

Don`t compromise your standards. If, for example, you feel a tooth requires full coverage and the patient asks, "Can you just do a filling and see what happens?" Don`t agree to it! The request usually is money-driven. The patient will forget this conversation and, when the filling breaks, he or she will never remember or admit to remembering that conversation. Instead, the patient will tell everyone within earshot that the filling you did was no good and what a terrible dentist you are. You are the professional. You know the right thing to do. Stick to your guns!

Visual aids

X-rays, intraoral pictures, videotapes, and study models are all helpful in vividly illustrating and describing a patient`s clinical condition. There is no question that one picture is worth a thousand words. However, you still need the thousand words to tell the story! You can`t just point at a picture and say, "Wow! That`s bad! We`ll have to fix that! That will be $5,000!"

Tell the story! It`s like reading a story to a child from a book with words and pictures. Remember, case presentation is about educating patients, enabling them to make the choices that are best for them. An informed patient feels more empowered. Don`t focus on the visual aids. Your eyes should make direct contact with the patient for the most effective communication.

Don`t talk down to the patient and don`t get hung up on technical details. You want to inform, but not confuse. A little information goes a long way. Use plain talk. The pulp is the nerve. The dark spots on the X-ray are cavities, not caries. The local anesthetic is the shot, not local anesthesia. It`s a tooth lying on its side in the lower jaw, not a horizontal bony impaction. And whatever you do, don`t look irritated or sound impatient if you have to explain something more than once. What`s obvious to you may not necessarily be obvious to the patient. Remember, this is an educational experience.

Happy travels!

Dr. Marvin Berman is an internationally recognized pediatric dentist. His career as a successful practitioner and lecturer spans almost four decades. He also is an ambassador for dentistry as a health reporter on CBS (News Radio 780) and via media appearances as a consumer adviser for the ADA, the Chicago Dental Society, and the Academy of Pediatric Dentistry. He is an associate professor at both the University of Illinois and Northwestern University, and still is the principal dentist in a thriving practice in Chicago. For more information regarding Dr. Berman`s seminar and lecture availability, as well as his videotape course on "The Berman Trilogy - Winning Friends and Influencing Patients," contact him by phone at (773) 764-0007, by fax at (773) 736-0143, by e-mail at Marvy18@, or write to him at 4801 W. Peterson Ave., Chicago, IL 60646.

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