Are you treating the tooth or the patient?

Sept. 1, 2001
Do you sometimes forget you are in a health-care profession, not a health-productivity profession? Listen to your patients!

Do you sometimes forget you are in a health-care profession, not a health-productivity profession? Listen to your patients!

by Gregory L. Psaltis, DDS

Your day is winding down as you go through the charts, making notes and treatment plans. It's been a good day — very productive, crowns seated with no problems, and you stayed on schedule. Then, your receptionist notifies you that Mrs. Peterson, a long-standing patient, has requested that her records be transferred to Dr. Maxwell's office, and that she wants you to call her.

Suddenly, your day has disintegrated and your stomach is sending you signals of trouble. This is difficult to understand because you've always provided excellent treatment to Mrs. Peterson. You've done three crowns, one of them an anterior, and she said she loved it. You feverishly scan through her chart, searching for some sign that your treatment was anything less than ideal. Your memory tells you that her treatment is on course. In the 11 years you've had her as a client, your work has been nothing but superb — perhaps some of the finest restorative work you've ever done! Now, she wants you to call her.

Calling patients is the job of Marilyn, your receptionist. She's the one who deals with people on the phone. You dislike this part of dentistry; you feel your job is to provide the highest quality of treatment. You hire others to handle the personal interactions with patients.

So, after some procastination, you call Mrs. Peterson, who thanks you for calling. You're not sure exactly what to say, but you begin by asking her if any of her teeth are bothering her. Mrs. Peterson informs you that her teeth are fine, but that she has chosen to leave your practice. When you ask why, she tells you that she hasn't sensed for quite a while that you are aware that she's even there. She tells you that she doesn't feel you've cared for her. Shocked, you can only think of the hours spent in treatment-planning her case and the time you spent meticulously instructing the lab on how the crown for tooth No. 9 needed to be shaped. You are at a loss for words. She thanks you for your work and says that she has heard from friends that Dr. Maxwell is exceptional in providing care, which is what she is seeking.

The conversation ends and you are mystified. How could you have done any better? What could Dr. Maxwell, the new dentist down the street, possibly have to offer this client that you haven't already given her? The answer lies with Mrs. Peterson's own words. Having spent four years in dental school learning the technical skills to bring people's mouths back to health, we tend to forget that dentistry is a health-care profession. It is not the health productivity-profession or the health perfect margins profession. It is still a health profession that provides care. Mrs. Peterson even told you this, yet you missed the message, because too often "treatment" becomes confused with "care." They are not the same!

Risk-management experts will testify that more lawsuits are brought on due to the manner in which a person was treated as a human rather than the manner in which that person was treated as a patient. Nothing goes as far toward building rapport with patients than paying attention to how you communicate with them. Let's look at some techniques.

Question behind the question
Regardless of how we may view ourselves, dentists are still "doctors" — or authority figures — to many of their patients. As such, they may be unable to approach you with a direct question. Instead, they will either infer their question or try to ask it in such a peripheral way that we completely miss the main point. I call this phenomenon "the question behind the question."

A simple example might be the patient, who, when presented a treatment plan for a crown, asks, "Can't this tooth be filled?" Dentists frequently answer that question directly, with a detailed and lengthy explanation about why a crown is the superior choice. These are not answers to the question; they are mini-seminars! In fact, this patient may have been thinking, "There's no way I can afford this treatment." Yet, perhaps due to ego, shame, or fear, the patient may be too embarrassed to tell you the real reason he or she prefers a filling. Instead, the patient resorts to a question that implies a dilemma, but doesn't state it clearly. If the patient's actual agenda has to do with finances, chances are your "dental seminar" will have little impact.

In my pediatric practice, the most common situation of this sort is when a parent — usually the mother — brings a child in because of "decayed front teeth." As professionals, we all recognize this prevalent pattern as early childhood caries. Our tendency is to provide a seminar on the topic for the parent. The mother will often ask me, "Does my child have soft teeth?" It is my firm belief that not every person posing this question is ignorant. Frequently, the mother knows exactly what has caused the problem and has an enormous sense of guilt about it. In other cases, she may be fearful about the treatment her child may face. Just as in the first scenario, this mother will not be attentive to a protracted lecture about bottle syndrome or anything else. She already has exceeded her comfort zone by simply bringing the child to the office to confirm her worst fears.

In both cases, the astute practitioner will try to determine the actual concern of the patient prior to beginning the dental reprise. This isn't always easy, since some people will continue to try to hide their concerns, while others feel things so deeply that they fear letting them out. I have had success in separating the literal question from the question behind it by posing a question of my own. You might need to customize the question according to each situation, but, in essence, the technique involves simply asking the patient or parent for more information. In the first case, I may be uncertain if this man is concerned about the crown itself, the actual procedure, the number of visits, the cost, the cosmetics, or something I can't even guess. I simply ask him, "Can you clarify your question for me a bit more?" This opens the door for the patient to convey his principal concern. You may be able to hear the genuine concern — or you may still need to pursue it. If you succeed in getting to the core issue without the patient losing his dignity, you will have shown a level of caring that goes far beyond the crown that you might place in his mouth.

In the second case, it may be easier to imagine that this mother has feelings of guilt or fear. I consider her question behind the question easier to determine than in the first case. When I feel that I have sensed the underlying issue, I will address it directly, such as, "I can imagine you've been worried about this for quite a while." When I make a statement like this, the mother often will open her own floodgates (which can be verbal or tearful) and pour her heart out. It's important for her to feel that the dentist has noticed her human feelings before she is ready to listen to dental information. Again, if you can notice that something is going on other than an ignorant dental question, you will be perceived as someone who really cares.

Learn from negative feedback
There are two main forms of feedback: positive and negative. With positive feedback, we feel a swelling of our inner selves — an affirmation that lets us know we have done something well and that it's appreciated. Very few people would ever say anything about positive feedback other than, "I can't get enough of it!" It may be worth more to the successful practitioner than the financial rewards or the work itself. In spite of this, my experience is that I sometimes don't even know what I did right! A client might say, "Your office is so great!" I'm just happy to know this client was satisfied. If that client has not been explicit in the way we were "great," then this comment has not taught me very much.

When it comes to negative feedback, some doctors may switch to the Mr. Hyde side of their personality and become defensive or even belligerent. While I'm not suggesting that negative feedback is easy or as fun as the positive type, I would say that it is often more useful and helpful to the recipient. This experience has grown out of my attitude toward receiving the information. Once you understand that this form of feedback is actually a gift from the speaker, everything changes. I do not necessarily solicit such gifts, but I have learned to open my mind and my ears when a client has a "complaint."

When I receive a negative comment, I have learned to not react, justify, explain, or refute the comment. Instead, I ask for more information. The speaker usually will state the problem in far greater detail; it is frequently some aspect of the practice that actually might require more attention.

I now make a point of trying to see the problem from the patient's perspective, so I can better understand his or her concerns and what I need to do to address them. I always thank people for negative feedback. I tell them that although I don't necessarily enjoy hearing complaints, I certainly learn from them and would prefer they bring their concerns to me rather than to a neighbor.

Perfectionists that we are, dentists may delude themselves into believing that our practices are perfect. They well may be perfect — for the dentist, that is! However, the lifeblood of the practice still depends on satisfied clients, not a satisfied doctor. It is this reaching out to our clients as actual people that results in loyalty to our office. This loyalty will far exceed the smoothness of a crown margin or the color match of an anterior composite restoration.

As for Mrs. Peterson, this situation presents an opportunity to discover something about your practice that you might need to know. If you had asked her for more information about her feelings, she might have expressed concerns to you about the words your receptionist used when discussing her missed appointment two weeks ago. Mrs. Peterson's son had just been in an automobile accident on the morning of her appointment. She was at the hospital, talking to the ICU doctors about his prognosis from his serious injuries. She would have told you that she didn't appreciate coming home to a message from your receptionist about how one hour had been reserved for her and the office would have liked a phone call to let us know she wasn't coming. She would have told you that she was so upset about her son that her dental appointment just wasn't on her mind.

Just as in the other cases, she wasn't in a frame of mind to get a "lecture," even a brief one. By pursuing this "negative feedback," you might have learned something important about your protocols or terminology. You also might have kept her as a patient by thanking her for this important information and then sending flowers to her son in the hospital. Those actions would have shown her you really cared for her — and that was what she really wanted all along!

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