By Alan Stern, DDS
Dentistry today is a very different profession than when I entered it in the early 80’s. Patient trust level in health care providers isn’t what it used to be either. Like it or not, our patients need more than just our clinical solutions to their problems, no matter how brilliant and elaborate they might be. They need to talk, ask questions, and better understand their situation before deciding on how to proceed. And of course, we need to learn how to listen better.
Over time, I have learned that case acceptance has much more to do with my listening skills than my diagnostic ability – an unexpected paradox. I have also learned that case acceptance has more to do with connecting emotionally with patients than fee levels, insurance coverage, or other commonly raised “barrier issues.” Taking the time to listen and explore a patient’s values, beliefs, perceived needs, and priorities naturally has a positive influence on those who seek our assistance. Most importantly, it makes a strong subliminal statement regarding our commitment to properly caring for others and, ultimately, the quality of our practices.
We call our new patient process “co-discovery.” To us, it represents an opportunity to learn with our patients and to help them discover more about themselves, us, and how today’s dentistry might be of benefit to them. It has created some unique scenarios in our practices. Consider the following story:
Kay is a 43-year-old real estate professional. She is intelligent, attractive, well educated, and highly driven. Kay came to my office by way of a live radio program that I conduct on a weekly basis. After proper introductions, Kay was rather perplexed when I asked her to join me in my office to chat. She was expecting me to take her to a treatment room and begin examining her. I could see it in her eyes.
Once seated in my office, Kay paused for an awkwardly long moment when I asked her what she would like me to help her accomplish. Kay then shared with me that her previous dental hygienist persistently lectured her regarding her “gum condition,” and threatened that if she did not stop smoking, she was going to lose all of her teeth.
Kay knew she had a problem, but the approach of her previous dentist and hygienist did not allow her to feel safe. She did not want to lose her teeth, but she also did not want to follow the advice of those who saw threats as motivators. So she did nothing. Kay said she wanted me to help her to keep her teeth and make them look more attractive.
Now, keep in mind that Kay’s temperament was that of a typical “driver,” someone who liked to take control and “cut to the chase.” Her previous negative dental experiences made her like a hair trigger ready to fire at the next threatening event. She paused after making her statement, expecting the same tongue lashing and embarrassment regarding her mouth – the one area of her life that she had not been able to successfully manage.
I chose not to take the bait, and our ensuing discussion revealed the needs and desires of a very sensitive, fragile lady with a significant periodontal problem. I remembered someone telling me that the people who are the most difficult to love are those who need it the most. I made certain that my words and demeanor showed empathy and respect. I then told Kay that it would be impossible to know how to best help her without completing a proper examination. After explaining the details of the process and gaining her permission to proceed, we gathered photographs, radiographs, study models, and occlusal records.
I then suggested that we get together in the near future so we could further explore her situation, discuss her options, and ultimately allow her the opportunity to make the best decisions for herself. In other words, I allowed her to remain in control of both the current situation and the ultimate outcome of the treatment process– very much the preferred emotional habitat of a driver.
When Kay arrived at the second visit, she was once again surprised to find herself in my office and not in a treatment room. I asked her how she was doing and if she had any questions since we were together last. She said she had none, and that she was anxious to get her teeth fixed. We first looked at her radiographs, photographs, and models. I encouraged her to pick them up and ask questions. And together we began to explore her clinical situation and how she felt about it. By starting the examination process at this point, (and not following a physical clinical examination) it became obvious to her that most, if not all of her teeth were periodontally hopeless. This conclusion was plain to see, and she was able to discover it for herself – a much less emotionally threatening scenario. I intentionally said little as Kay wondered aloud how teeth could stay in the mouth without any apparent bone holding them there.
I told Kay that x-rays are only two-dimensional images and suggested that we go back and gently measure how much bone is actually present around her teeth using a very small ruler. As I did this, Kay became very discouraged as the numbers and data did not sound promising. I noticed her attitude was again becoming negative so I stopped the periodontal exam and suggested that we go back into conference.
“So now what?” she said firmly as I closed the door. I responded by asking her what she was feeling now that she knew a little more about her current situation. “You’re not going to take my teeth out!” she said, ready for the all- too- familiar fight. But when I responded that I had no intention of proceeding with anything that she wasn’t ready to do, she again looked perplexed.
Kay paused for a moment and gathered herself, then we calmly talked about the reality of her dental condition, life situation, and – in a broad sense – her options. We ultimately agreed on creating a treatment plan that would allow her to keep her natural teeth as long as possible while she prepared herself emotionally and financially for their loss and more definitive treatment. At this point, Kay’s temperament had changed entirely. The intense driver was gone. She became open, sharing, and, more importantly, showed no interest in trying to control me or the situation. She left with a tear in her eye – a tear I believe was one of mostly joy. Someone had finally listened… Someone actually cared!
Our time together that day led to an epiphany for me, as well. I avoided a battle with a tough-minded driver and was proud that I handled this difficult situation masterfully. I also earned a huge emotional reward for taking the time to truly help a patient make the right choice when it would have been much easier to label her as a “lost cause” and turn my back. I felt that I had turned the corner, and was now consistently behaving in a fashion congruent with my long-term goals.
Kay is currently in a periodontal holding program, and will soon be consulting our implant surgeon regarding the next phase of her care. Her road to dental health will not be easy and it will not be fast. I believe, however that we have already helped Kay more than any dentist ever has. She now, for the very first time, has the opportunity to gain control of this area of her life and to make better decisions regarding dentistry and her entire health.
I asked Kay to reflect on her experience with us. Her words profoundly reaffirm the power (and the necessity) of the co-discovery process:
I can honestly say I knew I had problems, but, never understood the full extent. I still will spend sleepless nights for a week prior to going in for my hygiene visits. However, I do realize that this is a place where I can find assistance, help and no judgment.
The past is what it is and hindsight is 20/20. But, with the smallest of baby steps, which is something I need, I feel my dental health will be reversed. Dr. Stern’s office is a place of compassion and friendship – yet, he cuts to the chase.
I do not need to be told non-truths, just reassured that once we fully lay out a plan it will be executed with me in mind, on my schedule with my input. This is extremely important, since I have never experienced this type of treatment before. I do have some say! Thank you, Dr. Stern.
In the past, I would have considered Kay’s not moving immediately into definitive treatment a failure on my part. I too often put my short-term financial needs ahead of the long-term health needs of those I served. Now I strongly believe that we are doing Kay a great service as well as no harm by keeping her hopeless teeth for a little bit longer as she gathers the resources to address her needs. Also, we are doing her a world of good by allowing her to proceed at her pace.
This has allowed her to begin the process of overcoming her fear of dentistry and dentists. Along the way, Kay has become a raving fan and a pleasure to be around. Most importantly, she will eventually have a properly restored mouth for which she will take full ownership. For now, however, our first steps together have established a trustworthy and a helping relationship based on co-defined goals; the essential building blocks of a successful future.
In this day and age of third party payers, legal intricacies, deceptive advertising, government regulation, and the mad rush to sedate every moderately apprehensive patient, the sanctity of the doctor-patient relationship is indeed threatened; and with it the quality of healthcare itself. I believe that our relationships with our patients can and must be preserved and enhanced. This can only be achieved by facilitating an environment of mutual respect and trust blended with ethical, principle-centered, clinical excellence.
Alan G. Stern, D.D.S., is a graduate of Medical College of Virginia School of Dentistry. He has taught and served as Chief of Restorative Dentistry at Monmouth Medical Center’s Dental Residency Program, and practices comprehensive general and restorative dentistry in Ocean City, NJ.Dr. Stern is is an alumnus of The Pankey Institute, an adjunct faculty member at the University of Medicine and Dentistry of New Jersey and is an advisor and contributing author to Co-Discovery.org, a web forum for comprehensive restorative dentists. He can be reached at firstname.lastname@example.org.