Do your patients trust you?

Recently I was referred by my medical GP to a surgeon for a simple but elective procedure. Whilst I had been told of the surgeon’s prowess, in the consultation with him I didn’t feel confident about trusting him to carry out the procedure. The surgical procedure didn’t go ahead as a result.

Although clinical skill is essential to practice success, it isn’t enough. A strong practice can only be built by those possessed with good technical skills coupled with great communication skills. If you are like many dentists, your treatment may be better than your talk about the treatment. I once walked past an operatory where a young dentist was asked by the patient: “Are you wearing that mask because you have a cold?” She replied: “I’m not wearing this mask to protect you from me. I’m wearing it to protect me from you!” Sometimes without thought we can sabotage a professional relationship with comments such as this when we could take the opportunity to strengthen the professional relationship by describing how infection control procedures effectively serve to protect patients from the transmission of disease.

I recently saw an Orthopaedic Surgeon being interviewed once on daytime TV. He was asked “Why are some patients so dissatisfied with their orthopaedic surgeons?” He answered

“Well, I know of one doctor who was sued for cutting off the wrong leg.” Why would he have chosen that statement, I wondered, when he could have said something better like: “When a patient is dissatisfied, it’s usually not a lack of care, but a lack of understanding between the patient and the doctor. Through good communication, concerns can often be resolved. So if you are not satisfied with any aspect of your treatment, call your doctor first — not your solicitor.”

Good communication = practice success

Dentistry is an intangible service, not a product. Patients judge your service on the way it is delivered. Any part of the interaction with the patient can become a “moment of truth”, during which the patient forms an impression of the quality of care being provided. Because patients cannot accurately judge the quality of clinical treatment, they fill this vacuum in judgment by assessing non-clinical aspects of your care. Your reception room furniture may give the patient a view about your treatment as to whether it is up-to-date!

Research proves that patient satisfaction is created largely by the communication skill of the health care provider.[1] Conversely poor communication is the most common reason for dissatisfaction with care and for a decision to terminate the doctor-patient relationship.[2] Personal contact with you and your team, whether positive or negative, is the most memorable aspect of dental care for patients.

We all have days where the daybook seems full of patients hell-bent on making ‘mountains out of molehills’. The reports of ADA NSW Community Relations Officer’s indicate that patients actually want more communication with you than they are willing to ask for. Research has shown that patients are reluctant to raise questions, ask for information, or voice their important concerns to their doctors.[3][4] Patients who ask direct questions end up more satisfied with their communication with health care professionals than patients who ask indirect questions.[5]

Although patients may not voice their complaints, they will still leave your practice if they are dissatisfied. Patients don’t always tell you about the source of their dissatisfaction, but they do tell their family, friends and usually the whole suburb or town! Consider these findings in a 1991 national public opinion study commissioned by the American Dental Association[6]:

  • 60% of patients said they would change dentists if they were dissatisfied or had a problem
  • 23% said they would talk to their dentist to attempt to resolve a problem
  • 90% said they would tell family and friends about their dissatisfaction with the dental practice!

A classic study in health-care research shows that good communication between doctors and patients can lead to less postoperative pain, less medication and earlier recovery.[7] Furthermore, good communication increases patient utilisation of dental services and inhibits patient anxiety. Patients are more likely to comply with recommended treatment if they have a strong respect for the dentist and staff.[8] Patients who have a good relationship with their dentist are more likely to remember and follow instructions, refer other patients, and pay their bills. And finally, patients who are satisfied with their dentists are not likely to sue.

Building trust

Trust is the most important component of your patient relationships. With a mind-set of “I may not know dentistry, but I do know about people”, patients use how they feel about you to determine how they feel about your message — and what they are going to do about it. If patients trust you, they will trust your message. Only after they make an assessment of your character will they decide about treatment. Patients indicate that the honesty of their regular dentist is the most important reason they stay with a dental practice. In fact, patients act on trust far more than dentists think they do. In a recent study[9], 40% of the dentists surveyed said patients accepted treatment because they believe that it is necessary. However, of these patients, only 8% said that they accepted treatment for that reason! The most important reason that these patients accepted treatment (almost 60 percent!) was because they “trusted the dentist”.

Because you are an accredited licensed professional whose right to practice is granted under national legislation, most patients will trust in your clinical abilities. But we all have had patients who have initially questioned our competence. Four communication techniques will build credibility in your clinical skill and professional judgement. The first two can be used every day to enhance patient confidence. The last two are for use in individual conversations with doubting patients.

Highlight your professional credentials

Display your degree and other certificates on the reception room wall, along with the certificates and licenses of your whole dental team. Choose a prominent location and invest in fine frames. List your credentials in your practice brochure. If you produce a practice newsletter, when you or a member of staff attends a CE course, note it in your practice newsletter. Further, when your office is closed for training, make sure that your answering service answers with a positive message that your team is attending a professional education seminar. When you have an opportunity, mention your professional education activities if relevant. You can mention to the patient what you learned by speaking at the university or speaking at the hospital.

Have staff compliment the practice

Patients appreciate messages which reinforce that they have received quality treatment. Your hygienist or chairside nurse can say to the patient “She’s an excellent dentist. That’s one reason why I like working here”. The dentist can say to the assistant “Thank you that was perfect” or the dentist can comment to the patient “The hygienist did a superb job on your cleaning”.

Many dentists and even team members are not used to emphasising their competence; some will minimise their skills in the name of professional modesty. Just as patients believe messages that put your treatment in the best light, they will also believe messages that devalue your service or are negative.

Compliment the recommended treatment

Dentists and staff sometimes miss opportunities to talk about the excellence of a particular treatment recommendation for a patient’s unique dental situation. If for example a young patient’s mother questions the value of her son having sealants, rather than give a generic reply (eg “Sealants are important for every child”) you could personalise the message by saying “Sealants will be a great benefit to Johnny. He did have those two cavities last year in spite of his enthusiastic brushing. Sealants will protect his teeth from decay now and in the future.”

Mention sources that the patient trusts

When a patient questions your expertise, let them know that you don’t stand alone in your opinions. For example, a patient who seems suspicious of fluoride might be reassured to learn that fluoridation is supported by the ADA, the AMA, the Royal College of Physicians, the American Cancer Society and the World Health Organisation. Or a patient asking you about sterilisation protocols might be reassured to know that you practice universal precautions which are recommended by the National Health and Medical Research Council, the Dental Board of Australia, current Occupational Health and Safety Standards and the American Centers for Disease Control.

Patients and your commitment

Patients want to know if you really believe in what you are saying. We have all been asked by a patient sometime or other “Would you have this treatment yourself?” or “Would you provide this treatment to your mother?” In these situations, you have to let the patient know that you are personally committed to your professional recommendations. It has to come from the heart. Many patients have very strong ‘bulldust meters’ and can smell a phony a mile away. To build a patient’s faith in your recommendations for treatment, you can:

Discuss your own experience: Dentists as technical people with specialised training may prefer scientific facts to personal anecdotes. However most of your patients are the opposite and will respect your personal testimony. An example of using personal experience to build trust would be “I provided a similar fixed bridge for my brother after he had a front tooth knocked out in a car accident. Rather like your situation, really. I only recommend treatment that I would want for myself or my own family”. Or, conversely, if a patient prevails on you to carry out treatment that is not going to be successful, say “Because I wouldn’t want that treatment for myself or any members of my family, I wouldn’t feel right about doing it for you. Frankly, I don’t think it is in your best interests.”

Explain your recommendations: Let the patient know that you are aware of a range of treatment options and have good reasons for selecting amongst them. Let them know of the benefits to them for proceeding with the treatment, but don’t forget to advise them of the limitations and risks.

Some patients will think you are telling the truth, but not the whole truth. They might ask you about seeking a second opinion or ask you about the competency of another dentist. When they do this, they are testing your candour.

  1. Present a balanced message: When you are faced with an apparent lack of patient trust, it’s tempting to focus on the benefits of the treatment and downplay the risks. You may be torn between your professional responsibility for full disclosure and your personal desire for persuasiveness. However this is no longer a dilemma as research has shown that two-sided messages (those presenting advantages and disadvantages) are judged as more trustworthy than one-sided messages (those presenting advantages only)[10] By giving a balanced picture of benefits and risks, you build credibility. For example “This treatment has both benefits and risks to you. I want to be as clear as I can in describing them to help you make the decision that’s right for you. I want you to be fully informed”.
  2. Avoid jargon: Research suggests that dental jargon will confuse patients. Your goal is to choose words that are understandable to patients so they think “This dentist speaks my language. I feel better when I know what’s going on”. Remember that the dento-legal literature is full of stories about patients have successfully sued dentists who have provided warnings which were not given in plain English that a lay-person could be expected to understand! For example, if you are warning about the risk of post-operative paraesthesia after third molar surgery, don’t say “There is a risk of you sustaining inferior alveolar nerve paraesthesia which is usually transient”. Instead say “There is a risk that you could end up with a numb lip, tongue or chin, and that numbness may be permanent”.
  3. Open the doors to information: Today we live in the era of information, whether we like it or not. The knife cuts both ways, and there is a lot of pseudoscience and misinformation on the internet, posted by unknown people who may have no formal education or knowledge, and in some cases be more than one sandwich short of a picnic! Dentists believe that they are the holders of dental knowledge and sometimes do not take kindly to this ‘authority’ being usurped. I once overheard a senior dentist say “Your mother told you what? Where did she go to dental school?”

Whilst this pseudoscience is of course very frustrating to the consummate professional who has dedicated his or her life to amassing scientific knowledge and skill the hard way, patients wonder if you’re hiding something when you discourage them from gathering information on their own. If a patient says “I read somewhere that this treatment doesn’t work”, don’t waste your time quizzing them on the source of the information (“Was it A Current Affair?”) or try to criticise the publication (“Well, I’ve never considered the Woman’s Weekly a dental journal”). Instead, you might say something like this: “I know there have been some articles in the press and on the internet. Sounds like you have done some research into this. Would you be willing to consider or read some additional information?” Provide the patient with brochures, research reports, and if requested, referrals for second opinions. Believe it or not, a patient does not actually have to read the material or go and get the second opinion. Sometimes your willingness to go this far with them is enough to build their trust!

  1. How do you communicate confidence?: When it comes to building patient trust, it is not just what you say but how you say it. Your non-verbal behaviour is as important as your word choice in communicating confidence in your abilities. Eye contact, body language and vocal style are all important factors in developing a dynamic and confident presence. Speak with energy, not in a tired monotone. Smile, but vary your facial expressions. Make and hold direct eye contact and don’t look down or away when you are speaking. Have a good forward posture so the patient feels that they have your complete attention. Don’t fold your arms or fidget.
  2. Voice respect for the patient’s concerns: When a patient expresses a concern involving any of the trust issues, begin by understanding the concern and stating it in your own words. It is all too easy to take the other approach when your credibility is being brought into question. Some dentists will leap to their own defence and suddenly they are on the opposite side to the patient. In all of these situations, the patient will hold fast to his or her views until they are acknowledged. It’s the universal law of indirect returns, which you should learn if you don’t already know. The law says that if you wish to receive something, you should first learn to give it. So know this: you must grant credibility to gain it.

You need to practice the skills of ‘active listening’, a concept first introduced by Psychologist Carl Rogers. Simply put, it is understanding what the other person is saying and feeling, and then communicating back in your own words what you think has been said. You thus serve as a mirror. In this way, you validate the patient’s position, without necessarily agreeing with it.

If a patient voices an opinion and you respond immediately with information that contradicts that position, the patient may think “He doesn’t get it. He must have not heard or understood what I said. I better say it again, louder.” And so he does. People are prone to repeat their message until they get a clear signal that the message has been received. Ask any parent of teenagers, who are surely the masters of this technique!

The best clue for effective paraphrasing is to ‘voice the value’. If you voice a patient’s values in a given situation, you can make a positive statement of his or her views. You will frequently find that you and the patient agree on the value and can search for a way to meet it. For example, if the patient has said “Really, I‘m not comfortable about a treatment that costs that much” you could reflect the patient’s values by saying “It certainly is a significant investment. You deserve to know precisely what you are paying for. Perhaps it will be easier for you to make the decision if we review the benefits of the treatment for you and the risks of not having it.”

Don’t say “trust me!”

More is less! The paradox of trust is that the more you ask people to trust you, the less they trust you. Again the law of indirect returns, but this time, upside down! Trust is built when trust is unnecessary and not asked for – such as when patients are given a sense of control over their situation and a way to judge your abilities for themselves.

First off, invite doubtful patients to judge their dental condition for themselves, the so-called mutual or co-diagnosis. For example “That’s an excellent question. If you have a look at the image shown on the screen by the intra-oral camera — do you see this — and this — in your mouth? Have you noticed X or Y symptoms? You have? Then you have experienced for yourself the existence of this problem and you can now see the cause.”

Don’t forget that most patients do not have a high dental IQ. You have to bring their dental IQ up by providing educational materials so that patients can assess your recommendations. Some patients will not watch the video or read the brochure. Sometimes the offer is all that is necessary and the fact that you have provided these things to assist them to come to an informed decision.

If you insist on a treatment plan without input from the patient, the patient will likely reject it. The problem will lie with the patient’s suspicion of a process which excludes him or her. One treatment plan does not fit all! Patients are individuals and will rail against a universal approach which dictates the same plan for all patients! Patients are far more likely to accept treatment if they are involved early on as partners in their own care.

This article has been about establishing trust with patients. There are many tough questions that a dentist may get asked every single week of his or her practicing life. Whilst all such answers must take into account the many factors that are only revealed in an individual consultation, there are some tremendous answers to be found in Robin Wright’s book Tough Questions, Great Answers[11]. A highly recommended read for all practitioners who wish to improve their communications skills.

Some examples of trust-based questions and answers from Robin’s book are below:

Patient: “Wow! I can’t believe that those specialists are so expensive. Do you get any kickbacks from your specialty referrals?
Dentist: “What an unusual idea! (Dentist surprised at question) I suppose people do wonder how we select the specialists we refer to. We refer our patients to specialists based on the excellence of their clinical skills and patient care. The only ‘kickback’ we ever receive is a patient telling us they were pleased with the specialist!”

Patient: “My neighbour/husband/co-worker etc says that . . .”
Dentist: “Well, it’s good that you have a family member willing to discuss your treatment with you. Dental researchers actually looked into that idea. It actually works for very few, and unfortunately you are one of the people for whom it won’t work. What we have found is far more successful in our experience is . . . “

Patient: “My old dentist/hygienist cleaned my teeth for years and never said anything about gum disease. How long have I had it?”
Dentist: “I can tell that this diagnosis comes as a surprise. I can certainly sympathise. Were you wondering about how severe the condition is right now, or wondering when this condition began? (Wait for the answer)

Patient: wondering about how severe the condition is (and thus the accuracy of your diagnosis!)
Dentist: “Yes, of course you want to know how serious this is. It is the only way of knowing whether this is something that you would wish to be treated. If you hold this mirror/If you look up at the screen of the images from the intra oral camera, I can show you the signs of gum disease in your mouth. Then we can compare what you see with this chart of the progression of gum disease. That way you will know where you are now with this and where you may be headed in terms of your oral health.”

Patient: wondering about when the condition began.
Dentist: “I can’t tell you precisely how long you have had the gum disease, because it progresses at different rates in different people. It can be slow or rapid, depending on such aspects as your general health, age, stress, medications, smoking, and many other factors. However, we can talk about the condition of your mouth right now based on a thorough diagnosis. Then we can set up a program of treatment to bring your mouth back to the best dental health possible”.

Patient: “Would you have this treatment if you were me?”
Dentist: “Wow, that’s a good question! In truth, I would never recommend a treatment I wouldn’t want for myself or for a member of my family. In fact, my sister actually had this same treatment and it turned out really well. But this treatment is for you. You might ask yourself the following questions to be sure you are making the best decision for your particular situation. Will you be happy with the expected treatment results? Do you understand the benefits and risks? Are you clear on what will happen if it’s done and if it isn’t done? Have all your questions been answered?

Patient: “Gee, I’m not sure about all of this. Do you ever recommend a second opinion?”
Patients who doubt your clinical judgment don’t ask about second opinions, they go out and get them! Patients who ask this question are wondering about your candour, and whether you are prepared to provide all necessary information.
Dentist: “You know, I know that this is a big decision for you and I want you to be as comfortable and confident about what I am proposing to do as I am. If a second opinion will help you with that, I would strongly urge you to seek one. I am more than happy to refer you for such an opinion.”

An early discussion with a friendly Advisory Services team member can provide reassurance and assistance as how to approach a patient if you feel that they have come to you with trust issues or tough questions. The Advisory Services team have considerable experience in dealing with such situations and we all love to assist members with such enquiries.

Contact: (02) 8436 9944  or email advisory@adansw.com.au

By Dr Roger Dennett – ADA NSW

 

Bibliography

[1] Thompson TL. Patient health care: Issues in interpersonal communication. Communication and Health: Systems and Applications. Hillsdale, NJ; 1990: 27-44.

[2] Kasteler J et al Issues underlying prevalence of “doctor shopping” behaviour. Journal of health and Social Behavior 1976: 17: 328-339.

[3] Adler K Doctor-patient communication: A shift to problem-orientated research Human Communication research 1977; 3:179-90.

[4] Korsch BM, Negrete VF Doctor-patient communication. Scientific American 1972; 227:66-74.

[5] Roter DL Patient question-asking in physician-patient interaction. Health Psychology 1984;3:395-409.

[6] Dentistry in the 90’s: Consumer Attitudes and How They Affect Your Practice American Dental Association 1991.

[7] Egbert LD et al Reduction in post operative pain by encouragement and instruction of patients: A study of doctor-patient rapport. New Eng J Med 1964; 270:825-27.

[8] Jepsen CH Some behavioural aspects of dental patient compliance. Journal of Dental Practice Administration 1986;3(4):117-22.

[9] Boswell, S The Mystery Patient’s Guide to Gaining and Retaining Patients. Tulsa: Pennwell Books, 1997.

[10] O’Keefe DJ Persuasion: Theory and Research. Newbury Park CA: Sage; 1990.

[11] Wright, R Tough Questions, Great Answers: Responding to Patient Concerns about Today’s Dentistry. Quintessence Books, 1997.


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