Written by Donna Zaitz, RDH Sunday, 31 July 2005 19:00
As hygienists and healthcare providers, the standard of care we provide is at the core of our profession. We should continue to review and update our philosophy, values, and proficiencies just as we update our clinical and treatment skills through continuing education courses. The reassessment of values includes our treatment of others through a refining of professional goals and communication skills. Communicating the highest standard of care to others is sometimes lost in the frustrations of financial challenges, insurance restrictions, patient fears, and most commonly, the patient's perception of his or her need for treatment. Integrating a high standard of care into your dental practice involves recognizing your own feelings and emotions (limiting beliefs) and understanding that the patient may have a different understanding of his or her challenge than we have.
Communication skills are not limited to verbal skills alone but also include body language, empathy, and the ability to listen; we must keep in mind that the patient can only hear what we project. If we are not confident in our presentation, our patients won't be confident in us.
As hygienists, our first concern should always be to inform the patient what is necessary in the way of treatment. In addition, we need to communicate the rationale of treatment as it pertains to the patient's total oral and physical health along with the expected outcome (assuming they accept treatment) compared to the alternative outcome from declining treatment.
We often struggle on a personal level when we explain treatment because we feel the patient will view the treatment as being costly. We are afraid the patient might get upset at hearing the dollar value for treatment. If money is not an obstacle, then we dread to hear that no one has ever told the patient before about his or her needs. But wait a minute, aren't these our fears? They may not have any bearing on the decision the patient makes.
Starting at the beginning, we should acknowledge the validity of the patient's true concerns. If money is the true concern, acknowledge verbally to the patient that the cost of the necessary treatment is expensive. (I have frequently expressed to a patient that if someone told me I would have to write a check for a large, unexpected amount of money, I also would have a difficult time writing that check.) I often like to point out to other hygienists that we are healthcare providers, which means we have to put the emphasis of caring on the health aspects of our patients and less on the financial aspect of our patients' needs. While the patients' actual concerns may be financial, our first concern has to be about their health and necessity for treatment.
When presenting treatment, ask the patient what concerns he or she might have. Case presentation actually becomes much easier and more direct if both you and the patient understand where the obstacles might be.
THE DREADED QUESTION
Let's imagine you're the new hygienist in the office, and Mrs. Jones comes in for her routine prophy. After doing a full-mouth periodontal probing and confirming your findings with your new employer, how do you tell her that she needs root planing and scaling? There is so much to consider. Your new employer has already informed you that his last hygienist was very nice and everybody loved her, but he is hoping that you will be better equipped at case presentation for patients needing to be placed into a periodontal therapy program. Now here it is, on your first day with your first patient. How will you handle informing the patient without hearing that dreaded question, "Why didn't anyone tell me this before?" If you are like me, that question always makes you immediately begin to feel like an accused child who ate the last piece of chocolate cake, and just before dinner at that.
This is when you need to sit back and begin to draw on your education and knowledge to answer a very easy question. The question isn't really about "why no one ever told her." It's more about "How do you know I need root planing? Why do I need root planing?" You do have to address the question Mrs. Jones thinks she's asking, and you need to be honest about answering. Remembering that communication skills are paramount to the success of integrating the standard of care into your practice, listen, observe, and then respond. Do you really have any idea why Mrs. Jones was never informed? Do you think her periodontal disease has only occurred since her last dental visit? Where can you go to find the answer?
The most obvious answer is in your hands...in her chart notes, radiographs, the documentation from the previous probing notations, or maybe even in her medical or dental history. Take a minute to look. If you find chart notes stating things such as BOP, gingival redness or swelling, tenderness, or moderate plaque or calculus, you may have found the answer to her question. Now you can answer honestly. You can inform Mrs. Jones that the last hygienist was aware of her condition according to the chart notes, so he or she may have been watching it. For reasons you don't know, it was being treated conservatively. However, your findings are now that her gum disease/infection is presently in an active stage, so it must be treated more actively.
Suppose, however, you find no chart notes referring to the obvious visual signs. Then what? You've just completed a full-mouth probing. There must be visible signs of bone loss on the radiographs; use the radiographs to identify and relate the visual signs to Mrs. Jones. Explain that the last hygienist was aware of her condition and he or she may have been watching it, but for reasons you are not aware of, it was being treated very conservatively. Your findings now are that her gum disease presently appears to be in an active stage, so it must be treated more actively.
Where else to look? What about the patient's medical history? How many times have patients replied that their medical history has not changed only to reveal through further questioning that they have had an addition to their diabetic medication? The patient's question remains the same: "Why didn't anyone tell me about this gum disease before?" And the answer also remains the same. Explain that the last hygienist was aware of the patient's condition, and he or she may have been watching it, but for reasons you are not aware of, it was being treated very conservatively. However, your findings are now that the gum disease presently appears to be in an active stage, so it must be treated more actively.
The patient is aware of the state of her diabetes in that it has become less stable or more serious because of the changes to her medication. In a case such as diabetes, patients are generally aware of the medical complications involved in their healing processes and understand the complication of lowered host response to infection. Explain to her that there is a connection between diabetes and periodontal disease. Due to her lowered host resistance to bacteria, her diabetic condition has actively worsened, her gum condition has worsened, and it presently appears to be in an active stage. It must be treated more actively also.
THE NEW PATIENT
Let's now consider that Mr. Daniels is your next patient and that this is his first visit to your office. Your findings are similar...he has inflamed gingiva, BOP, pocket depths to 5 and 6 mm, and obvious radiographic bone loss. Your employer has finished with Mr. Daniels' comprehensive exam and has discussed his restorative needs with him but leaves his periodontal education in your hands. Your dentist has the confidence that you will have no problem gaining patient acceptance for treatment of his existing periodontal disease prior to starting his restorative phase of treatment. When you begin to explain his periodontal status, Mr. Daniels asks the same question—"Why didn't anyone else ever tell me this before?"—with that same ac-cusing distress in his voice.
How do you answer the question this time? You truly don't know why because you don't have chart notes. And that is your answer. You can help to clarify for the patient that the previous hygienist may have been aware of his condition and may have been watching it, but he or she obviously was treating it in a very conservative manner. However, your findings at this time are that his gum tissue appears to be in an active stage of disease/infection, so it must be treated more actively.
However, Mr. Daniels insists that all he wants is the usual cleaning that he has always received in the past. Quoting him the nomenclature and descriptors of the CDT codes or the legalities of providing services your doctor considers to be substandard care is not going to sway Mr. Daniels. Once the patient understands the necessary treatment and the cause, effect, and cost of his or her dental care, acceptance of treatment can definitely be the next significant challenge. In this case, we are asking the patient to make a psychological commitment, a financial commitment, and a lifetime change of behaviors.
Remembering that communication skills are paramount to the success of integrating the standard of care into your practice, you must now listen, ob-serve, and then respond calmly with a tone of understanding. You could ask him to explain why he would prefer to decline treatment. Listen to his reasons. Maybe he is not being unreasonable but merely needs time to digest all that you've told him. Additionally, he could be in denial that there truly is a problem with his health. Remember, you are not talking about his dental health; you are talking about his total well-being. It can be a shock in any situation. Give him time to reconsider and let him know that you will do everything you can to help him. Decide on the direction you need to take, then act on it in a positive manner. Suggest that if he is uncomfortable with your recommendation, he may want to get a second opinion. Offer to give him a copy of his radiographs and probing documentation. Remind him to ask if he needs anything else; you are here to help him get healthy. Let him know that if he changes his mind, your front desk will be happy to reschedule his next appointment. If he does come back, you'll have a dedicated patient who believes in you and trusts you, your doctor, and most importantly, the standard of care you are providing.
Developing your own policy for these situations is the easy part. If you are unsure as to what the office policy is, ask your doctor before you start. Ask for an explanation as to the practice beliefs and understandings, and as these patient challenges arise, they will be much easier to address. If there is no specific written policy in your office, create one. According to Webster's dictionary, policy is no more than "a principle chosen to guide decision making." Begin with a mission statement and let it grow from there.
MASTERING COMMUNICATION SKILLS
Good communication skills take time and practice to master. However, they are never mastered without practice. You may have to experiment with different phrases or scripts, and you may stumble and stammer in the beginning. The key is to have a positive attitude for success. Keep practicing and you will master the task. Isn't that the way we were trained to master the task of instrumentation? Keep practicing...you'll get it.
Managing the needs and concerns of each patient re-quires thought and adjustment for each individual. At the same time, consistency and building a foundation are important as a way to address and evaluate each patient's individual concerns. The final step is learning how to integrate your knowledge and education into clinical applications. In this way, you will gain confidence in your ability to answer patient questions without hesitation.
Don't be afraid to tell patients of their needs and allow them to voice their concerns. Listen to what they are saying and don't assume guilt just because you are the messenger. Remember that informing patients of their needs for dental treatment does not ensure acceptance of treatment, nor does it mean we've failed in our attempts when patients decline our recommendations. But you can rest assured that patients who are not given the education about their oral health absolutely cannot take action to improve it.
Once your patients understand that you care about their health, personally and professionally, they will begin to listen and trust your recommendations for their preventive and restorative treatment. As you begin to do away with your own limiting beliefs of what patients will or won't accept as treatment (and stop diagnosing their wallet), you'll find case presentation of their dental health needs will become second nature. Your credibility as a healthcare provider and dental hygienist will be accepted, and you will be recognized for the bright, talented professional you are.
Soon, your patients will be-gin to partner with your philosophy of care and respond with an interest in their oral healthcare and the quality of services you and your doctor provide.
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