Written by James Fondriest, DDS Friday, 30 September 2005 19:00
Do you have clinical talents that you don't get to use very often? Do your patients have low dental IQ? Have you ever lost a patient to another dentist who ends up doing substantial care that the patient never seemed interested in doing while in your office? Improve how you begin your relationship with your new patients by taking the time to interview them prior to an examination. Starting your relationship in the right manner with a well done new-patient interview can increase the scope of care, case acceptance, compliance, patient gratitude and appreciation, and your enjoyment of dentistry.
The new-patient interview is the initial doctor/patient conversation as patients enter your practice. It is face-to-face and can last anywhere from 15 to 60 minutes. The new-patient coordinator determines the scheduled length during the initial phone contact. The interview is the most important part of the first visit. It usually consists simply of the doctor sitting down with the patient and getting to know him or her better. Although many astute dentists will know approximately what is going on in the patient's mouth before this interview is over, there is no clinical assessment or treatment speculation at all, just active listening. The manner and depth of this conversation will have a profound effect on how soon and how much dentistry will be done for this patient in the next 5 years. It also determines the likelihood of developing another referral missionary for your practice.
Many believe that we build a trust or distrust with our patients within 30 seconds of meeting them. The limbic system of the brain informs us at a very primal level whether the other is a friend or foe. The new person you just met is asking himself or herself 3 questions: can I trust you, do you care about me, and are you the right person to help me? All 3 of these questions will have a better answer if handled in a preclinical interview rather than in the sterile clinical setting with masks and gloves.
Sitting as equals does not negate the fact that the patients have come to you for exper-tise, but the new-patient interview isn't the time to show expertise. The purpose of the interview is not to educate, suggest, and debate but to help your patients open up and tell their stories. Their stories are what they want them to be. It can be a summary of past dental experiences, fears, dreams, and expectations, or something totally nondental. The point is, by having patience and letting the patients lead you, you help them to view you as a friend and partner who wants the best for them.
Getting started is as simple as asking your patients to tell you about themselves. They will usually respond with "What do you want to know?" Tell them, "Whatever you want me to know." Then, be quiet. Open your ears, and let the patients guide you. Look for information they have that you don't (for example, how they make decisions and their dominant influences). Don't be passive in this conversation. Your role is to help your patients identify and examine their issues. Help them find the words to describe them and to clarify and prioritize them.
How likely are you to do what someone else suggests if that person doesn't seem fully aware of why you see things differently? Yes, we can have great influence on people, and it can be compounded if we pull them and not push them. When we set out purposely to change someone, this rarely results in substantial change. On the other hand, when engaging someone in a conversation where mutual learning is the goal, change often takes place. Why is this? When we set out to change somebody, we are likely to attack his or her perspective rather than to listen. This approach increases the likelihood that the person will be defensive of his or her position rather than learn something new. Patients are more likely to change or be compliant if they think we understand them and they feel heard and respected. They are more likely to change if they feel free not to change. When people are aware they have choice, it pulls them into participation. Allow them to construct a vision to work for that is consistent with their values.
This little story, which is found in the book Difficult Conversations,1 illustrates the point that people need to feel heard. Andrew is visiting his Uncle Doug. While Doug is on the telephone, Andrew tugs on his uncle's pant leg and says, "Uncle Doug, I want to go outside." His uncle says, "Not right now, Andrew." Andrew repeats that he wants to go outside. Doug raises his voice a little, "Not right now, Andrew, I'm on the phone!" Moments later, Andrew is asking again, "May I go outside?" Very irritated, Doug gives him a louder "No!" Five minutes later, Doug is still with an important phone call, and he sees Andrew coming back to him with the same question. Doug switches tactics and says pre-emptively to the boy, "Andrew, you want to go outside, don't you?" "Yes," Andrew says with relief, and Andrew goes off to play by himself. You see, Andrew just wanted to know that his uncle understood him and to know that he had been heard. Andrew's story demonstrates a feeling common to all of us: we all have a deep desire to feel heard and to know that others care enough to listen.1
PEOPLE WOULD RATHER BE UNDERSTOOD THAN TO UNDERSTAND
From the start, many dentists want to control the conversation. However, it is better to let the patient lead and to explore with questions only if you are truly curious or if you want to clarify what he or she is saying. Remember that even if you are asking questions, the patient will feel it if the questions are used to lead and direct. Your patient will become guarded and close down if you manipulate the discussion—so avoid it. To help with your listening or understanding, constantly take what the patient says and reword it in your mind. When he or she repeats something, don't assume the patient is lost or emotionally hung-up; it is best to assume he or she perceives you didn't "get it" the first time. If the patient wanders off topic repeatedly, it may be necessary to exercise some control by redirecting, but remember that if your patient avoids a topic, then he or she is usually telling you something. When your perspective is from a learning stance, your conversation will never get stuck, and the patient will feel safe and share trust. The bottom line is that if you get nervous and start controlling the conversation, the patient will not lead you to the answers.
What we first hear from our patients is often not what they are saying. We tend to hear their words with our filters. Filters could be described as perspectives, paradigms, interests, or limitations in our understanding due to our experiences or lack of experiences. When our patient doesn't speak our language or there is a failure to understand each other, fear or discord develops between both parties. What happens when you meet someone who speaks a foreign language? Isn't it human nature to repeat your point, to speak more slowly, and to speak louder? This does not improve communication. Although your patients may not speak a foreign language, there is often a patient/doctor misunderstanding over exactly what is being said. Dentists will frequently be in situations where there is a failure in comprehension due to the patient's lack of descriptive vocabulary. It is the successful dentist's responsibility to put the information into words that can be mutually understood.
"WE DON'T SEE THINGS AS THEY ARE" WE SEE THINGS AS WE ARE" --ANAIS NIN
As the conversation continues and many of the patient's issues have surfaced, then begin the work to identify the implications of these issues. When developing implications, focus on how they think (not how you think) making changes will affect them personally. These questions will raise the discussion to an emotional level. When a patient is talking about fears or emotions, don't deny the reality of these feelings (even if you think they may be inaccurate). Allow or encourage patients to share their fears and thoughts. Help them to clarify emotions and then reconfirm them. Let them know that what they are saying has made an impression on you and that you are working to understand. When you remain truly curious, you avoid the trap of judging or accusing.
During the new-patient interview there should never be a time when you and your patient disagree on issues. If you feel disagreement, then you have made a judgment, it will show in your body language, and the patient will see it. Remember what the purpose of the new-patient interview is. You are working for a mutual understanding, not necessarily a mutual agreement. In the book Difficult Conversations, the authors point out that every conversation can be divided into 3 stories or questions: (1) your story, (2) the patient's story, and (3) the story that would be told by a good-listening third party in the corner. It is important to have all 3 stories in the conversation so that both you and the patient can make informed decisions.1
As it is described in the book Emotional Intelligence,2 the successful communicator will acknowledge misunderstanding and lack of connection and try to see what the other person sees through his or her eyes. Break down the barriers with responses such as these:
•Help me to understand that"
•Help me to know how"
•I respect the fact that what you are bringing me is your understanding and/or reality at this moment"
•How are you coming to that conclusion?
A great student of tae kwon do once asked his teacher and mentor, "Sensei, you never seem to lose your balance." The great teacher told his promising student, "Actually, I lose my balance often, but I have learned to regain it quickly." The same applies to your conversations in a new-patient interview. Good conversations don't always flow; it is easy to lose momentum, the spirit of the moment, or even to hit a brick wall that a trained psychologist could not break through with years of counseling experience. The trick is to move on seamlessly and to regain your balance in the conversation.
The deeper your questions, the faster you can gain the patient's perspective. Questions are like knives with sharp edges on both sides. The top edge can be used for the good, to cut out the extraneous information, to bring up great points, and to help bring clarity to complex issues. But the bottom edge can be damaging by controlling the conversation and bringing judgment. No formula or question works every time. Just know that some questions do a better job than others and that different people need different questions. The best questions are the ones that will get the patient talking at the emotional level.
I have many questions in the bag that are pulled out for just the right occasion. See if any of these sample questions might work for you:
(1) Situation questions:
•What's bothering you?
•Tell me about your history.
•I am not sure I know what you are trying to say.
•What was your experience with the last dental office?
•What is an ideal relationship with a dentist?
•Who will decide what will be done in your mouth?
(2) Problems and priorities questions:
•How would you describe your present state of health? " of dental health?
•In our work together, what would you like to accomplish?
•What are your goals and objectives in coming to this office?
•What do you feel is the most important thing I can do for you?
•To what level of health do you want us to counsel you?
•Does going to the dentist frighten you?
•Do you like the way your teeth look, feel, and function?
•Are you happy with your teeth?
•How do your teeth feel?
•Are you a perfectionist?
•How would you feel about having your teeth extracted?
•On a scale of 1 to 10 and 5 being average, how healthy are your teeth? What rating do you want to be?
•If you could make your teeth be any way without regard to time or cost, what would your teeth be like?
•How do you feel about the teeth you have" that God gave you?
•How important is it for you to finish jobs you have started?
(3) Implication questions (how they think making changes will affect them personally):
•Would you like to address only those things that are hurting you?
•What do you do intentionally to maintain your health?
•I see emotion in your eyes...tell me what is behind that?
•In what kind of shape do you want your teeth to be in 20 years?
•How much do you feel your teeth contribute to your well-being?
•Will you have your teeth when you die?
•Do you believe that sometimes you can get anything you wish for?
•Are you a health-oriented person?
•What do you think about that?
•How do you feel?
(4) Needs questions:
At the end of the interview, again after the exam, and just before the case presentation, ask "needs development" questions. These questions connect the already stated priorities with the implied needs stated earlier in the interview or found during data collection. These questions serve to let patients sell the case themselves. Remember that every statement you make can be turned into a question. So you can help the patient here.
•Are you a person who tends to do things now that will benefit you later? Can you illustrate that?
•When all this work is completed, what do you want it to look like?
•It sounds like this is really important to you.
•What do you want from me?
•What can you see yourself doing?
•Can you think of anything else that we need to do?
•How can I help you?
I finish up my interviews with a request for a summary. "I have heard all that you have said and written it all down, but just so I know that I do have your priorities correct, will you just recap it or summarize it one more time?" It is at the end of the new-patient interview and for the remainder of your relationship with this person that you will begin to assume the role as "doctor" or educator. The highest role of an educator is to impart knowledge that will change behavior and facilitate growth. Changing someone's perspective about an issue or lifelong behavior is not an easy task. When was the last time someone changed your views or beliefs, or changed how you take care of yourself, your diet, your hygiene, or your weight? Yes, it might be easy to convince a patient that a tooth needs fixing if it looks bad, hurts, or is broken. But what about a major life change? There is a significant difference between repairing damage caused by disease one tooth at a time versus a full-mouth reconstruction to restore health. The dentist who offers a nonhierarchical relationship with emotional openness is far more likely to be the life-changer for his or her patients.
When baby ducks hatch from their eggs, they imprint the caregiver as "Mama." There have been other studies on the imprinting or bonding that occurs when a person goes through an emotional experience. These ties can be very strong. When trying to minimize the reality of discomfort with dentistry, dentists also inadvertently or consciously de-emphasize the emotional aspects. Direct the patients to their emotions and don't discourage them. Enjoy the wonderful relationships that develop when you and your patients share feelings. The relationships that really have an impact on your happiness and on your practice success are deeper and are blessed with trust and intimacy. They are based on the sharing of values and commonalities. Trust is built layer by layer, drop by drop.
1. Stone D, Patton B, Heen S, Fisher R. Difficult Conversations: How to Discuss what Matters Most. 1st ed. New York, NY: Penguin Putnam; 2000.
2. Goleman D. Emotional Intelligence: Why It Can Matter More Than IQ. New York, NY: Bantam; 1997.
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