Patient Complaint Review Shows That Chairside Manner Matters as Much as Clinical Skill

Dentistry Today

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A two-year study of complaints made to the Royal College of Dental Surgeons of Ontario (RCDSO) between 2007 and 2017 is yielding new insights into perceptions surrounding oral healthcare professionals and their standard of care

The study found that there were as many complaints about patient interaction and interpersonal skills as there were about clinical outcomes, errors, and safety. The fewest complaints were focused on areas like management and access to care.

“This is a unique study of its kind internationally,” said Carlos Quiñonez, DMD, MSc, PhD, an associate professor in the University of Toronto (UofT) Faculty of Dentistry and lead researcher of the study. 

“People have conducted similar studies in hospital and other healthcare settings using questionnaires and patient satisfaction surveys, or case files of regulatory findings once the regulator has weighed in,” said Quiñonez. “But no one has taken this volume of complaints to a regulator and quantified them.”

The researchers examined 2,199 letters drawn from a total of 4,627 complaints to the RCDSO, which is the regulatory and licensing body governing dentists and their standards of practice, making it what is believed to be the largest longitudinal study of patient complaints to date.

“One’s experience when receiving care is so subjective, so how that translates into the letters themselves is very unique,” said Monika Roerig, MA, a research associate at the UofT Faculty of Dentistry and a lead organizer of the study.

To overcome that challenge, the researchers piloted a framework that turned qualitative complaints into quantitative data. With a primary batch of 100 letters, the researchers were able to code individual words or expressions like “examination” or “pain.”

Those complaint codes then were organized into domains—clinical care and treatment, management and access to care, and relationships and conduct—which then were broken down into subdomains.

The remaining 2,099 complaints, chosen randomly by RCDSO staff involved in the project, were subjected to the same taxonomic coding. Overall, the researchers counted 17,752 complaint codes in the analysis process.

The coding framework then was revised, tested, and revised again during the initial pilot study. It was fine-tuned as the study continued so the researchers could ensure the coding was as free of bias as possible and asserted the complainants’ perspective. 

Meeting weekly for a year, the researchers would often recode the letters so they “could ensure the rater’s reliability and make sure” they “were all on the same page,” said Quiñonez, who also is the director of the UofT graduate program in dental public health.

The researchers found that 59% of all complaints were related to clinical care and treatment, while 56% involved interpersonal relationships and conduct, such as how the patient was treated, and issues around informed consent. The lowest volume of complaints, 42%, involved management and access to care.

Since there often was more than one issue in a single complaint, the numbers do not add up to 100%. The complaint analysis allowed the team to observe trends over time, said Julie Farmer, RDH, MSc, a PhD student at the Faculty of Dentistry who collaborated on the project.

For example, the researchers noted a small increase in patient letters over the past few years, which coincided with the development of an online complaint submission process. But Farmer said the number of complaints per category didn’t really change. 

“They stayed consistent,” Farmer said. 

While most of the complaints originated with patients, samples also had been collected from family members, dentists, hygienists, nurses, pharmacists, and more.

“I think this study really revealed some valuable information from all members of the public,” said Roerig, who is now a research coordinator at the Institute of Health Policy, Management, and Evaluation at the Dalla Lana School of Public Health.

“The study shows us that it’s important to have excellent clinical care and safety, but communication and interpersonal skills were extremely important. The two work hand in hand,” said Roerig.

“One of the big things was how a large percentage of the complaints were about interaction and communication,” said Farmer. 

Laura Dempster, MSc, PhD, an associate professor at the UofT Faculty of Dentistry and a key investigator in the study, said the findings support what dental educators already know—namely that “communication is a core skill integral to clinical care, and communication competence is necessary for all healthcare providers.”

Now that data can be put to work improving patients’ experiences in the dental office, the researchers said.

“The results have implications for the regulator,” said Quiñonez, adding that curriculum is a key component. “It’s really important from an educational perspective. I don’t think we do enough on communication, on relational competency. We can do better from the point of view of social competence in dentistry.”

The study could influence practice standards or trends in continuing education, where content can be tailored to fill those gaps. However, Roerig cautioned that any changes to regulations or curricula cannot rest on the results of the study alone.

“I think it’s a tool they can use in conjunction with other research,” Roerig said. 

After giving a presentation on the study at the annual meeting of the International Association for Dental Research, the researchers were approached by a group from the United Kingdom that was interested in adapting the taxonomy for a similar health study.

The study, “Analyzing Complaints Made by the Public to the Royal College of Dental Surgeons of Ontario,” was published by the RCDSO and the UofT Faculty of Dentistry.

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