Business of Dentistry
As clinicians we all believe that we have good to excellent relationships with our patients. Rarely, when relationships break down patients leave the practice, or better, if we can recognise early signs of discontent, we can transfer that patient to another colleague working in the practice; a good outcome for all.
Psychologists would regard the qualitative descriptions of patient relationships above as too vague. The have described three patient relationship possibilities.
Active – Passive
In the situation the dentist is active and the patient passive, and is exemplified by treating patients under general anaesthesia. Prior consent is required and there are special rules for solving any unexpected problems or complications that might arise during the surgery.
Guidance – Control
This is exemplified by the statement ‘you need’ whatever procedure. It was the usual mode of communication with patients when I first qualified. Perhaps too many surgeons had been influenced by the irascible behaviour of Sir Lancelot Spratt in the ‘Doctor’ movies current at that time. However, this concept is still prevalent especially within the NHS and results in both complaints and some of the horror stories of failed care we read far too frequently in newspapers.
For example, last year I needed a lumbar puncture following which I was told ‘drink plenty of fluids’ This raises the unanswered questions, which fluids, what is plenty, and for how long? I had worked out my own solution before the next LP, when another doctor gave the same inadequate advice.
In dentistry a commonly used phrase might be ‘you need to clean your teeth twice a day’ or ‘you need to use interspace brushes’. In the above examples the patient can be left to find out for themselves what to do. It is hardly surprising therefore, that the hoped for results on follow up appointments have not been met and a vicious downward spiral continues.
It follows that, if we are to apply the Cochrane principles described in Tips no 1, such a relationship has no place in modern dentistry simply because the advice that has been given is inadequate and therefore ineffective.
This is the correct approach and recognises that we need patients as much as they need us. The essence of this relationship is sharing, and this is based on (i) communication, (ii) listening and (iii) the passage of information in a way that patients can understand, remembering that at least half of that given verbally during consultation will be forgotten or misinterpreted.
When we learned our professional skills it was based on the well-known educational principles of tell, show, do. We were told what to do in a lecture or tutorial and took notes or were given handouts, saw a demonstration of the procedure, and then tried to follow those instructions. The key point here is that our teachers watched what we did and the outcomes we achieved and gave further advice, help or comment to improve our performance to help us reach the required standard.
In contrast when we tell patients what to do how often do we give written reinforcement of our message? Do you have patient friendly information sheets about the different aspects of dental treatment?
In over 40 years of clinical practice I have never yet seen a patient take notes at the chairside. Then we might show a procedure, for example using interspace brushes, and then send the patient away to follow our instructions expecting them to be followed to the letter. The next appointment when you ask the patient to demonstrate to you, in their own mouth, what they have learned in my example about interproximal brushing is a key stage. I never cease to be amazed what a significant proportion have got it wrong and need a further demonstration etc.
Perhaps the most salutary lesson about mutual participation came quite late in my career from a patient with moderate bone loss from adult periodontitis who had the courage to complain. She had been prescribed previously one size of interspace brush although the spaces in many cases were much larger than her brush diameter and her plaque control was therefore poor (Fig 1).
I showed her different sizes for the relevant spaces. On review she complained again as she couldn’t remember what went where, so I drew a little diagram. The next visit led to a further complaint as my diagram showed conventional charting with her right side on the left side of the page. A one hundred and eighty degree flip solved the problem and led me to develop the Spacemark Dental computerised charting system (see www.spacemark-d.com and Fig. 2)
I have added two more scenarios to the above classification.
Passive – Active
In this case the dentist is passive and the patient active, usually as a result of reading about some new treatment that they want to have regardless of whether it is technically and clinically right for them. Examples are ‘I want a Hollywood perfect smile’, ‘I want my teeth even whiter’,’ I want my crowns shortened’, ‘I don’t want my wisdom tooth removed’ despite several episodes of pericoronitis, ‘I want another course of antibiotics to cure my abscess’ and so it goes on.
In Tips No 1 the risks of complying with patient requests that cannot be justified and the attendant risks have been reviewed.
In this case the relationship is of a very personal nature, usually adultery, and can result in serious problems with the General Dental Council.
In summary, consider what information you would like to receive if your and the patient’s roles were reversed and in what form. Showing information about procedures on a waiting room television may be of value, but nothing beats the written word. In over 30 years of giving postgraduate lectures and courses my most frequently asked question at the start of the day is ‘are there any handouts?’