Collection of resources for the learning and teaching of communication skills
What I don't want to hear from past students...
I had no formal training [in communication skills]... apart from what we saw and heard in the demonstration clinics... the people holding those were other similarly ungifted, older dentists, or even sometimes people that's a couple of years older than us
(Dentist talking about role models and communication learning. BMJ 2018)
Presenting a treatment plan
The best talks I have heard about presenting treatment plans to patients are given by Dr Cigdem Kipel
e.g. Cigdem Kipel Facebook DentalX talk 5 June 2020 What I think Dr Cigdem says that is thought provoking:
Our aim is not to "present a treatment plan". It is to discuss a treatment plan. (You aren't doing an exam - you are speaking to a person)
It is a two way conversation and not a one way sales pitch.
You are the ADVOCATE for this individuals shared decision making.
Don't make this a scenario where you see the outcome as "win-loose or accept-reject scenario". The goal is to get a yes to one of the options you have given. [Cigdem Kipel- want rebooking, retention, referral]
Note for dental students. The treatment plan must be relevant, ethical and clinically indicated. That is what Uni is trying to get you to understand by creating a treatment plan.
The more listening you do at the start of your interaction with the patient, the less 'selling' you do at the end. Right from the beginning we want to do pre-education so the patient already understands what is going on. A patient can't engage with a solution if they didn't think they had a problem in the first place.
Get your body language right: Same level, face-to-face, not laying back, eye contact
Active listening: Nod, acknowledge, clarify. THEY MUST KNOW you are listening.
Expression and Mirroring: adapt to the patients vibe
People don't remember what you do or what you say - they remember how you made them feel. We are working in a very private place and people can be really sensitive -embarrassment, judgement or shame. It may be normal talk for use but be conscious of this.
Ask more and talk less. Try and be curious and be thorough. The aim is to try and understand what are the motivators for that patient - what their understandings are, what their barriers might be.
Q - what's prompted you now? When did you notice..? What has changed?
Do you know from listening to their history what they judge or value about dentists?
This is critical when we talk about the treatment plan because it needs to be aligned with their values .
You don't want to be talking for too long and their eyes are glazing over. Stop and ask them a prompting question.
e.g. Does that make sense so far? Is this along the lines of what you were expecting? Is this something that you'd been previously made aware of? What are your thoughts?
As they are talking you are formulating a problem list and building a mental treatment plan. e.g. if they say they have had lots of filling then you are thinking heavy restorative mouth, high caries risk etc.
Once Cigdem has a problem list from the patient then she starts to use 3rd party explainations - e.g. some people find ..... Also plant FYI/educational seeds using photos, simple fast analogies.
Once you think you know what you will be diagnosing then you might say to them how you will be diagnosising e.g. it hurt to bite my tooth - so you are thinking cracked tooth - what I will be looking at is etc etc
Give context and reference to normal. So if you have told them you can see lines in a tooth with a crack and you take a photo of the tooth with a crack they already know they have a crack.
If you have explained normal with perio probing pockets is 1,2 or 3 and over that is bone loss, then when you call out an 8 they know they have a problem etc
Clinical exam time - The patient is listening to everything that is said between the DA and the patient so everything said is to elevate their understanding and ownership of their condition or to elevate their confidence in the dentist and the team.
Codiscovery - if you have educated the person when they see or hear what you are diagnosising with you.
People are visual communicators - give people context to normal e.g. this is normal in your mouth and this is a problem. Use photos so they can see.
Have fast access to photos you will need e.g.1. before and after and 2. consequence photos e.g. what a condition looks like if it progressses e.g. show tilting teeth and this is a possiblity so it helps with decision making.
Clarify treatment options in your head (dont open your mouth until you have simplified it for yourself): e.g. problem list - treatment options.
Identify what is optimal (and alternative solution). Best if choices are binary because that is easist. The brain may just want to defer because they are overwhelmed. You can break down each decision as you go so they remain binary e.g. denture repair or fixed solution - fixed, then bridge or implant - implant etc so as you drill down it is more binary.
Don't think out loud (there are a million ways of doing something and you dont want to patient to think you aren't decisive)
Keep it simple
Get a rough sequence, starting with their chief concern - make sure you are talking ALL of the patients values as you do this)
Give options not recommendations
BECAUSE it makes the patient feel they are in control
Not an accept vs reject scenario
Don't own the problem
The choice is up to the patient
and they don't think they are having a sales pitch.
You want to be an advocate for the patient - so if they have time or money issues they may choose to do it later.
Presenting the options
Ask permission to give options (I am going to give you the range)
Conditions - options - decision (this is the structure for each conditions)
Condition - explain simply - what it is and what is has progressed to and where they will end up
Options - Pro's Con's and Costs - then gauge the patients position before moving on
Focus on what the treatment MEANS to the patient, NOT how it is done!!!
Keep it short
Do not teach dentistry to the patient - dont need to go deep into the technical things. See it from the patients point of view. THEY are not doing a Uni exam!!
Don't create unnecessary questions e.g. We are going to make you a "x" crown. The type of crown is your decision this is what they are paying you to make these decisions.
Bundle things for simplicity - eg. if they need a crown with their endo - put it together!!
You will need to address risks but the treatment planning phase may not be the time. That is informed consent and doesnt need to be for every option and maybe at another time.
Treatment plan efficiently
Next step - investigate, clarify and decide before the next step
Decisions and commitment
Don't do this in the hallway. Decisions are made in the surgery. You and the patient should be clear on the decisions that are made - what would you like to do, which options would suite you best. You need to know what the barriers and fears are - to make it as easy as possible for them to make a decision. Clear next step by the patient - these are more likely to cancel or not turned up. Make sure this is a really good handover. Talking money (be neutral)
Are you projecting your own convictions, biases, preferences to others?
don't make assumptions about what people can or cant afford
simplify your fees. make it easy to remember and say out loud
people dont buy on price alone and dont reject on price alone
dont discount based on fear
dont fee bad - it is just an option for them to choose. You didnt put caries in their mouth.
recognise your upper mental price limit
Doing more optimal treatment or bigger cases
Simplify it - you dont need to talk more because it is more costly
Expalin the benefits not the procedure
Before we do x. let me know if you want to do y
Social proof - use the most people in your case would chose x
How does a patient judge you as a good dentist?
1. Find out what they value e.g. gentle, meticulous, sensitive, thorough, caring
2. Communicate it
Communicating to patient who doesn't want to go to a specialist.
Cigdem Kipel and Oral Surgeon Amanda Phoon Nguyen 15 minutes
Value proposition for learning additional communication skills:
You cant get to use your clinical skills unless you have the opportunity to use them.
It doesn't take more time, but saves time
Efficency: Listening and excellent questions are the fastest way to know what information will be helpful for that individual patient.
Reduces confusion or information overload: Listening more at the start of the consult will make the conversation at the end of the consult more efficient and effective. Throwing buck loads of information at the patient at the end to convince them is confusing (information overload; irrelevant information -turn off). Patients are stressed already when they attend so it inhibits listening. Confused patients don't "buy" and stressed patients don't listen.
Old paradigm = small pre-exam discussion ->EXAM ->CONSULTATION NEW PARADYIGM = BIG PRE-EXAM DISCUSSION >Exam >consultation
Recommended further information especially with regard to time saving and effectiveness in dental settings:
DentalX - closed Facebook page. Vidcast with Cidgen Kipel speaking from June 21 2020. Well worth joining to see this.
One hour with Dr Cigdem Kipel talking to Dr Colm Harney about the need for dentists to be good communicators to utilise and develop their clinical skills.
The 90 sec treatment plan (12.30) Ok youtube - interesting proposition about why ask questions.
More effective and professional means of building rapport than social chitchat.
(I don't care what you know, until I know that you care). Talk less - be curious and ask better questions
You want to be remembered as being professional, and a skilled dentist and not just "she is a really nice girl". You want to be perceived as professional; trustworthy; and compassionate. Think about what you would expect if you are talking to a lawyer or medico, would you like to be paying top dollar for 20 minutes social chitchat. You will gain the patients confidence and trust. It is an error to consider that the quality of rapport and relationship you have with a patient is related to the amount of time you spend on social chitchat.
Enable you to develop your clinical skills and will increase job satisfaction.
They are not aimed at making you a sales and marketing dentist. Youy will only be exercising good clinical options and your skills if you have the communication skills to unlock opportunities.
Improves or minimises health literacy issues. Health Literacy has been defined as the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. So basically everyone with crap teeth has poor health literacy independent of their language abilities - yet it is so easy to just focus on it being a language issue! Changing language may not change health literacy.
Health literacy = increase acceptance of you and good dentistry
How to make learning of communication skills better/easier/more effective.
Science of learning
From - Making it stick : Science of better learning (good book)
Retrieving knowledge from memory has the effect of making that knowledge easier to call up again in the future.
Repeated retrieval strengthens memory because the act of retrieving a memory strengthens the memory, making it easier to retrieve later.
Retrieval must be spaced out and require some cognitive effort.
Testing is an important retrieval technique. Testing interupts forgetting. Simply asking someone to fill in a word's missing letters results in better memory of the word! (generation effect)
Delaying feedback produces better long-term learning (even though it feels counter intuitive). So if you keep interupting with feedback you can imped deep learning .e.g.. like learning to ride a bike with training wheels - learner becomes dependent on the trainers and so learning task actually takes longer.
Also it is felt that frequent interruptions for feedback make the learning session too variable, preventing an established pattern of performance.
My thoughts - (if people believe that doing something well has a randomness element in it then they may not feel that retrieval practice will improve the outcome - this is especially true where they don't have any cognitive elements to link to controlling a better outcome. e.g.. I will waste the good tennis shot because sometimes I do it well and I am not sure why)
Working memory: We have a fixed working memory and use it in the process of retrieving information. If your working memory is also occupied in worrying about not doing something correctly; what people are thinking of me etc then there is less room for retrieval of important information.
People who don't "believe" in making errors or see it as failure will do worse in exams because we have a fixed working memory and if you occupy it with fear of error then there is less working memory to do the test. Being penalised for errors in learning can reinforce fear of errors and be a hinderance to deeper learning and understanding.
The best exam prep is "doing" ; "testing" and the worst is just reading over material because unless the task involves retreiveal of information from memory it doesn't get "better processed" into the retreival base in your mind.
Hinderances to acquiring or using additional communication skills
Cultural expectations about dentists and doctors. Are my values inhibiting my adoption of additional communication skills? Are dentists are the people with the knowledge and "position" of authority and control?
Do I believe that dentist has the knowledge and the patient has the answer?
(No, that doesn't mean the patient knows what the answer is!)
Health diagnosis and treatments can be a very complex algorithm. In teaching there is often the need to simplify the algorithm both for learning and assessment. Diagnosis is the art of asking better questions.
The quality of the answer from the patient is the dentist's responsiblity and relies on the quality of the dentist's questions.
The quality of the dentists questions increases with the dentists knowledge. Students often say to the patient -"Tell me about your problem"- if the patient describes their problem as "x" and you give them the solution to "x", then haven't you fulfilled the requirements of the task? It can be hard to explain that diagnosis is the skill of asking questions to understand as much as possible so that you can deliver good health outcomes. e.g.. if someone has a clean fracture cusp: if you actually knew they chomp on frozen lollies does that change your solution?
Do I believe that patients decisions are fixed and logical? [Behavioral economics, Motivational interviewing change talk, understanding that health isn't what we do but what has been down to us, Neurolinguistic programing etc etc]
Believes that communication skills are not learned skills. Belief that their core values/being/integrity will be lost if they use communication skills. (Solution is to let them live with a 3 year old and see how much of "who we are" is the result of parenting.) Lack of responsibility for how their communications effects others. Lack of awareness of the unintended consequences of what they say.
Lack of balance when teaching communication
We are asking for some change in present communication so it is good to remember that:
(Knowledge + Vision + Skill ) X Confidence
As a teacher we may have preferences towards one aspect to change.
For communication learning Knowledge: Make sure you can define the communication strategy that you are trying to teach and not just a example of it. If you don't know "what" it is then there is a high likelihood of the student not "getting it". e.g.. co-discovery techniques; reasons for summary (how does it benefit the clinician); small chunks; checking in; teach-back; righting reflection. Vision: Everyone is surviving very well thank you with their existing communication skills. What is in it for them to bother to try something else. The research from the Calgary-Cambridge model suggests that medical students only do those things while they are being evaluated in an academic situation! So for dental students - Cidgem Kipels podcast about saving time; efficiency and being able to use it to gain better job satisfaction. Students and many dentists will resonate with the feeling of "pushing the barrow uphill" with getting patients to do "what we want". Imagine if you could lessen the load. Skills: Make available opportunities for students to try new communication skills in a safe environment (batting practice). Communication is like dentistry in that it is 'close to our soul" and there are big opportunities to feel judgment, fear and shame.
Confidence: There is a great fear that communication change = sales; a fear that you will be asking a person to be a lesser version of themselves; a feeling that communications is not really a learnable skill - because we have no conscious recall of the time and effort our parents and teachers put in or the cultural norms embedded in communication. (e.g.. eye contact with elders - indigenous and other cultures; please , thank you, comedy with physical damage; )
- see judgment, fear and shame. Talent = speed at acquiring a new skill
Resources for teaching especially where English is not your first language
Doctor Speak up http://www.doctorsspeakup.com. This resource is excellent for anyone because it explains different aspects of communication. You don't need to be an OS person to find it useful.
Basic outline to use with Calgary-Cambridge model
Introduction: clear respectful
Good opener: For Example
"Welcome Jane and I understand that you spoke to Amy our receptionist and you said that something on the left has chipped but if it is ok I would like to get you to start at the beginning and tell me about your past dental history, any treatment you have had , anything you've had done, that is leading what is bothering you now."
Listening skills: (Handing over the microphone) Biggest thing to learn is how to structure the communication to get the patient talking more. Ask better questions and talk less: Stop and let the patients chime in: (after 20 sec)
Good questions to encourage the patient to elaborate about their dental history/ drill down into things they say. Aim is to find out both for diagnosis of their condition and their values -what they would value in a dentist.
Ask open ended questions to show GENUINELY curiosity; care and real genuine interest :
so when did you notice that.
and I am curious about what that felt like
Is this something you were aware of previously?
and how long ago did that happen
[How are you making the patient feel in your questions? Do they feel you are genuinely interested in them? What are you doing to make a patient feel like that? Body language; position; contact]
Empathy and attention to feelings: People don't remember what you say or do; they just remember how you made them feel (easy to make people feel embarrassed, judgment and shame because people are really sensitive about this part of your body e.g.. when did you last get a clean; how do you feel about the color or your teeth...CAN ALL BE VERY EMBARASSING
Show your patients that you care—that’s what all customers are looking for! Patients, after all, may not remember what you said or even what you did. But, they always will remember how you make them feel.
Non-jargon explanation for all dental conditions
If you can't explain it simply, you don't understand it well enough.– Albert Einstein
Keep it short (1-2 sentences) Explain in terms that relate what it means to the patient; not in terms of how it is done. e.g. a crown is something that covers the tooth to minimise the risk of fracture - instead of that you are going to cut a layer all around the tooth and take an impression and send it to the lab. (this is just how we think of things procedurally and technically) Do not teach dentistry to the patient. You don't need to go deep into the procedural part of things, what they need to know what it means to them and what are the downsides. (explain the benefits and not the procedure e.g... what does it mean to them). You do need to give the patient the opportunities to ask more about the "how" but this is not the starting point. Develop a list of sentences that you can always use: e.g.. Dental conditions (under development because I think this is quite hard!)
Dental caries or dental decay: is a hole in the tooth that, unless something is done to stop the hole getting bigger, will get so big that not enough tooth will be left to ever fix the tooth.
Periapical abscess: bag of pus in the bone at the end of your tooth. Dental treatments
Crown : cover or cap that protects and overlays a tooth so it envelops a split in that tooth so that when you chomp down, you can chomp knowing that the tooth is unlikely to be split any further.
Aiding accurate recall and understanding
Simple structure (for each condition) Condition -options - decision.
Condition - what it is; where it has progressed to and what they can expect if it continues along that way. Use co-discover if possible.
(This is what a patient should have (how does health look); This is what the patient has now; What happens if it is not attended to or progesses)
Once patient understands that they have a condition; they can take ownership of what they have been diagnosed with; they have the control and power to
make a better decision for themselves.
Always point out an example of a healthy tooth
and why it is healthy (color, shape) and "this is an example of a really healthy tooth, and a really great crown/filling...and can you see the difference over here on this tooth (and stop talking) let them say it (so it is revealed to you and the patient at the same time so you don't need to convince them of anything - you are co-discovering it) The patient will be far more motivated to do something about it if they understand it.
Option (see below): Pros and cons, cost.
You never want to talk to long without the patient buying in-ways to bring them back into the conversation. Prompting questions:
Am I making sense so far?
I am sensing this is a bit of surprised to you?
Is this along the lines of what you were expecting?
is this something you have previously been made aware of?
What are your thoughts?
Shared decision making: Not treatment plan presentation - it is a treatment option discussion. It is not a one-way pitch. It is a two way discussion and we need to be adaptable to our patients. Not acceptance versus rejection scenario-
treatment option discussion and reach a treatment option conclusion.
Clarify your treatment options in your head -[ as simply as possible; optimal and alternative. Be decisive and keep it simple; rough sequence - starting with the patients chief concern.
Presenting to the patient: Give options and not recommendations because:
Control (patient feels they are in control)
Avoids the accept vs reject scenario
You don't own the problem - the patient does
Choice is entirely up to the patient- you want to remain in the position of the advocate for the patient (they may have lots of other needs)
Give 2 choices - don't overwhelm (e.g.. it may be between fixed and removable - then if they pick fixed ,then other choices.
Ask permission to give the options to the patient. (so this is to make the options accessible to the patient. e.g.. I am just here to give you the range - some people do this and some people do that). Alternative: "Peter we have seen that there is a bit of an issue with one particular tooth, but don't worry, we can fix it but there are a number of options for you ... so what can I tell you first (this is designed to get the patient "present" with you and engage them otherwise they are thinking a mirearde of things and you cant be sure what they are- are you even answering a question that they have) Don't create unnecessary and irrelevant questions - e.g.. we are going to make a zirconium crown
then the person asks what is a zirconium crown (when in fact that decision is for the dentist to make) Don't give them decisions that they don't need to make. e.g... this kinds of splint or this type of splint. You should be making those decisions.
Bundle for simplicity e.g... endo with a crown as one item if this is what they need Risk discussion - you probably wont do all the risks for everything so maybe leave specifics to the phase where they have made their primary decision. (use your common sense with this)
A commitment to re-booking is success (retention and referral.
Decisions and commitment: Goal = crystal clear commitment of next step
What would you like to do?
Which option would suit you best?
How does that sound?
Which way are you leaning?
What are your thoughts so far? ( you want to open up the conversations so you can understand and discuss the barriers)
For more understanding of what can "nudge" people towards certain decisions - see my page on behavioral economics
Closure: Clear next step - no doubt, no confusion.
Technical language (jargon) philosphy
Jargon removal : developing explainations that are patient focused.
Traditional system of developing explainations for dental conditions and treatment for patient was that as students we are taught the scientific basis of dentistry. From there we will develop ways of making the information and knowledge we must hold for exams, as accessible to ourselves for recall. It is this information that we then must convert into "patient friendly explainations". Hence, even when it is jargon free, the primary purpose of the information may not be to make it relevant to the patient experience and need for better health. It may always remain as less jargon version of the information we need to explain the science to ourselves and our past examiners.
How not to speak - dont use jargon
Can you drop all technical term and make it language most anyone can understand? You are not talking to a dentist. They may be very intelligent but they may not have "dental language".
Communicating health podcast - Dr Colm Harney
Dr Aengus Kelly Oct 21 2019 - hear the "I hate the dentist" conversation, talking about burnout. Anxiety- Sensory Adaptive Dental environment. Giving patients a control cue. Asking permission. Confidence, assertive with humility.
Against empathy - Paul Bloom (Book)
Introvert power. Give and Take - Adam Grant. The overstory by Richard Powers
------------------------------------------------- Presenting for a communications exam on zoom
1. How you present yourself
Zoom hints (try these things on your iphone - flip so you can see how you look:
Lighting - have a window or light in front of your face, not behind you
Check out your surrounds - declutter and clean looking
Camera angle - just slightly above your face. e.g.. put your laptop on books and check out the distance to your face
Clothing - look like you are respecting the process e.g.. makeup and professional appearance
How to introduce yourself (4.35)
In the first seven seconds people make decisions about you - see video (12.9)
------------------------------------------------------------ Managing your communications in the real world (which includes communication exams)
Think fast; talk smart (58 minutes) Matt Abrahams
This talk has excellent exercises to practice his suggestions. Listen to the end for great info.
Practice: get out of your own way; take time to listen; use structure
49:17 managing a hostile communication (e.g.. complaint situation) Interesting that he says acknowledge the emotion but don't name it because he says otherwise you are just arguing about the emotion!
50:51 - speaking remotely - good ideas for zoom supervisors.
52:32 - when you go into a planned situation
53:12 - paraphasing is the swiss army tool you need
Presenting a treatment plan to a patient
Know why you are here and be confident about about it -e.g. you are here to help your patient have /gain good dental health for life? (6 min).
Validation: What not to say (article in new window) esp what not to say no. 2 I'm sorry you feel that way!
Check out this video (4.17) esp the way to react to a patient who may say something that doesn't fit in with your spiel
This is a means of intentionally being aware that when a person is conflicted (ambivalent) about something. What we say to a person can influence that persons choices within that conflict. It also is being aware that we may be able to influence whether a person becomes conflicted about something by what we say/do/show. Remember
the aim of advertising is to find someones conflict or cause it and then use it to move a person towards a choice.
Using motivational interviewing in primary care
Motivational interviewing (34minute explaination)- motivating people who are ambivalent (behaviour change)
"documenting consent appropriately, including considering the need for written consent for procedures which may result in serious injury or death." from Ahpra Dental code of conduct.
Being with the patient (and not in our mind) exercise
Ask the group to look around your room- take them on a Zoom tour and ask them to notice all the orange and red things.
Then bring them back and ask then to tell you everything blue they saw.
The object is to point out that we are most aware of what we have already decided to look for.
Sometimes that is really appropriate but sometimes it hinders us seeing other things that will be important.
Can we develop the gift of Affirmations? Building rapport without deception
PURPOSE: We know that affirmations to patients and anyone we interact with are exceptionally meaningful ways of connecting and have actually been shown as one of the most significant factors in inspiring people to change. Whether this comes easy or hard to us may be related to the 'norms' of our family of origin.
HISTORY: I have found some students repeat an affirmation that was suggested to them but they don't understand that without the context this isn't helpful for communication. Affirmation-context=platitude This activity helps students increase their affirmation vocabulary and to verbalise affirmations.
Do the "what we notice" exercise. Ask the students to write down something they enjoy doing (or have done), that they get joy out of and that they consider themselves good at or reasonably good at. By writting it down we want our mind to know that we dont need to put our attention in this exercise, towards what we are going to say. We can be free to listen and be attentive to what our fellow students share. (discuss charismatic people and their ability to exude the feeling that they are totally present with whoever they are talking with)
a) put the students in breakout groups of 3
b) Ask the students to talk for 30 seconds about the activity that they wrote down.
c) After they have finished talking, tell the students that the next part of the exercise is that they will introduce one of their fellow students to the other student in their group and will include a "characteristic" or strength that they noticed or thought of within that person, as part of the introduction. (30 sec) Each person must have someone speak about them so you need to go around the group so people dont introduce each other.
Email students the series of strength cards (see attached) because sometimes we dont have a good vocab.
d) back in the bigger group. Ask people to pick one of 3 things (hold up fingers to show)
1. Your affirmation
resonated with you
2. Affirmation didnt really reasonate with you but you can understand why the other person said it
3. You thought what was said was totally off track
Use this as a discussion; How did it feel when it was right/wrong neutral? How can you tell?
Why are affirmations so productive in relation froming/ change? How we each love the feeling of being "know"? How others can remind us of the better parts that make up "me".
Learning that "Health is not just what we do; but what has been done to us."
PURPOSE: Helping develop compassion/empathy for our patients.
HISTORY: We often dump our students in the discordant world of student/public healthcare. They start by telling patients that they are in a student clinic so they have to have all this stuff done to them or they cant come - and then we say "but we are patient centred". They hear that dental health is a behavioral disease; that people in public health don't appreciate dental care as much because they are not paying for it etc etc. The purpose of this exercise is to try and bring student awareness to the fact that their own dental health is not only of their own making but is because of the influences outside their control.
a) groups of 3 or 4 - one person in the group discusses their teeth cleaning and mouth health routine in as much detail as they can; the others in the group can ask them questions about it so they really understand the what; why, when and how of that person. Probably write it in quick notes so you get it clear
b) The members of the group should list the factors that have contributed to that particular care routine.
c) bring them back to discuss and then point out AFTER they have come back, the influence of family or others e.g. who taught you to brush, who supervised you, what was the family norm for doing that (or any healthcare)- why did you do that - characteristics of person and of the family etc.
d) back in the groups and ask each person to discuss these for their own mouth health. e) whole group - insights and summary.
Dealing with difficult situations exercise -with emotional awareness
PURPOSE: To help students name an emotion (increase vocab) ; gain some awareness of our own reaction to certain emotions and then feeling more comfortable in reflecting others emotions in a non-judgemental way.
HISTORY: I asked the students what they imagined they would feel if they broke a file doing endo. They all said they would feel "bad" so I thought it would be helpful to increase normal vocab. They also said that they could tell what a patient was feeling but patients couldn't tell what they were feeling! Interesting! Students also found reflecting for a complaining patient was difficult. (Aren't we all problem solvers!!)
a) groups of 6 or more - the aim is to hear as many different examples as possible so a smaller group may not result in this.
b) email out the emotion cards and ask people to pick one or two emotions that they find hard to deal with in other people and one emotion that they find hard to deal with or that they dislike in themselves. (you will need to note these to do the next activity - or reask people)
c) Get each of the group to then do a reflection on another person - for the emotion that they don't like in themselves or another - it doesn't really matter) d) this would lead well into a discussion of what to say when things go wrong; what to say when someone complains.
NOTE to self: being aware of what emotions you find uncomfortable in others is really important in your strategies for complaint management.
Before you expose a deeply carious tooth this is a good thing to say (pre- rubberdam):
“There is a possibility that one or more of your teeth may be infected, and if that infection spreads to the center of your tooth, I’d like your permission to treat the infection before it spreads into the bone.” “Infection” and “bone” are strong words, and patients usually get the picture.
If you tell the patient, “This won’t hurt,” and it does, you’ll likely have difficulty rebuilding the trust that has been damaged.
Perhaps the most important aspect of dealing with an apprehensive patient is to acknowledge the patient’s feelings. When the patient asks, “Is this going to hurt?”, resist the temptation to say, “No, you won’t feel a thing.” The message the patient receives could be “I don’t care how you feel” or “Your opinion doesn’t matter.” A more effective approach is to touch the patient’s shoulder lightly and say, “I know how you feel. Your comfort is my first concern.” Make the patient who is afraid of the needle feel accepted. Say, “We have a name for people like you—‘normal.’”
His favorite endo consultation begins with, “If I promise not to hurt you, what else would you like to know?”
This approach tends to help patients relax and lets them know you are concerned about their comfort. I’m constantly amazed how infrequently patients have any follow-up questions after hearing this simple, direct question. Plain English delivered in a warm, confident manner will enhance your effectiveness in educating patients, motivate them to have the dentistry they need, and project a professional, caring image.
A tooth needing endodontic therapy even though the patient is not feeling any pain. Remember to keep the explanation simple. Say something like, “I know you’re not feeling it, but that tooth is hurting you. The infection is eating away at the bone, and eventually the spreading infection will cause pain—usually at the most inconvenient time.”
Some patients question the need for root canal therapy when there is no cavity.
Explain that you don’t know “which straw broke the camel’s back, but the nerve inside the tooth is irritated after years of trauma. It had a deep cavity before, and that was irritating to the nerve. The deep filling was another irritant. We chew thousands of times a day without even thinking about it. We eat ice cream and then drink coffee. All of these things are irritating to the nerves. And now, this tooth needs therapy.”
Tell the patient what is needed. Remember, informing the patient before treatment has begun is considered an explanation, but anything you say after treatment will be considered an excuse! If the tooth needs a crown, do not begin the root canal treatment before explaining why immediate restoration is critical.
Incidentally, I never start a root canal without a firm commitment from the patient to have the tooth restored within 30 days of completion of the endodontic therapy. I say something like, “Root canal therapy takes care of the pain and infection, but it also ‘hollows out’ the tooth, leaving what’s left susceptible to splitting. It’s very important that we cover the tooth with a cap or crown to protect it from breaking. This is a back tooth with a lot of biting force. We’ll also need to build the tooth up to hold the crown on. You might have some friends who say they had a root canal and then lost the tooth anyway. Well, that’s usually because they didn’t get the proper restoration.”
Many patients want to know how long the tooth will last after treatment. It’s a good idea to answer in relative terms, such as, “Generally, the tooth will last longer than a new car or a trip to Hawaii.” Dr. Mike Goldstein, co-director at our LVI Root Camps, recommends the following statement: “After your tooth is properly restored, it will be as healthy as any other tooth in your mouth.” Further, Dr. Goldstein recommends you tell your patients after treatment that a very small percentage of patients may have a “reaction” to the treatment. He further recommends that patients who notice any swelling or are running a fever should call right away. By using the term “reaction,” any complications will seem to be caused by a normal body response and not by something the dentist did wrong.
Explaining rubber dam use:
When placing the rubber dam, it is imperative that you explain its use in terms of the benefits to the patient. “We’re going to put something around the tooth now so that you won’t have to swallow the disinfectants we’ll be using during treatment. Once this protective shield is in place, you’ll be very comfortable. You still will be able to breathe right through your mouth if you want to, and through your nose, too.”
Be very careful how you refer to the “rubber dam.” I like to say, “For your comfort and convenience, I’m going to place a protective shield over your tooth.”
For kids, we call it a “raincoat.” Whatever you do, don’t refer to the “dam” clamp or the “dam” clamp-holder. If you do, the patient may think you’re cursing!
WHAT TO SAY IF A ENDODONTIC MISHAP OCCURS
If an instrument separates in the canal during treatment, the first thing you should say is nothing. You will be very emotional, so it’s best to be quiet for a moment.
Finish your work for the visit and then sit the patient up and establish eye contact. Do inform the patient before he or she is dismissed. Be matter-of-fact, rather than apologetic. “Mrs. Smith, let me tell you about what happened today. Root canals are curved and tortuous. While we were working, a tip of one of our sterile instruments, one of those little files that we use, separated off inside the canal.”
It’s also a good idea to point out the broken instrument to your patient on your digital x-ray. You do not want the patient to see this for the first time at some time in the future at another dentist’s office. Be sure to document in the chart that the patient saw the x-ray Depending on the situation, explain that you don’t think it will be a problem or you think that you can get it out. Otherwise, explain, “You many need a surgical procedure,” or simply recommend that an endodontic specialist be consulted. The good news about separated Ni-Ti rotary files (and they do break on occasion) is that they almost never cause treatment failure. They frequently can be left as is without affecting the prognosis of the case.
If you perforate during treatment—and we all have—explain that while you were searching for the canal, “an extra opening was created in the tooth.” Depending on the situation, explain that you repaired this opening and would like to monitor the area, or that you think a periodontist should be consulted. Teeth with perforations have a guarded prognosis, and immediate treatment with a product such as MTA (ProRoot [Tulsa Dental]) is critical. It is often best to explain that this root probably cannot be saved, or that the tooth is too weakened to save. Explain the options to consider, such as a bridge or an implant.
Fracturing tooth during condensing. Let’s say you are condensing gutta-percha, and you hear a loud “crack.” The patient underneath the rubber dam asks, “What was that?” You might say something like, “Mrs. Jones, I think we’ve located the fracture line.” Although this response may sound humorous, any tooth that fractures during obturation almost certainly contained a microfracture before treatment.
Informing a patient of a procedural accident does not immunize the clinician from malpractice litigation. It does maintain rapport with the patient, make any such litigation less likely, and make negligence more difficult to establish. Simple gestures like calling your patients the night of treatment will build your practice and are part of being a caring professional.
Role play because you don't want the first time you practice a new skill to be in front of a patient.
Cost Complainer: - Remember you are not trying to talk the patients into something.
Are we projecting our own bias, convictions on others?
Separate or recognize your own convictions about money
1. don't make assumptions about what people can or cant afford
2. Simplify your fees, make it easy to remember and say out loud
3. People don't buy on price alone and don't reject on price alone
4. Don't discount based on fear
5. Don't feel bad - it is an option for the patient to choose
6. Recognize your upper mental $ limit
from Jesse Green - dentist communication guru - "The one thing that I ask my team every single day - What do you need from me?"
When and Why Saying “Thank You” Is Better Than Saying “Sorry” in Redressing Service Failures: The Role of Self-Esteem Journal of Marketing 2020, Vol. 84(2) 133-150
In this study they looked at the differences to saying things like -Sorry for the wait (apology) to thank you for the wait (appreciation).
Sorry for the wait (apology) - points out the service providers failure
thank you for the wait (appreciation) - honors the consumer and highlights their merits and contributions
HENCE - appreciation should be superior to apology in boosting consumer postrecovery satisfaction.
Yohsuke Ohtsubo, Masahiro Matsunaga, Toshiyuki Himichi, Kohta Suzuki, Eiji Shibata, Reiko Hori, Tomohiro Umemura & Hideki Ohira (2020) Costly group apology communicates a group’s sincere “intention”, Social Neuroscience, 15:2, 244-254, DOI: 10.1080/17470919.2019.1697745
The result of these researchers study suggest for an organisation or business to do an apology that is interpretted as having "sincere intent" the organisation or business might give a "costly" apology after committing some transgression.
The 'cost' can take any form e.g. financial, physical, time, verbal, BUT it must be perceived as costly to the victim. Hence when we might consider our time is precious as practitioners but the patient may not. The benefit of giving an unasked for financial benefit e.g. refund, may be more meaningful to the person (or it may not). Non-verbal clues e.g body language contributed to the perception of sincerity (and costliness)
- hence dont email it!!!
An example which may not be that uncommon is someone coming back after losing a filling that was done quite recently. It may be best to thank the person for coming back and letting you fix it rather than going somewhere else - because you are not able to then assess how/if it can be prevented in the future. e.g. people want to know that their complaint makes a change - especially globally (less so individually) [my thoughts]
Research shows that physicians interrupt patients too frequently!!
Phillips, K.A., Ospina, N.S. & Montori, V.M. Physicians Interrupting Patients. J GEN INTERN MED 34, 1965 (2019). https://doi.org/10.1007/s11606-019-05247-5
BUT sometimes you do need to interrupt especially when you are running out of time in an OSCE - you need to actually do the task which may be, for instance, to give a diagnosis and get informed consent for moving on.
Helping manage a patient in a confined time includes:
Clarify patient expections for the session (and yours in the exam situation). Ask the patient at the begining what they want out of the session today.
Set a time frame
Listen attentively (ask them if it is ok to take notes and then repeat back to them what they said - for clarification and so they know they are heard)
Wrap it up with a "Because you said earlier that you want to ...., I just need to clarify a few things and have a look at ....Is that ok with you?"
Wrap up other examples:
Validate their most recent point (acknowledging you listened and acknowledging their point) then;
So back to ... either your original question or the topic at hand.
"that is a really interesting (important) question (concern) and I would like to come back to that next visit. So back to look at where we go from here (because we only have a really short time left) ....
("That's a great question" podcast by Freakonomics)
Oh! Sorry to interrupt but I just noticed the time and
I’m so sorry for interrupting but I’d like to make sure I understood you correctly.
I hope you'll excuse me for interrupting but could I quickly get you to...
Influence by Robert Cialdini - or any of his books
I am worried if I tell someone all the risks of a procedure, e.g. endo, then it will put them off having it done. How do you balance what the risks are or present it in a way that doesn't frighten a person off?
1. Your internal angst: If you feel that you have failed or are rejected when the patient makes a choice that is not your ideal then the patient will sense this emotional 'push' from you (and no-one likes to be pushed into a decision). The patient isn't rejecting you. You may not have been able to explore deep enough into the patients decision making to find the real reason or they may just simply have made a different choice to you. They are not rejecting you - unless they leave your practice.
2. Bring the future to now and make sure you explain consequences in a way that is meaningful to the patient now (not to you!) e.g. taking a tooth out will probably mean the area is sore for the next couple of days anyway - just the time frame where your pulpotomy medication is likely to have sorted out the persons pain anyway. e.g. some people could have every second tooth out and the gap wouldnt worry them - others absolutely hate it. You wont know until too late. If you want the tooth back because you cant stand any of the removeable alternatives then the cost of an implant is massive. Students dont seem to put enough emphasis on the loss of a tooth in a way that means something to the patient - they are too technical in their talking.
Daniel Kahneman won a Nobel Prize for showing that if you’re trying to mobilize people under conditions of uncertainty, notions of loss are psychologically more powerful than notions of gain. "Moving people under conditions of uncertainty is difficult—they freeze. They’re scared of what they might lose. It’s good to tell people what they will lose if they fail to move." Robert Cialdini
A second thing that happens when people are uncertain is that they don’t look inside themselves for answers—all they see is ambiguity and their own lack of confidence. Instead, they look outside for sources of information that can reduce their uncertainty. The first thing they look to is authority: What do the experts think about this topic? You need to use this wisely.