Where Are We?
It should be obvious by now that this presentation is not a “best practices” consensus on the subject of periodontal therapy. Rather it is my personal, but experienced advice on what I consider the best way for dentists to treat and manage chronic periodontitis. I also believe that reading and implementing some or all of my recommendations here will help your practice grow.
The purpose of these blog posts, which will eventually be consolidated into a manual and used in training seminars on line or in person, is to explain in a comprehensive way how to establish and then operate a periodontal therapy program; one that provides the best care beginning in the general dental office that is working in concert with a periodontist colleague. In other words it is assumed that there will be patients who fall outside of the more predictable and routine, so for this reason, it is always smart to have a periodontist on your Periodontal Therapy Program team. This brings confidence to patients in your program and makes referrals, when indicated, easier to achieve. Remember, it is important that your referral recommendations are followed by your patients in order to make sure they return to you later. Patients who leave any office to find “somebody” to help them with “something” easily lose confidence in the practice that seems to have sent them away. On the other hand, when patients understand the story and how and when referrals are made, and to whom they are made, as simply a matter of fact in the early presentation, this builds greater trust in the referring dentist.
Briefly, here are some of the unique elements of this periodontal therapy program that differentiates it with others:
1. It starts with the dentist.
Often this isn’t the case. This is why, if what I have written up to now, has moved everyone but the dentist, the office periodontal program is still at the starting block. Dentists who are employees in a corporate structure, government system or non-profit entity still have to take on this role within the office in order to change the culture enough for patient’s to feel supported within the program.
2. The dentist needs to understand the power of story and create an office culture that listens carefully to patients.
Patients have a story we need to hear. Often, however, we are afraid their talking will mess with our finely tuned schedules. There are ways to manage this and it is my next topic below. I call it The Story Exchange.
3. Create a story for the office that can effectively be given to patients in the context of their unique situations.
This requires an office team with the ability to connect and care for people even at the emotional level. The broader the ability of the office to care for people of all personality types, the broader the patient treatment base and the healthier the practice. Another way to put this is to understand that the less patients have to look, think, and act like you and your team, the healthier practice you have.
4. The story for the office must be personalized with the dentist’s story.
In other words, as I have already said but can’t emphasize enough, without the involvement and endorsement of the dentist empowering the team, the effectiveness of the program goes to almost zero. This requires intentionality also known as rehearsals. This is fun and scary for some. I will talk more about this later in another post.
5. I will teach you a simple story that explains dentistry and periodontal disease in layman’s terms.
This information is transferable through all members of the team, but it again, starts with the dentist. This story doesn’t speak down to patients but it helps them understand what they need to know in order to manage their chronic problem. Uninspired, disinterested patients who believe that cure for this condition is solely the responsibility of the dentist will not get better. This is because the patient’s activities are foundational to any procedures performed in the office. Uninformed, unfocused patients place the dental office at risk for accusations of malpractice when therapeutic results do not turn out as they expect. For this reason the story should be established within the office in a way where it can be shown that the patient was informed early in care on the essential information about this condition and how it is treated and managed. In fact, those patients who hear the story understand that when they don’t fulfill their obligations to themselves, treatment results will be disappointing. Consequently, thoughts of legal actions are automatically understood to be unproductive and without merit.
Do all patients do well in the program? Are you kidding? But what does happen is that those patients who are potential problems for the practice self-eliminate, usually doing so in ways that keep doors open for their return. Also they go without fireworks.
6. The story, although focused on the patient, aligns the activities of the team.
It teaches the front office and youngest dental assistants what they need to know in order to talk with patients who may be older than they are. It also reduces the weight of responsibility from the dental hygienists for being the exclusive program managers, trainers and cheerleaders. This actually makes them more effective within the office performing duties unique to them while enabling them to support, and be supported by, other members of the team.
The Story Exchange
People like visiting. They like telling their stories to people who are good listeners.
Good listeners are not mute statues.
For a good BAD example of this we need go no further than the classic picture of the patient lying on the psychiatrist’s couch. The doctor is sitting in a chair looking anywhere but into the patient’s eyes while scribbling notes and periodically mumbling something.
In contrast, a great word picture is that of two people sitting in a coffee shop talking. When one is listening the other is supporting the conversation non-verbally through smiles and nods. Periodically the listener interjects questions and comments that propel the conversation forward. Ultimately when one has spoken and is satisfied that he or she has been heard, the roles can then reverse. A good rule for dentists in private practice is never teach until you have first listened extremely well.
In school we are taught the important questions to ask and they usually come in a list or on a certain form. I am not arguing that the information is unimportant, but seasoned practitioners know how to collect this information by allowing the patient to tell his story in the course of a directed conversation.
So here is how I might start this conversation: “Good morning Mrs. Schmedlap, I’m Dr. Young. It’s nice to meet you. How may I help you?”
I make sure the patient, if in the dental chair, is sitting up. I position myself on a stool in front of the patient looking eye ball to eye ball. I have a pen and paper and as the she speaks I am taking notes.
Of course the worry is that the patient is a talker and she will give me three pages of notes. So what? The more you permit her to talk, the more you will learn and the more she will trust you. Worst case scenario is that she talks for the scheduled time and nothing else is done. That’s OK, you simply tell her that the two of you need more time to document and complete the conversation and examination.
There is one exception to this general pattern and that is when the patient is in pain. People in pain are not able to listen and make long-range decisions. Your objective for them is to get them out of pain and then have the conversation and more comprehensive examination at another time.
Drop the objective of accomplishing a comprehensive examination on the first appointment. If you can do it, great, but this should not be the objective. The primary objective of the first meeting is to get acquainted and establish trust. I know to many this will seem like a big waste of time, so let me stop and ask you to think about the appointment, not based on what you want to get out of it, but what the patient wants to get out of it. Obviously you want to know what the technical problems are and what you can do to fix them. What does the patient want to know? How do you really know if you do not ask? Why assume and be wrong most of the time?
I can say this in general, patients want to know if you are kind, gentle, safe, and respectful. Are you in it for the money or do you care about them? To understand more about you, they will study how you relate to your team members. They see this as a big clue as to whether or not you are a good dentist technically. If the team is relaxed and happy, you must be good. If there is tension or any other bad vibe, maybe you’re not so good… How else will they be able to determine your skills? After all, they aren’t dentists.
Many doctors get into ruts and they use their social status to move patients to do what they want. After all, they are the doctors. The problem is that people can give us external messages of respect and still not trust us. So if you are thinking you don’t need to do what I am advising, it’s possible you are just not tuned into the real situation.
So here comes a dentist who sits down and listens to the patient’s concerns. How important do you think this is? If this dentist can stop everything she is doing and focus on this patient who is afraid and uncertain and simply listen and take notes – without giving any immediate answers and launching into some automatic lecture, it is very possible that this patient will be a patient for life. And if this took five additional minutes is it worth it? By the way, it is always less time to listen than it seems at the time. That’s why I take notes and work hard to look and stay interested.
Objection! Dr. Young, what if the patient is no-nonsense and wants to get on with the work?
Not a problem. Remember, you asked the patient and are listening to him. If he doesn’t have a lot to say and wants to move on, I will pick up the pace. By this, I mean I will ask my unanswered questions. (I list a few of these below). However, let me give you a cautionary note here.
When talking with the brief and brusque personality, remember that there are some patients who want to move past conversation because they are not planning to cooperate. They believe that they can maintain control of the dentist by treating him with suspicion and so obligate him to bow to unreasonable demands. This doesn’t work and isn’t healthy for either party. When a patient begins dictating treatment, what she will and will not allow, then this becomes a part of our conversation. I do not believe I am everyone’s dentist or periodontist, and so I also believe I have to be comfortable in the relationship just like the patient. It’s rare that I elect not to treat someone, but on occasion it has happened. One more thing, and I will leave this unpleasant and fortunately rare situation. Any patient who disrespects any member of my team answers to me. I do not permit patients to verbally attack someone who is my public representative. This is important because my employees should not have to defend themselves in my office. I want them concentrating on being nice and respectful to others, which means I am the one responsible to defend them. I guess I don’t buy into the idea that the customer is always right. Fortunately I have only had to do this a couple of times in thirty years, but I’m prepared and will respond if and when necessary.
Now let me give you some of the questions I need to have answers to. Remember, because we are having a conversation, the order is not important. So don’t have a list of questions in front of you. A pen and blank sheet of paper are best in my opinion.
But what about a computer or smart device of some sort to help take notes?
I personally think this is a bad idea. I love technology, but I want it in the background supporting the interpersonal communication in the office. Who do I want patients to think they saw during the appointment, me or a computer monitor?
Good Questions to Ask
- – What is the patient’s primary problem or concern? Many are trained to call this the Chief Complaint. When people have lots of problems, don’t waste your time trying to identify which is most important. Just listen and take notes. As long as they have a problem to tell you, you are listening.
- – When did the patient last see a dentist? Who, where, why and what happened?
- – When did the patient last have a cleaning?
- – Has the patient ever had periodontal treatment? What was it and what happened after that?
- – When was the cleaning before the last one? I am wanting to know what the interval has been for patients in dental offices and having routine cleanings. Ultimately I want to know the patient’s entire history with dentists and dentistry at least back to childhood or when the care was provided by their parents. Even then, I want to know if they thought it was good care.
- -Is the patient afraid of dentists and dentistry?
- -Is the patient happy with her smile?
- – When was the patient’s last medical physical examination?
- – How does the patient feel about his overall health?
- – How long has the patient lived here and is she planning to stay a while?
- – If I could do anything for this patient and money was not an issue, what would this be?
- – What is this patient most afraid of happening to themselves or their teeth in the future?
Keep in mind, it is not possible to create a complete list of questions that need answers because some answers by the patient should stimulate more questions. Also it isn’t necessary to ask every question listed above. If they don’t give me certain answers then there are no problems in that particular area. Remember, once you have established a conversational rapport with the patient, should a question need an answer going forward, you simply ask. After all, that’s how friends behave.
Does the dentist have to be as transparent as the patient in this conversation?
No, because this conversation is about the patient and why he or she made the appointment.
Does this lack of disclosure on the dentist’s part inhibit the patient’s trust?
It might if there are no ways for the patient to learn about the dentist. This is why the office needs a good website that includes a well written dentist bio. Also, the office team is responsible for answering questions about the dentist to patients. So dentist, make sure your team knows about you well enough to give patients a few important details. For example, do your employees know where you went to dental school and when you graduated?
One other website tip — rather than pictures of people who are obviously models, have nice pictures of the office personnel including the doctor. As patients get to know you better through the website, it takes less time in the office talking about who everybody is, and this translates into more time available to listen and get to know the patients.
Where is the dental assistant during the patient interview?
The dental assistant is listening and might be taking notes as well to pass to the front office. Everyone in the office needs to understand who this patient is and what he needs. Dental assistants work to know this along with the dentist. Also, the dental assistant’s primary responsibility in my office is what I call “Patient Support.”
Dental Assistant Duties
(Consider this bonus material)
This is as good a time as any to give you my dental assistant job description, and I will put it in the order of most important to least important.
Broadly speaking the assistant has three areas of responsibility. Keep in mind that these are areas where the assistant must accomplish tasks with little to no direct supervision. If I cannot trust the assistant to perform these three functions then this assistant cannot work for me.
1. Patient Support.
The dental assistant is the friend to the patient who is there for them in a potentially scary environment – the treatment-side of the office. The assistant will greet the patient in the waiting room and escort her back to the dental treatment room. While doing this, the assistant is friendly and conversational in order to assess the patient’s mood. If the patient is worried, the assistant is supportive and gently encouraging. Nobody likes to hear that everything will be OK as a brush-off dismissal of their real feelings and concerns. What they want to know is that they are heard, understood and will not be left to handle this on their own. My rule is that an assistant stays with patients in dental treatment rooms keeping them company until the dentist arrives. The only exceptions to this are when they inform the patient that they need to do something quickly and obtain the patient’s permission first. Then they make sure that their departure is brief and that the patient has something to occupy the time in the interim.
One of the most powerful behaviors in treatment I require from my dental assistant is to touch and lightly rub the patient’s shoulder during a dental injection. It is distracting the patient’s attention away from their mouths and also assuring them that someone is here with them. They are not alone.
As the dentist I am automatically a threat to the patient. I can inflict pain. Therefore, it may never be that patients are completely comfortable in my presence and why the dental assistant’s primary job is to be that patient’s advocate in care. It is healthy for the patient to hear the dental assistant speak up on their behalf telling the dentist what the patient has just shared with them about their pain or problems. Also the assistant is able to help explain any questions the patient has after the conversation with the dentist. I think I am very clear in my explanations, but it doesn’t matter what I think. Fear affects listening. The office environment must be one where patient’s questions are always taken seriously. So when the dentist leaves, a good question the assistant can ask the patient is, “Did you understand everything Dr. Young said? Would you like me to go over anything with you?” Sometimes it is smart just to call me back in and explain in front of the patient, what the question is once again. The patient learns by this that the assistant has clout with me and therefore is a good person to have in the room if you are a patient.
One last, but important point, about dental assistants and patient support. Dental assistants do not talk about patients away from the office.
2. Office Safety
The dental assistant is in charge of infection control. This individual stands between some very nasty bacteria and viruses and the other human beings in the office. Most of this work is not directly supervised. For this reason dental assistants must be intelligent and of high moral character. Beyond infection control, general treatment room, hallway cleanliness and patient restrooms are in their area of responsibility. They must be up on CPR and know what to do in any and every emergency scenario.
3. Assist me
Unless the dentist assigns the duties as I have done here, most dental assistants will assume that assisting the dentist is their most important function. They believe that they are primarily judged by the dentist for their ability to assist during procedures. I am all for dental assistants making me happy, but they can only really do this by making patients happy and making sure that none of us in the office are getting sick due to failures in infection control. And when there come moments when the patient needs the assistant, or infection control requires something that takes the assistant away, I will get along by myself if necessary. Later, of course we can look back and discuss how to improve our systems so this happens as infrequently as possible, but I want my assistants to know that I trust them and understand that their primary duties will sometimes inconvenience me — and that I’m actually good with this.
Next time we will get into the periodontal therapy story I call A Tooth Has Four Parts.