Dr Michael Sernik, Dr Phillip Palmer, September 2007 - When we graduate from dental school we have learned how to provide the best dental care for our patients. We are skilled in our examination and diagnosis and know what the optimal treatment is for particular conditions.
But in the real world, diagnosis isn’t that easy. A dentist that discusses the ideal treatment for a patient can be seen as being insensitive if the treatment is way beyond the patient’s financial means. If that dentist then makes their best effort to have the patient accept the ideal treatment they may then be accused of maliciously manipulating them into making that choice in order to line their pockets.
The alternative that many of us will choose is to unconsciously size up a patient before we diagnose. We will make assumptions about:
We then match the treatment we recommend that will suit what we feel the patient is after. We think that if we don’t match the patients’ expectations, the patient may object.
The result can be that your patients are deprived of:
At some stage in their careers most dentists will adopt this approach because they get tired of the rejection that follows if they offer solutions to all the problems they see in patients’ mouths. However, I doubt if any dental educator would call this approach satisfactory or ideal. The result can be that patients are deprived of the full picture of their problems and their ideal treatment and hence are unable to make a fully informed decision. Is allowing a patient to make an uninformed decision ethical?
The different approaches to treatment case presentation can be summarised like this:
The Dental School Approach
Examine the patient—diagnose and chart
Tell the patient your diagnosis
The Standard Approach
Examine the patient —diagnose and chart
Tell the patient your diagnosis —give options, recommend treatment
Educate to convince and handle objections
The Tired Dentist
Examine the patient—diagnose and chart
Find out what the patient wants
Tell the patient your diagnosis – give option that you think they want
If all the approaches that we can take are fraught with potential problems, which way should we err? What is the difference between ethically influencing someone’s decision and being guilty of malicious manipulation?
The answer could lie in the biblical ‘do unto others’ aphorism. It is entirely unethical to convince a patient to have a treatment you wouldn’t have for yourself, if you were in the patient’s shoes. Some would argue, it is actually part of the dentist’s job description to influence patients to want optimal treatment.
There is another fourth approach to diagnosis. An advanced communications approach explained in a 3 day introduction to advanced communication workshop, (PrimeSpeak, regularly run in Las Vegas and Sydney). The challenge in writing this article is that this approach is counterintuitive. When dentists do the workshop, it is not until the last half of the third day that the puzzle all starts to come together!
This approach exposes the patient to some knowledge that relates to the patient’s clinical needs before the dentist has looked in the mouth (we said it was counter-intuitive!). The patient starts to receive an understanding of what the deleterious consequences are for a condition that they do not yet realise that they have. Then the patient discovers that they have this problem and starts to become concerned about the outcome of their newly discovered condition.
The last step involves responding to the patient’s questions about treatment possibilities and helping them choose what is appropriate for their newly discovered ‘wants’. Done correctly, rejection is an impossibility because we are not actually making suggestions or recommendations…we are just helping the patient solve their own problem.
Someone could be excused for asking ‘Is the risk of malicious manipulation so high that we should not teach dentists these skills?’ If the answer is yes, it implies that the majority of dentists are unethical and unprofessional… We know this is simply untrue.
In any case, we should ask ourselves the question: what does the population in general suffer more from: being over-treated or under-treated? We believe there is no doubt that our patients will benefit from improved oral health when more of the profession improve their ability to influence their patients to want the same sort of treatment that we would want for ourselves.