I have done a complete examination. Reviewed the findings. Sent the case to the laboratory with some notes and paid for a diagnostic wax-up. Showed the patient the pretreatment and posttreatment models mounted on an articulator. Illustrated tooth by tooth what the needs are. Discussed the ramifications of not performing these restorative procedures. Showed the patient photographic and radiographic evidence of the affected areas on my 21-inch monitor. Used a number of different charts, pictures and models, as well as educational software. And still, all I saw was the back of the patient’s head as he left muttering something like "Is it covered by insurance?" and "I’ll think about it."
What went wrong? I am pretty sure I followed the formula: examine, diagnose, plan treatment, present treatment plan. Why didn’t the patient say "Yes"? Does he not understand what will happen eventually if this work isn’t done? I told him what he needs to do to achieve good function and esthetics. After my flawless treatment plan presentation, he should understand how badly he needs this work. The evidence is overwhelming.
More or less, this formula is what most of us learned in dental school with regard to treatment planning and presentation. Sometimes the patient does say "Yes" (thank goodness), and sometimes we can convince him or her after offering a mountain of evidence, testimonials and what unfortunately may border on fear tactics. The premise on which this formula is developed carries with it assumptions that are not as valid today as they once were. This has prompted me to look at case presentations with a different paradigm that ensures success rather than leaves the practitioner merely to hope for it.
In the model presented above, I assumed the following three things:
- – Patients care as much about signs as symptoms.
- – Patients are curious about their dental health.
- – Patients want optimal oral health and esthetics.
I will look at each of these in more detail and then at how we can shift our paradigm and become more effective.
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SIGNS AND SYMPTOMS
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Patients have a predilection for seeking treatment to eliminate symptoms that have developed. Pain, broken teeth, dysfunction, disfigurement and other overt symptoms that patients view as undesirable drive treatment decisions both logically and emotionally. It is easier to discuss treatment options for a broken tooth than it is to bring to a conscious level the signs that often lead to broken teeth. Loose, periodontally involved teeth, pus and bad breath easily motivate patients to seek care, but a recommendation for treating a 6-millimeter pocket nonsurgically with frequent débridement often is answered thus: "If I need this treatment, why does my insurance cover only two cleanings a year?" These are tough conversations we must have with patients time and again.
Early treatment of carious lesions is one arena in which we have influenced a paradigm shift effectively from symptoms to signs. For more than 50 years, we have shown patients explorers that stick and small dark areas that appear on radiographs, finally convincing them to consider treatment before the decay increases and possibly even leads to the need for (pause for effect) root canal therapy. I am not sure if it is our tenacious demonstrations, the threat of endodontic treatment or, more likely, their insurance coverage that precipitates this positive patient response. But patients do accept our plans regarding treatment of incipient and early carious lesions, even though they may involve only signs and not yet symptoms.
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CURIOSITY
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Most of our patients did not go to dental school. Many of the things about which we are curious in an examination and treatment planning solution may not create the same level of interest in the patient. Patients want freedom from pain, dysfunction, disfigurement and disease. That is distinct and different from prevention of those conditions.
Patients also have an amazing ability to morph information, data and observations that we know are important into meaningless perceptions: "My teeth are soft." "My gums have always bled." "My previous dentist never mentioned that." "My gums never did that until you stuck that thing up there." These rationalizations are born from long-held beliefs: "If it ain’t broke, don’t fix it." "Some things are inevitable." "It will not happen to me." It is a challenge to move these patients toward accepting that just because a system is functioning, it is not necessarily healthy, and the absence of pain does not necessarily mean health. Understanding these distinctions is much easier for health-centered patients who are curious about their health and cognizant that there is an optimal attainable level.
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WANTS VERSUS NEEDS
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As we demonstrate clear and unarguable needs to our patients, it would seem logical that they then would choose to fulfill those needs by accepting treatment. Clearly, this does not happen as often as we would like. All of us prefer to purchase what we want rather than what we need. If you look at the wants-driven economy in place today, it is clear that needs take a back seat. Food, clothing, shelter, safety and other basic human needs notwithstanding, it is what we want rather than what we need that drives our purchasing decisions—even when it involves our health.
It is not the cost or availability of funds that limits this choice. Consider gambling, alcohol, cigarettes, dog food and the several other categories of goods, services and activities on which people spend more annually than they do on dental care. This is not because people need those things, but because they want them and find the economic support to attain them. We complain loudly when gasoline costs $3 per gallon, because it is a needed item that we must purchase to assist our individualized transportation model. But we gladly shell out $8 to $16 per gallon for bottled water that for pennies could flow from our taps—simply because we want it.
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THE PARADIGM SHIFT
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I would like to offer a different way of looking at the problem of treatment plan acceptance. Consider breaking free of the timeless model—examine, diagnose, plan treatment, present treatment plan—and focusing instead on a patient-centered approach that helps educate the patient about the freedom of choice, develops his or her curiosity and is framed with a discussion of signs more than of symptoms. Let there be no misinterpretation: in this new model, the clinician would not ignore or delay treatment of symptoms. Options abound that allow the dentist to reduce pain, restore function or improve esthetics in an initial phase of care while keeping the focus on signs, the patient’s choice and the development of the patient’s curiosity about his or her own well-being that is likely to lead to better long-term health.
The tools for doing this are used by successful practices all the time. The most important of these is the codiscovery examination, in which asking rather than telling occurs and in which patience is needed. This is not a method offering an easier answer or a quick fix. Investing appropriate time in developing the relationship between dentist and patient, while it may involve delayed gratification, often yields trust. It is from this dividend that the relationship moves more easily to what is in the patient’s best interest rather than the dentist’s.
Consider a situation that puts you in a role analogous to your patient’s. Imagine taking your car to the dealership for routine scheduled maintenance. After you have waited for 40 minutes in the sitting area, the service team representative comes to you with the news that your car needs a new serpentine belt. You feel justified in your conviction that mechanics cannot simply fix what they were asked to fix—that they always seem to find something wrong and then try to talk you into buying something they proclaim you need. You ask what the charges will be, and the representative proceeds to enumerate the costs for parts and labor, describing in detail how difficult it is to gain access to the pertinent area in a late-model car such as yours. When you finally hear the $382 charge, you retort, "For a fan belt?" You feel sold, or even oversold. You wonder why they cannot simply perform the scheduled maintenance and leave it at that.
Now I will examine this situation again in the context of the new paradigm I am suggesting. The representative returns, and you ask if the car is ready. He says, "Not yet, but the mechanic would like to show you a couple of things if you have a minute." You are introduced to the mechanic. He removes his work gloves and shakes your hand. He makes some positive comments about your car and your maintenance of it. He then hands you a new serpentine belt, noting that this one long belt does the work of three; it snakes around the alternator, water pump and fan—hence its name. He asks you to describe the belt’s color, surface and makeup. You reply that it is black, made of rubbery material that looks new and is smooth outside but filled with fibers inside. "Exactly," the mechanic says, adding that the fibers give the rubber more strength. He then opens the hood of your car and asks you to describe the condition of your serpentine belt. You report that it looks more gray than black and that it is cracked along one side, exposing fibers that have frayed and broken. "It looks like it’s ready to snap!" you say. "Exactly," the mechanic says.
By asking for your input and observations, not dictating to you what the situation is, the mechanic has generated a shift from symptoms (broken belt) to signs (worn-out belt). You have become curious about your own serpentine belt’s condition. You are concerned about the safety of continuing to drive with that belt in place and actually want to know what should be done. Interestingly, because of these three paradigm shifts, you care much less what the repairs will cost and whether they will be covered by insurance. You do not feel you are being sold something you do not need. You have begun a relationship with the mechanic and even the service team representative that has roots in your best interests, not theirs. You feel inner stirrings of trust.
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CONCLUSION
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How different our examinations, treatment plans and presentations can be if we adopt a strategy that involves the patient more fully. Conveying the importance of signs, developing patients’ curiosity and helping patients come to want what we observe they need is both art and science. Einstein defined insanity as doing the same thing over and over again and expecting a different result. Try approaching the examination as a codiscovery. Listen and ask more; tell less. Emphasize signs, help patients become curious and remember the role that want plays in humans’ decision making. It can help you make small changes in your approach to treatment plan presentations that yield vastly different results.
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SIGNS AND SYMPTOMS
CURIOSITY
