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The Three Most Important Steps to Case Acceptance By Mark T. Murphy, DDS

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I play Texas Hold’em poker and have had pretty good success at it. The math is easy enough when it comes to knowing the chances of making a better hand and comparing that to the pot odds that the bettor has created. There remain two intangibles in the game: one that is a learned skill, and one that is pure chance. Reading another person’s “tells” helps players decide whether others are bluffing or representing a real hand. Reading people can be taught and become a skill that helps players make good poker decisions. Then comes the random distribution of the remaining cards. Even if you hold the strongest of hands before all the cards are played out, a chance exists that your opponent can beat you if he or she “draws out” a better hand than yours.

I wish there was some kind of a green/yellow/red light on every patient’s forehead indicating their level of preparedness to move to the next level in discussions when presenting treatment plans. I would be able to tell if they had become aware and interested in my educational component and then gauge their trust in me and commitment to move forward with the actions I would recommend. In fact, those are the six steps of the learning ladder (illustrated at left).

I often lecture about striving to achieve “total case acceptance” and use this very valuable tool that was given to me in 1985 at the Pankey Institute by Dr. Don Absjornson of Lincoln, Nebraska. It has six distinct steps that we can use to guide a conversation and case presentation, but in reality, we can only control some of these steps and the rest are a bit like playing poker. If we understand the entire process that leads to case acceptance and develop our skills to improve our chances, it might still “seem” like poker, but the odds of winning will be squarely in our favor.

What I have observed over the years is that two of these steps are easy to do, and one results from the success of the others… that leaves three “variable” steps that are key to gaining case acceptance. Moving a patient from unaware to aware is second nature to us. As dentists, we have become adept at educating our patients and have many resources that we can call upon to help. Models, charts, interactive software and our own explanations help a patient become more aware than they might have been about their present condition. When a patient is truly committed to doing something to improve his or her health, function and aesthetics, the movement to action is a foregone conclusion. At that stage, it become important to have tools on hand to help execute on the decision to act, such as patient financing, staged treatment planning and clear expectations. Overcoming those impediments are relatively easy. CareCredit, for example, provides a multitude of payment options that help overcome the financial barriers to treatment more easily than we could ever design on our limited resources and platforms.

It is the other three steps, interest, trust and commitment, that present the greatest challenge for us. Like playing poker, the better we can learn to set these steps up and read our patients, the higher our case acceptance will be. Look at each of these steps and find out how we can apply them on a daily basis.

Interest

Awareness does not imply interest. I wish it did, because I would have been more effective with patients in my early years. Interest develops when someone begins to see the value for them. “What’s in it for me?” is the question we should focus on to move a patient from being made aware of a periodontal, restorative or occlusal situation, to getting them interested. It can mean “what is in it for me if I don’t” do something about the situation at hand as well. The key here is that they must realize the interest for them; we cannot prescribe it or simply tell them about the consequences. It is more about asking questions to guide their thinking than it is about telling them. We have to have the patience to let them co-discover with us what we are observing. If we do an exam and just tell patients what we’re seeing, chances are slim we’ll create any real interest. If we have the patient examine with us and stay in the questions about our own observations, they will have a better chance of becoming curious and interested as they co-discover what we see. For example:

“Mrs. Jones, can you see this area here where the filling is chipped and broken? This restoration fills more than half of the entire tooth and is barely holding on. I am curious, how was it that you decided to place this large of a silver filling in that tooth when you had it fixed?”

Patients often respond by saying they really didn’t decide; the dentist did. We now have an opportunity to ask them if they would value being involved in the choice of materials when we get ready to talk about how that tooth can be restored. This generates curiosity, and yet we have not gone anywhere near solutions or presenting treatment. We are just staying in the question and discussing the problem or concern we have. We are letting them know there are choices. You will be able to read patients’ verbal and non-verbal communication in relation to the level of interest generated. As they ask their follow-up questions or stare at the monitor or mirror to better see what you have described, you know they have stepped up the learning ladder with you.

Trust

Honest, verifiable comparisons that you allow a patient to apply to your co-discovery process is a quick way to establish trust. If you show the health (especially in their own mouth) and then let them compare and score themselves in a diseased area, they are likely to begin to trust your opinion and observations because they can come to the same conclusions themselves. In this way, you are not telling them what you see; instead, they are co-discovering again and understand the standards that we keep score with. They (not us) conclude that something is wrong and needs fixing. They believe and trust themselves and you for leading them this way:

“Mr. Smith, can you see this gum here? Can you see how it is pink and not red? See how it lays flat against the teeth and is not puffy? See how it comes up to a nice point in between the teeth not rounded or blunted? And see how the surface is rough like and orange peal, not swollen and smooth? This is really healthy gum. And when I try to measure the health of this gum with this instrument (perio probe), I cannot go deeper than this first line which is 3mm. There’s no bleeding either. This is a healthy gum. Now let’s take a look around all of your teeth and measure the health of the gum in six areas about each tooth. 31, 323, 313, 323, 557…! Take a look up here with your hand mirror. See how different that gum looks. It bleeds before I can even remove my measure. It’s blunted, swollen and reddish-blue looking.”

The patient comes to the same conclusion as we do, that something is wrong. The patient does not feel we are making something up or selling them something. We all understand the early detection of disease, and can come to conclusions ourselves when we have the standards (120/80 familiar to anyone?). We trust the results and the person delivering the information.

Commitment

The toughest step to allow a patient to take is the commitment statement. When we hear, “Doctor? What can I do about that?” we have finally earned the right to tell the patient what we have observed that they need to solve their problems. All too often we lead with the solution instead of waiting until we are asked. Patients commonly move through trust and commitment together almost as one. When they are sure you are really acting on their behalf and with their best interest in mind, they know you are the right person and they want to know what to do. Just listen, they will ask. Sometimes they ask with their eyes or through body language, but usually they ask out loud and want to know what their advocate – you – would do.

“This flattening here and here, as well as on these other teeth is from the excessive force you can put on your teeth when sleeping. We eat with 45 pounds per square inch and our teeth only touch 20 minutes a day. When people clench and grind at night, they can apply up to 400 pounds per square inch and a lot longer than 20 minutes. Those forces can wear, crack, loosen or even break teeth. Eventually several more of your teeth will break like this one over here and you will need more crowns and maybe even a root canal like this one did.”

When patients have climbed up the learning ladder with you and have become interested and trusting, they will ask what they should do. Now you have earned the right to discuss a splint, occlusal therapy and restorative needs. This is a better way to have patients want what we know they need.

Reading patients’ responses and being patient while we develop the relationship and let them climb the learning ladder will help us become more proficient at case acceptance. With the present condition, technical solution and behavioral riddles solved, we can turn our attention to the financial riddle. Patient financing options like CareCredit or phased treatment can help us get to the final yes. Will the learning ladder and our observations work 100 percent of the time? Of course not. But just like in poker, understanding patient behavior and observing them will help us win more often. You can bluff if you want to, but getting your money in with the best hand is the best way to win. Reading the signs that patients are moving along that ladder with us will make treatment plan acceptance much more predictable and profitable, for us and for the patient. I’m all in!
Author’s Bio

Mark Murphy is a featured presenter for the National Dental Network and the National Lab Network, and lectures internationally on a variety of dental clinical and behavioral subjects. He practices part-time in Rochester Hills, Michigan, and teaches at The Pankey Institute in Key Biscayne, Florida, where he served full-time as the director of professional relations during 2005 and 2006. For more information or to contact Mark e-mail him at mmurphy@pankey.org or visit www.mtmurphydds.com.
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