Diagnosing Yes – A Patient-centered Approach to Treatment Success Michael J. Melkers, DDS, FAGD

You just finished your polished presentation to your patient. You had all of the records – the groomed study casts, the digital photos, the radiographs, cone beam images and diagnostic mock-ups. The treatment plan was crisply printed on your letterhead and neatly packaged in the monogrammed folder with your business card and financial options. Everything was there. All of your verbal skills honed over the years intertwined with your commitment to technical excellence in treatment planning. You finished your case "performance" for the patient and sat back waiting for the patient's favorable reaction and commitment to treatment. And you waited… and the patient looked over the materials… and you waited… while the patient glanced around at the desk… and the walls and the floor. And you waited…

Then, the patient thoughtfully replied, "Doc, I am going to need to think about it." Nine simple words that are uttered in every language, in every country, in every dental practice around the world. Nine simple words that crush us, frustrate us and in the end lead to the patient never scheduling treatment. We wonder what they "need to think about." Did we not give them enough information? Perhaps we should have included more pamphlets on periodontal disease and comprehensive care, or the tooth drawing with the nerve and dentin drawn out in red and blue pencil. What was it that we were missing? What a waste of time.

The patient walks out of our office, overwhelmed and frustrated. "What was that doctor thinking? Didn't he know what I came to see him for? What was all of that garbage that he wanted me to do? What a waste of time."

As doctors, we want to help our patients. In some way, shape or form it is why we chose the profession that we did. First, Hippocrates implored us to first do no harm. Following that, it was the natural progression that we committed ourselves to our patients' well-being. Patients seek us out to help them achieve their health goals. They seek, we provide. It seems like the perfect arrangement, yet we still encounter the "Nos," "maybes" and the "I will think about its." Where and how does this disconnect occur?

When we consider the opening scenario between the patient and the doctor, there is a tangible frustration that stems from unmet expectations. The doctor expected for the patient to understand, appreciate and accept the treatment recommendations. The patient had an expectation that the doctor would provide treatment options to choose from that would address his concerns and goals. Each had invested time, money and effort into the process, yet no one was happy with the end result.

Expectations can be better understood and achieved by breaking down the process of offering dental care options.

The first step in meeting expectations is awareness. We as practitioners must seek to understand the patients' level of awareness regarding their dental health conditions. Assumptions of their level of awareness can lead to offering "solutions" that have little or no level of value or relevance for a patient. Steven Covey wrote, "First seek to understand, then seek to be understood." This commitment is a foundation for meeting expectations but also for a successful and continued patient-doctor relationship. Once we have put forth that effort, we can share our additional observations and do our best to raise patients' level of awareness.

Awareness should also be considered when it comes to patient goals. Without awareness of their conditions, they might not have the same goals that we do. Considering their level of awareness, are we ready to present appropriate treatment options? Mind you, awareness of conditions does not mean that the patient has any desire or urgency to address the condition.

Consequence is the "information" that might or might not motivate a patient to treatment. Once we have established a co-awareness of the conditions between the patient and the doctor, we can begin the educational process of discussing benefits of treatment as well as the consequences of inaction or delayed treatment. If the benefit or consequence is great enough for the patient, and appropriate as a motivator, he or she will seek treatment. However, if the benefit is not of interest or the consequence is not a concern, then he or she might just "think about it."

As a simple example, we all frequently see cracked yet intact and asymptomatic premolars or molars. The patient likely might have been unaware of the condition until we pointed it out. Even then, they might seem completely unmotivated to do any treatment. Why should they? There is no consequence.

By referring to a third party – like your other patient who had his tooth crack and it was too late to salvage – you might be able to get the message across. In the absence of our own awareness of the patient's concerns, we were able to communicate through third-person analogy, the classic consequences of inaction to the patient. These consequences are common motivators that inspire patients to seek and accept treatment recommendations.

Some patients come to us in pain, looking for relief. Others might come to us hoping to avoid the onset of pain. Patients might even decline treatment due to the perceived pain involved with the procedure. They might balance tolerating their existing pain to avoid what they feel will be a greater pain.

Like pain, money can be a motivator or barrier. Patients can be inspired to seek treatment before treatment fees escalate. They can also feel a financial barrier to treatment if payment options or phasing is not available. Money can be a barrier to patients when they consider prognosis, longevity and re-treatment costs. I recall a patient reacting quite strongly to the financial aspect of root canal therapy, but following up by asking for an extraction and implant restoration. Her concern, while financial, was not with spending the money. Her concern was with the longevity of initial treatment, future treatments and ending up with an implant restoration anyway. The better we understand patients' financial concerns, the better we are equipped to discuss them.

Aesthetics and Social Embarrassment
As I imagine we have all experienced how aesthetics can be the chief motivator for some. Trying to communicate the benefits of treatment from an aesthetic standpoint to a patient who doesn't have concerns about aesthetics is not only ineffective but could also be perceived as insulting. If a patient seeks a beautiful new smile but is only focused on her two front teeth, she might need to be counseled on how her desired treatment might not actually help her achieve her goals. In fact, we could communicate how limited treatment could have the consequence of making her smile worse.

What do the patients want from treatment? Do they want their dentures to stay in their mouth while they eat? Or is their goal to be able to eat corn on the cob and steak when they are 70? Are the patients' treatment decisions consistent with their goals? Do we communicate the consequences associated with their choices?

Once we are able to better understand a patient's awareness of his or her conditions, we can better communicate the consequences of denying treatment and offering appropriate and affordable treatment options. All of our technical know-how and continuing education is of little value to us or our patients if we are unable to apply it and step beyond Hippocrates' charge. When we can look the patient in the eye at the treatment consultation appointment or at the exam and say with confidence "Based on your goals, as I understand them, what I would recommend is…" we can feel that we have taken that step. It is then that we can move beyond diagnosing conditions and toward diagnosing "yes" and treatment success.

Author’s Bio
Dr. Michael Melkers maintains a private practice with his wife, Dr. Jeanine McDonald, in Spokane, Washington. Their practice focuses on comprehensive and restorative care. Dr. Melkers is the founder and author of the Nuts & Bolts Occlusion programs & DVD series and visiting faculty at The Spear Institute. He can be contacted at info@michaelmelkers.com.
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