"A crown? What
if I try to floss
we maybe just
do a really big
filling instead? I
will be really
careful with it."
Me? Oh doc,
you got the
wrong guy. I
brush and floss
every day. I
"What! Are you
nuts? I have
the same dentist
for the last
20 years and
he never told
me any of that!"
"A crown? What
if I try to floss
we maybe just
do a really big filling instead? I
will be really
careful with it."
"I can't believe
I need all of this
work… I have
care of things. Why did all of
In our practices, we hear some variation of these phrases week
in and week out. These patients get labeled as having "low dental
IQs." Why don't they get it? Perhaps a better question to be asked
is "Is there something that we are missing?"
In 1969, psychiatrist Elisabeth Kubler-Ross introduced "The
Five Stages of Grief " in her book On Death and Dying. Inspired in
her early residency work, she was deeply affected by the manner in
which terminal patients were treated by their caregivers.
While we do not deal with death (hopefully!) in our day-to-day
practices, there is a striking similarity between the Stages of Grief
that Dr. Kubler-Ross presented and the manner in which our
patients process the information that we provide to them.
As we discussed in "Diagnosing Yes…" in the May issue of
Dentaltown, patients who have not only an awareness but also a
concern regarding their dental condition are more apt to accept our
treatment recommendations. It would make sense since they have
a concern and are asking for our help. They ask for help. We offer
a solution. They accept our treatment recommendations.
The Stages of "No" deal more with how our patients process
and react to information and our recommendations that they
were not expecting. It should be noted that the stages are not
intended to be a hard and fast rule of how every patient reacts and
in what order, but rather an attempt to better understand and
serve our patients.
The First Stage: Denial
One of the first and most natural reactions to negative information
that we were not aware of or expecting can be to deny that it
is true. Have you heard yourself or one of your colleagues say "I
don't need loupes. My eyesight is just fine." or "An open margin,
short fill on a tooth I worked on? I don't think so…"
Our patients can and will respond similarly if they were not
aware of the issue or concern that we try to communicate to them.
If it does not hurt, and it is not an aesthetic or functional concern,
they might not even be aware that it exists.
Take for example, the following:
Denial of pain: "I don't need a root canal… it doesn't even hurt."
Denial of loss of health: "I don't have gum disease. I am way too
young for that."
Denial of aesthetic concerns: "A cavity? I don't see anything that
needs to be treated."
Denial of functional issues: "Grinding my teeth away? I don't do
that. I eat fine!"
How our patients react to the information can provide us with
valuable insight on how we can best interact with our patients.
Part of that interaction might just be to make them aware of the
existence of the condition. An additional and far more valuable
insight that patients might provide us with is consequence that
can motivate them to treatment; pain or avoiding pain. Perhaps
they might be interested in addressing an aesthetic of functional
concern before it becomes a problem.
For the "it doesn't even hurt" patient you can say something
like, "Ann, I am so glad that the tooth is not bothering you yet. If you
can see this dark area on the X-ray; it has reached the nerve. I would
like to try to address this before it starts hurting if we can. Is that
something that you might be interested in?"
Or for the "loss of health" patient you might say, "Dale, I know
that many think that this is an 'old people' disease. The truth is it can
affect all ages. What I would like to do is help you with some options
for stopping or at least slowing the progression as much as we can. I
would like to try to even reverse the damage if we can. I know your
health is important to you. Would you like to hear more about the
options to address the disease?"
Denial can make us feel defensive. It can make us feel as if the
patients are questioning our knowledge or abilities. It can make
us react poorly. What it can also do is give us a clear road sign of
how and where to take the conversation next as far as awareness of
conditions and consequences and benefits of treatment.
The Second Stage: Anger
After patients have accepted the existence of a condition or
disease, the next natural reaction can be anger. They might feel
threatened with pain, loss of aesthetics, function or measure of
health. They might have a financial concern related to the cost or
unexpected aspect of treatment.
Our patients might also be thrust into the experience of losing
trust in their current or past health-care provider – "Why didn't anyone
tell me this before?" Anger can certainly be more confrontational
and uncomfortable for us to deal with as practitioners. We can feel
very defensive. We feel threatened. We might even feel the urge to
lash back at the patient in anger.
This can be one of the most difficult and uncomfortable situations
that we find ourselves in. It can feel that there is no way out
but to avert eye contact, escape the operatory and hope that we
never see the patient again. One of the most frustrating things is
there is nothing that we can do except to be there for our patients.
More information regarding the condition will not reduce the
patients' anger. In fact, it might even increase it. Part of our role is
to be there for the patient, to take the "blast" as they process the
You might word your reaction to his angry response like this: "Yes Bob, it does suck… and I can't change that. I have no idea
why you were not told before."
Sometimes simply recognizing that the anger exists and is
perhaps even appropriate can be exactly what the patient needs
to hear. Speaking the truth, without blame or judgment, can be
the easiest and most impactful role we can play. It is then, once
patients have passed the denial and anger, that they might be
more ready for treatment.
The Third Stage: Bargaining
The first step that patients takes toward actually asking for
treatment might not be exactly what we had hoped for…
"Doc, couldn't I just get one of those mouth guards from Wal-Mart?
They are only 20 bucks…"
While some of our anger toward these types of comments
might be valid, the fact that patients are actively engaged in making
and exploring treatment options is good news. This means
they have accepted the need for treatment and are weighing the
options, investment and benefits. Rather than criticize patients for
"cheap" choices, this is a fantastic opportunity to be a facilitator
and patient advocate.
"Chris, I know the mouth guards are only $20 from Wal-Mart
and that seems like quite a deal. The concern I have is that those
guards are not custom-designed for you. They can place forces where
you don't want forces or even lead to muscle pain where you didn't
have any before. While I can't recommend those guards, if you do
use them and feel like a tooth is breaking or getting painful or your
muscles start hurting, please stop wearing it and let us know. We
will be here for you to discuss some appropriate options with you."
If we remain the patients' advocate, with our own awareness of
their concerns, we can discuss the treatment options and benefits
as well as consequences of alternative treatments. Through it all,
we remain focused on the patients' well-being.
The Fourth Stage: Depression
While many patients do not actually enter a "depression" that
we might recognize as such, they can be overwhelmed by not only
their dental condition but also the extent and financial implications.
This stage can be very similar to anger in that it can be a danger
zone when patients fade away and leave our practice. They
might engage us in their discussions or slink away as they "think
about it" never to be seen again.
What we can do for our patients is let them know that what
they are feeling is OK and that we are there for them. I can think
of so many great patients that have found their way to our practice
after leaving another office, which they'd gone to for years.
They describe being ashamed or embarrassed, not necessarily by
how they were treated but how they regarded themselves.
"I just didn't want to go back. He is a great doctor but I just feel so
ashamed at how I had let myself get and what they must think of me."
Sometimes patients are just overwhelmed. We don't know how
they feel. It can be a powerful thing to validate that and even admit
that to our patients.
To acknowledge this you could say something like, "Doug, I
know this is a lot to take in. I know this is hitting you pretty hard and
it is a lot to process. When the time is right for treatment or if you just
have questions, we are happy to have you in our practice. We are going
to be here for you."
The Fifth and Final Stage: Acceptance
In the end, patients elect to accept and pursue treatment. The
whole process might take seconds… or minutes… or months… or
even years. They might have travelled through all of the stages of
process or perhaps just one or two.
Still, not all patients will accept our treatment recommendations.
What I can say with confidence though is that the more
opportunities we take to understand and allow patients to stay in
our practices, the better the chances will be.
Dr. Melkers would like to thank Dr. Lee Ann Brady,
Mary Osbourne and Joan Unterschuetz for their
friendship, mentorship and invitation to join the