Is the doctor exam too awkward?

Eliminate the stress by creating a positive, three-way communication triangle

BY WENDY HUGHES, RDH

The doctor/hygiene exam can be stressful for both the doctor and the hygienist. It can be hard for the doctor to prioritize the exam, balancing it with what is being done in the doctor's operatory.

In addition, the exam can be awkward in terms of communication. The hygienist has spent close to an hour with the patient, and has gathered much specific information. The question is how to download that information to the doctor, as well as to the patient, so that everyone feels informed about the next steps being recommended. Patients want to feel like they are "in the loop" when it comes to their conditions and their choices of care. Helping patients understand what is being said about their mouths can be underestimated, often making them feel left out of the discussion.

Avoiding "dental speak" is one way to include the patient. Dental professionals tend to share information with an emphasis on clinical accuracy. It's all in the best interest of the patient. Many times during an exam, however, dental professionals talk to each other, which can result in a disengaged patient.

This can result in a trust issue. This may well be unintended, but it is nevertheless the result many times.

Remember, consumers do business with people they trust. If they do not trust, they do nothing. Maybe they will stay with the practice, but they will not move forward. This could be a partial explanation for diagnosed treatment that is not accepted.

Imagine this: If a businessperson could be almost guaranteed that a customer - one who has bought their product before or experienced their service - would come through their door every three, four, or six months, would that be of interest? I think the answer would be a resounding yes. Maybe we should look at the hygiene appointment in that light.

Specific steps must be understood and easily incorporated. It is not a script to achieve "sales." It is a complete engagement with our patients to explain any procedure that would be in their best interest, and most importantly open a dialogue with the patient.

To support this assertion, we must have the support of science and clinical evidence to justify treatment recommendations.

Allow me to cite the following regarding dental hygiene diagnosis from "Dental Hygiene Process of Care."1 Understand that our observations in hygiene are "front line" and frequent, which bestows a responsibility of disclosure to our patients, and our doctor.

It is our responsibility to identify conditions and disclose them to our patients, via radiographs, intraoral cameras, mirrors, verbal skills, etc. Whatever the method, it must be acknowledged and understood by the patient. I am very much a fan of intraoral camera use in the hygiene appointment, routinely at the beginning of the appointment. If you have convenient use of a camera, it literally takes only a few minutes. The verbiage I share with my clients is something like this: "With your permission, Mary, I thought I would take a quick tour of your mouth with my camera, so you can see what I see when I look in your mouth."

It is important not to begin to recommend specific treatments. Just ask, "Do you see this?" It is beneficial to use plain language such as, "Do you see that crack (or brown spot, black area, worn surface, etc.)?"

This can become a stepping stone to interest and curiosity within the patient about any possible treatment proposed. If the patient becomes very curious, you can simply defer to the doctor by saying, "We will draw this to the doctor's attention during your exam, and he (or she) can give you more specific information."

Some specifics of a sample doctor/hygiene exam format include:

TIMING - First of all, the timing of the exam is critical. Traditionally, the exam occurs at the end of the hygiene appointment. The information-gathering in the hygiene appointment always happens before the clinical portion.

Why not signal the doctor for an exam once the information has been gathered? It will normally be less than 20 minutes into the appointment, and it will give the doctor at least a 40-minute "window" to respond, which relieves stress for the doctor, the hygienist, and the patient.

The purpose of the exam is not to check on the calculus removal or the polish step, but rather to create a comprehensive opportunity for the patient. We do not want to communicate a rushed or stressful exam. Patients really pick up on this.

COMMUNICATION - When the doctor comes in, it is helpful to have an order to what you download about your patient, such as the blood pressure reading, medical updates, periodontal information, and restorative issues.

Finally, and most importantly, what has the patient said or asked about in regard to what has been revealed? When we repeat back to the doctor what the patient has said or asked, it immediately says to the patient that you listen and you care, which builds trust. It also brings the doctor right up to speed, and avoids annoying repetition. Knowing where the patient is in their thought process is invaluable.

For example, after the general greeting between the doctor and patient, the hygienist jumps right in and directs the doctor's attention to the findings thus far.

"Doctor, Mary's blood pressure today was 110/67. Mary is having some allergy issues and is taking Claritin. Generalized pocket depths were between 2 and 3 mm, with no bleeding."

Now hand the doctor a probe and he or she can confirm your findings. Update the doctor about restorative/esthetic and occlusal findings, which should be supported by either radiographs, intraoral camera pictures, or a mirror.

Again, the most important part is to tell the doctor what Mary has said about these findings, so that the patient feels heard and honored. Whatever happens from that point forward is a dialogue conducted in a genuine and respectful way.

Many times what a patient says to the hygienist changes when the doctor agrees with the findings. In other words, the patient may initially say they don't want treatment. But when the doctor says, "Oh yes, I see this black area around this old silver mercury filling," the patient reconsiders.

One other very valuable component of effective communication is the nonverbal aspect; 75% of all communication is nonverbal. Eye contact and body positions are very important. Never communicate anything of significant dental/health importance when the patient is lying back. Your patient cannot hear you, on their back with their mouth open, and instrumentation going on.

Also, when the doctor enters the room for the exam, the hygienist vacates her chair, and goes to the other side of the patient (if possible), to form a communication triangle, where all three people can see one another. Facial cues are extremely important. Depending on your patient's personality, facial cues may be more present than verbal communication.

A couple of changes in the doctor/hygiene exam can make a big difference in lowering stress for everyone and having more predictable and positive responses to treatment recommendations.

There is no higher calling than to serve our patients with the best possible comprehensive dental care, and when there is a plan and clear communication with our patients, our ability to serve increases.

WENDY HUGHES, RDH, is the founder of New Dental Directions, and a dental practice consultant. View her website at Wendyhughesrdh.com and inquire for a complimentary analysis, or contact her at [email protected].

REFERENCE

1. Wilkins EM. Patient with Orthodontic Appliances. Clinical Practice of the Dental Hygienist. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:461-63.

Four steps for the doctor's exam

Step one - Involve the patient with what is in his or her mouth. I like to conduct a live tour with an intraoral camera. Allow the patient to see inside his or her own mouth.

Step two - Allow the patient/client to have curiosity about what is viewed. In other words, do not solve a problem that does not exist in your patient's mind. Once a patient asks the question, then you are in the position to "solve" their problem.

Step three - For the hygienist, agree with the patient that there is a curiosity, and defer to the doctor for specifics. That way, the hygienist does not get into the position of "diagnosing," which can be uncomfortable depending on regulations.

Step four - Dental hygienists all know that we see and discuss things with our patients that we wish we could share with the doctor. But time and the lack of a plan makes it next to impossible to execute routinely. There is a solution. Create a protocol that works for your patient, as well as for you and your doctor. I believe so strongly that the best way to serve our patients is to communicate strategically, and with their best interest in mind. Doing this truly gives meaning to our careers as dental professionals.