By North Shetter, DDS, FAGD
A letter to our new associate –
Dear Tracy –
Now that you have left the world of academics and joined our practice, it is evident that you want to get on with doing high quality dentistry. However, before you can truly practice your technical skills at an ideal level, it is important that you develop your behavioral skills. A great doctor-patient relationship is the key to delivering quality care. This is not “pie in the sky.” This is what we do every day. As the model for health-care delivery continues to change, behavioral skills will be a key factor in keeping us successful for the next 35 years. We believe the ideal model to help people move toward dental health is based on a behavioral approach. We like the seemingly simple model presented by Sandy Roth – Outcomes, Means, and Prices. These three simple words carry a great deal of meaning. You don’t have to be a psychologist to use this approach. However, you do have to honestly commit to placing the best interest of the patient first at all times. You cannot fake this. All of us have a built in “crap detector” that alerts us when others are not sincere. You need to personally commit to letting the patient drive the outcomes. Most folks really do want the best for themselves and their families. They will make good decisions if we provide the proper environment and education. The principles are not hard. They do require a serious commitment from you and your office team to become great listeners and communicators.
This means that your entire office must clearly understand the outcome desired by your patient, and that outcome must be congruent with your philosophy and standard of care. Both the patient and your office team must be comfortable with the means necessary to get to the outcome desired by your patient. Finally, both parties must be comfortable with the time, energy, and dollars involved in reaching a mutually agreed upon goal. This is a key element in eliminating stress and dependence on insurance. You are working on behalf of your patient. They are in control, not an insurance company.
Does this approach take more time and effort up front? Yes. However, once you adopt this approach, you will be forever glad you did. Patients who enter your practice through this system will value you, your staff, and your care. They will commit to more and better dentistry and pay with gratitude. You and your staff will have lower stress and more fun because you are dealing with people you understand at a deeper level. In the long term, these people will refer new clients just like them.
Following are five steps that we use in an effort to deliver behaviorally appropriate care. Under each heading are statements and questions. If you cannot answer yes, and explain why, to the questions, STOP. Reaffirm the question, rephrase it, and use your active listening skills. Each area requires yes answers before you move ahead with treatment. You can rest assured that every member of the office team will support you as you start on your lifetime journey. Please feel free to “lean on us” for support and especially know that there is no reason to hesitate if you have a question.
Kind personal and professional regards,
Dr. Shetter and Dr. Park
The Five Steps – vision, records, diagnosis, treatment plan, delivery
Vision – In his book “The 7 Habits of Highly Effective People,” Stephen Covey emphasizes these words –“Seek first to understand.” We must understand what patients see as ideal dental health for themselves at this time and in the future. Is their vision congruent with ours? If not, is it because of a low dental IQ? Is money a big issue? Have we asked permission to share our vision/philosophy? Do we know the patient well enough to discuss the differences? Do we have the listening skills necessary for the task?
The best interest of the client is always first. We don’t go forward until we have established that there is agreement on the vision. This is true for every point of contact with the client – from the first phone call to the last good-bye. At recare, urgent care, or comprehensive care, we must listen to our clients and reestablish the vision of doing our best on their behalf in concert with their desired outcomes. At our initial examination, we utilize interview forms and staff for much of this phase. The doctor is introduced once the initial information is established. The doctor then verifies, clarifies, and reintroduces the office philosophy when appropriate.
Examination and Records – We are documenting the status of the patient at this moment in time. This is an opportunity to restate the patient’s vision and ask for clarification. Before examination, we should ask permission to do the examination and to openly share what we are seeing. As Imtiaz Manji says, “We must always ask permission to tell the patient the truth as we see it at this time.” By doing this, we have stopped being “used car salespeople” and have become professional educators. This is an opportunity for codiagnosis, a resource for development of an ideal long-term plan, the start of the process of education, value creation for good health, and defining the physical, dental, and emotional status of the client. We believe that this phase includes a personal history, medical history including sleep/breathing assessment, and oral cancer examination. We do a visual examination of the hard and soft tissues and airway, periodontal screening/charting, full-mouth X-rays and/or panoramic film, photographs, and in potential comprehensive cases – mounted study casts. We allocate 90 minutes of chair time with 40 minutes of that being doctor time. The doctor performs the initial visual examination, verbalizing as much information as possible to a staff member. The doctor then directs staff to gather the appropriate additional information. The doctor reaffirms with the patient that he or she will review all the materials and will discuss the findings and options for care in the near future.
Diagnosis – We are determining the level of oral health or disease of the client. However we must address the whole person, the whole mouth, and each tooth. Have we asked permission to share the facts of what we see with the client? In most cases, we provide only a limited verbal diagnosis at the completion of our exam. (E.g. “You appear in generally good health. There appears to be a number of issues we should discuss in the future.”) However, we make a point to reaffirm that we have addressed the patient’s chief concern and that we have the patient’s permission to share our findings with him or her. We then take all of our history, notes, and data together and develop a comprehensive diagnosis and treatment plan that is shared with the patient at an appointed consultation.
Treatment Plan/Consultation – Imtiaz Manji says, “Think in 360 degrees.” Frank Spear uses a risk based analysis. Whatever method you use, these words should be in your head as you review your notes and records: Comprehensive, integrated, define accountability, define risk, structure. Define the gaps – what we know and what we do not know. What steps can we take to help the client achieve a mutually acceptable ideal? Are we addressing emotional values, good dental health, meeting value judgments for good treatment and good dollar value?
Develop your consultation based on answering client questions and addressing outcomes, means, and prices. Use technology to validate your understanding of client desires and to educate rather than to “sell.” Provide your best judgment as to the ideal treatment that meets or exceeds the patient’s desired outcomes. Welcome questions. It is not necessary to provide six options. With the comprehensive information you have gathered, you should be able to provide one or two options and then open the discussion to questions. Will this take more time? Yes. Will you find yourself doing more comprehensive dentistry? Yes! Consultations should be done in a private setting with a staff member present who understands dentistry and can make financial plans.
When a patient understands his or her diagnosis and agrees that the means to get to his or her desired outcome make sense, the doctor needs to move on to the final phase – prices. By this time in our relationship with this patient, we should know quite a bit about what motivates him or her. Often people will use money as an excuse to defer treatment when the true cause is much different. In our office, we talk about prices as a multifactor item. We point out the time, effort, potential discomfort, and cost involved in treatment, and we point out the care, skill, and judgment required on the part of our dental team. And we talk about the effects of deferring treatment. Sandy Roth says, “It will never be faster, easier or cheaper to resolve your problems than it is today.” The client may value treatment but not the investment. Have we developed a level of relationship with our patient that allows us to ask, “What are the barriers keeping you from moving ahead with treatment?” Once we have clarified the true price of treatment, the doctor departs and the staff member defines available payment options. Our goal is that our clients leave the office appointed for treatment feeling that they have made an investment in their own good health or the good health of a loved one.
Delivery – What can we control and what can we not control? Inside the mouth we control only during the time we perform treatment. After treatment, we give up control. Outside the mouth, we do not control. The head, heart, and values of the patient can be assessed only by our level of emotional intelligence. We are not trying to psychoanalyze ourselves or the patient. However, we should be aware of how we are feeling emotionally as we deliver care. Our goal is not to allow “outside influences” to impact quality of care. We must remain constantly alert to the spoken and unspoken responses of our patients. Constant communication at every step is critical. Excellent staff is a key in creating the value experience. It is imperative that we not only coordinate treatment within our office, but that we maintain great communication with our referring doctors and staff members. When discussing outcomes with patients, keep in mind the following saying by friend and local orthodontist, George Harris: “Underpromise and overdeliver.” If you want patients to refer their friends, you must constantly strive to deliver the highest standard of care. Standard of care is not about money. It is about doing your professional best to deliver care that you would be happy to receive. Delivering technically excellent dentistry demands that you are a student for life. L.D. Pankey used to say that he and his friends who started the Pankey Institute called themselves “The Perennial Sophomores.” When the technical aspects of a case are complete, our delivery is not done. We must assess whether we have created value in the mind of the patient. You, doctor, are a part of the process, but your staff is the key. When your left brain services are complete, set your right brain free to compliment your patient and ask how he or she is feeling. Emphasize the importance of maintaining what patients value on a regular basis. Thank them for their trust and ask them to refer their friends. Then get out of the way and let your staff manage appointments, recare, and financial issues. It is important that there is coordination between all team members as this generates value and makes it easier for patients to invite their friends. Ask yourself and your staff this question: How do clients feel when they get to the parking lot? Discuss this question at a staff meeting. What steps can create follow-on value? When you see clients back for routine recare and they have been referring their friends, you can assume your delivery of care has been good – so far. Keep striving. Life is a journey, not a destination.
Editor's Note: References available upon request.
Author bio
Dr. Shetter is the senior doctor in a three-doctor practice located on the Michigan–Wisconsin border in the small town of Menominee, Mich. We are successfully practicing comprehensive dental care. We are not participants in any insurance plans but we submit claims for patients. Sixty percent of our patients do not have insurance. We are a blue-collar community. The population of our local area is approximately 25,000. We have 18 other dental practices in the area. We have been a part of the community for 35 years and we continue to attract new patients daily.
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