Having the difficult conversation: When patients opt for no treatment
When a patient declines treatment, it hurts because we want to help. Here's what we can do as dental hygienists to increase case acceptance while still respecting the patient's right to say "no" to treatment.
Looking closer at the problem
Every dental hygienist has a certain percentage of patients who are truly prevention-minded. They accept treatment recommendations because they trust our professional judgment. These patients make our days easier. We get to feel that we’ve saved a person from a future dental emergency. Examples of this include identifying a marginal breakdown around an old restoration, recommending a crown to address a fracture before a tooth breaks, or treating gum disease before a tooth is lost. We may feel even more accomplished if a larger treatment plan like implants or orthodontics is accepted.
Although patients have similar problems, they are very different in whether they accept, postpone, decline treatment. Even worse than refusing treatment is when they give you the impression that they accepted treatment recommendations during the appointment, only to decline scheduling at the front desk or cancel a scheduled appointment after leaving the office. But this is a reality that we, as professionals, have to deal with.
It's the patients who aren't easy who show us that case acceptance is a tricky thing. There are so many considerations and potential barriers that influence it. Case acceptance involves more than just saying "yes"—it involves factors like how we identify problems, propose treatment, and ultimately complete treatment. These factors also include clinician values, patient values, standards of care, communication, timing, and financial concerns. I've intentionally listed financial factors last. This is because I believe firmly that of all the factors, financial considerations should almost never determine whether treatment is done or not. Even in rare cases when finances are an impossible barrier to overcome, there are treatment avenues that can be pursued. For the majority of patients in our everyday practice, it is the other factors that prevent them from completing proposed treatment.
Saying "no" is a patient's right
First and foremost, we must first accept that saying "no" to treatment is a patient’s right. In other words, no treatmentis a treatment option. This may come as a surprise to many of you. As consumers of health care, we can all think of other times when people are put in a position to choose to accept proposed treatment. A good example is vaccination. The health benefits of vaccinations are very clearly presented in the literature. However, there is a certain percentage of people who still choose to decline vaccinations for their children. Rightly or wrongly, they have the right to make that choice. We do not live in a society that forces parents to vaccinate their children.
In dentistry, we face similar opposition. People will choose not to pursue treatment for a variety of reasons. It is incumbent on the dental professional to present the evidence for and against treatment, thus allowing dental consumers to make an informed choice regarding their oral health. All case presentations must include an option for no treatment. And when patients ultimately choose this option, we will just need to be OK with it. Before this point, however, it is our professional responsibility to present all treatment considerations and effectively enable patients to make the right decision.
A closer look: Factors that influence treatment acceptance
Before we discuss the "no treatment" option, we must remember the other factors influencing treatment acceptance: values, communication, standards, and timing. In presenting proposed treatment, dental hygienists must first answer the following questions:
- What is our practice's standard of care in this situation?
- What is my personal value system in this case, and does this align with my patient's value system?
- What are the patient's values for making health-care decisions? Is the patient driven by pain? Is the patient motivated to be prevention-oriented?
- Is my communication style received well by the patient?
- Is there anything I need to know about this patient's communication style for which I need to adapt in order to effectively reach him or her?
- Is there anything in this patient's life right now that is influencing his or her decision to accept proposed treatment?
These questions so often influence a patient’s decision-making process that we must address them. Not doing so can lead to frustration when we cannot understand why a patient declines a treatment. Getting the answers to these questions throughout the appointment will also shape how we present, so let’s break down these questions a bit more.
Values and decision-making
Values influence every aspect of decision-making. Many times, what the dental professional values and what a patient values are diametrically opposed. Dental professionals believe in preventing pain, whereas patients often do not act until there is pain. In these cases, getting to treatment acceptance means helping the patient see that untreated conditions can result in greater pain. It sounds like a simple concept to us. But patients don’t always see it that way.
In these cases, the dental hygienist may need to state how pain can manifest when decay enters the nerve chamber, or when an abscess starts forming on the root, or when a tooth cracks off. Patients may need to be reminded that dental emergencies can happen at the most inopportune times, and that these conditions are better treated in a controlled situation rather than waiting for an emergency.
Communication and voice
Communication is an extremely important factor in case acceptance. Dental lingo is so ingrained in our everyday conversation that we may not even be aware when we're talking over our patients' heads. They simply do not understand why "an open distal margin on tooth number 19" might be problematic. Instead, telling a patient that "having an open edge to a crown on the back side that allows bacteria to enter and potentially cause decay where we can’t easily see" is much more relatable.
Another common example in the dental hygiene appointment is the control of gum disease. Patients do not see the significance of having pockets and the importance of biofilm control. We all understand why treating gum disease early is important, but in the absence of pain, a patient may not understand our urgency. One strategy is to draw analogies to medical conditions that patients can understand. My favorite is blood pressure. I tell patients that people do not generally feel elevated blood pressure and do not know it is a problem until it is measured. When measured to be high, a physician may recommend lifestyle changes to manage it, such as exercise and diet modification. The dental equivalent is better home care. When lifestyle changes are not enough, intervention with medication may be needed for high blood pressure. The dental equivalent is scaling and root planing. The catastrophic result of untreated blood pressure may be a stroke, just as the catastrophic result of untreated gum disease is tooth loss and systemic risk. Using language that patients understand and drawing analogies are two very effective communication styles that patients can identify with.
One overlooked aspect of communication is what I call "communication voice." This is the manner and style in which concepts are delivered. Communication voice includes volume, speed, and pitch, but it also refers to style. For example, communicating concepts to a mechanical engineer might be different than to a professional athlete, a fellow health care worker, an accountant, or a tradesman, because each of these have different backgrounds and experiences. They are also used to solving problems differently. Understanding where a person is coming from, framing conversation to his or her world, and using terms he or she can identify with are very effective for helping case acceptance. It is human nature that people will be most receptive to those that speak in the same communication voice as they do.
Understanding the patient's world
The last strategy for increasing proposed treatment is understanding the patient's world. This is where dental hygienists excel, and this is why our patients love us. Dental hygienists know when our patients are getting married, what’s going on with their kids, when work travel has taken over life, and what their major stresses are. I have often thought that patients' dental hygiene recalls feel like get-togethers with cousins to get caught up on life.
Kidding aside, dental hygienists and patients have a tremendous amount of our personal lives invested in each other. As a clinician, I hold this with utmost honor and regard. Doing so helps us to better understand why a patient may postpone or decline treatment. Perhaps a patient may be caring for a terminally ill parent or spouse, and the patient is lucky to have just enough time to get away for a cleaning appointment. Perhaps work travel dictates a person's life, and the patient is simply not in town. Perhaps the patient just became unemployed and is dealing with the stresses of finding employment. Knowing these factors can help the dental hygienist develop a strategy for getting treatment done. Showing empathy will go a long way toward treatment acceptance.
One strategy to help patients dealing with major life events is to adjust treatment planning so it’s managable for a person. Someone who is caretaking may only be able to come in for short appointments since they cannot be away from their loved one too long. Someone who travels a lot may appreciate longer appointments to get all treatment done at once. Someone planning a wedding may be too excited in the preparations to deal with dental appointments. Offering to wait until after the wedding shows appreciation for the big event. The unemployed person will greatly appreciate postponing treatment until his or her financial affairs are in order.
Making adjustments to our treatment proposals, when appropriate, shows that we appreciate what patients are going through while presenting treatment in a manner that does not take away from its importance. There is a fine balance between acknowledging all that is important in patients' lives while maintaining the importance of our proposed treatment. Finding that balance helps to connect our values with patients' values.
Even with these strategies, a patient has the right to refuse, postpone, or decline treatment. Presenting treatment should include all treatment possibilities: the ideal (which should reflect our treatment standards), the alternatives and their associated risks, delayed treatment risks, and consequences of choosing no treatment at all. Doing so fulfills our professional responsibility to provide the appropriate information for patients to make informed decisions.
Susan L. Quan, RDH, MBA, has been a private practice dental hygienist for 27 years. She is works as the director of the oral wellness department at Ueno Center, a large-scale periodontal practice in Campbell, California, that is bridging the gap between dentistry and medicine. Susan is also a member of the American Academy for Oral Systemic Health.
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