September 2012, Volume 8, Issue 9
Published by AEGIS Communications
They aren’t “special needs” patients in the traditional sense, but special handling instructions may be in order to deal with patients who are difficult to treat because of their anxiety, unrealistic expectations, aggressiveness, or unreasonable demands.
Chances are, the dental office is not alone in its difficulties in coping with those sometimes referred to as “the 1% of patients who cause 99% of the problems.” People who are unreasonable, aggressive, and demanding with their dentists often have problematic relationships in other areas of their lives as well. However, this may be difficult to keep in mind while they are attempting to direct their own treatment, pitching a fit about their unmet expectations, or either cowering in fear or instilling it in others with their bullying rages.
Bruce Peltier, PhD, MBA, professor of psychology and ethics at the University of the Pacific School of Dentistry in San Francisco, contends that dentistry is difficult for all involved, and prefers to focus not on difficult patients but difficult situations. “Dentistry is a challenging profession, and the work can be difficult for dentists. It is also difficult for patients—many of whom are fearful—because it can be uncomfortable or painful, as well as expensive and time-consuming,” he explains. Some of the people dentists call “difficult,” he says, are not difficult in other areas of life—only when they go to the dentist. However, he does recognize that there are patients with issues—self-centered narcissists, impossible-to-please fanatics about esthetics, and those who view themselves as victims—who can send the dental team running for cover.
Harvey Levy, DMD, a private practitioner in Frederick, Maryland, takes pride in his ability to find solutions to such difficult situations. Although his expertise is in “impossible patients” by virtue of their disabilities, he finds it possible, and profitable, to successfully treat patients who are especially anxious or have physical difficulties—such as flailing arms, a jerking head, or gag reflex—with the right attitude, special equipment, and a staff trained in desensitization and familiar with equipment and drugs, including nitrous oxide. “We have successfully treated over 31,000 ‘difficult’ patients in our office. These are patients who, for whatever reason, needed to be sedated, subdued, gassed, drugged, restrained, or effectively relaxed in some way—sometimes even using general anesthesia,” he says. He finds it most difficult to treat patients with unrealistic expectations—sometimes due to emotional issues such as body dysmorphia. “They are the ones most likely to complain if they feel that all their requests were not honored and all their needs were not met, even if not communicated. They are also likely to sue,” he warns.
Slow Down and Listen
Patients likely to try the patience of the team generally reveal themselves in short order during the first consultation. The key is taking the time to listen.
Carlo Ercoli, DDS, chair and program director for Eastman Institute for Oral Health’s Prosthodontic Division, considers the half hour or more he allots for patient discussion during the first visit to be time extremely well spent. “I have found that they will tell you everything you need to know about their expectations and whether you can manage what they want to achieve,” he says.
Bhumija Gupta, DDS, too, sees the patient’s chance to talk at length as an investment. When faced with patients who seem most demanding and aggressive, the Rochester, New York, dentist listens patiently for keys to the reasons for their behavior, and makes an effort to educate them about their role and responsibility. “I have seen these patients change their behavior and calm down once someone listens to them carefully and addresses each of their concerns,” she says.
Levy employs the “magic wand” technique advocated by many of his colleagues to get a sense of the person’s needs and wants, listening attentively to the answer to this question: “Exactly how can I help you?” Their responses, he says, speak volumes. Red flags cited by Levy include the patient who shows up with a paper bag of old failed dentures, challenging him to make one that works, or the patient who badmouths his four former dentists and challenges him to go where no dentist has gone before. “I know that I am good, but odds are that I will be failure number five, and will be condemned either in court or on social media a few months later.”
This first visit is the ideal opportunity, says Peltier, to find out what’s on the patient’s mind and try to determine if there’s a fit between what the patient wants and what the doctor is willing to offer. The doctor who efficiently rushes from operatory to operatory, he says, may unwittingly send the message that patients’ questions or concerns aren’t important and could invite unwelcome responses such as irritability, refusal to comply with care instructions, showing up late or not at all, or delayed bill payment. Unhappy patients will find a way to communicate their negative feelings, even if no one is listening, he says.
While many busy private practitioners feel they can’t afford to waste time, Cathy Jameson, PhD, Founder of Jameson Management, Inc., in Oklahoma City, Oklahoma, consults to dental practices, and she says that dentists can’t afford not to listen. She says doctors who take the time to get to know their patients’ oral issues, to clarify their recommendations, and to make an effort to build the relationship right from the start have higher case acceptance and fewer issues related to miscommunications—including lawsuits.
Be Perfectly Clear
Gupta says patients should be informed at the very outset what can and cannot be done to restore their smile and function. “I provide a clear explanation of what is and isn’t achievable. I assure the patient again and again that we will do our best, while reminding him or her of the achievable goals. The strategy I use in these cases is underpromising and overdelivering,” she says.
There needs to be no room for misunderstanding, stresses psychologist Elaine Rodino, PhD, of State College, Pennsylvania. Because the dentist cannot assume the patient understands, she recommends that the dentist have the patient “reflect” back the explanation and what he or she expects the outcome to be.
Ercoli says it’s important to keep clear records of the conversations had with the patient. However, in addition to his own documentation, Levy has the patients “sign off” on a treatment agreement. This, he says, is especially important with patients who have unrealistic expectations but insist on proceeding with a suboptimal treatment option. “The patient then signs and witnesses that this is their wish, and an acknowledgement that they did not select my first choice,” he explains, adding that this “release from responsibility” is similar to an “against medical advice” form, and just as binding.
Jameson says that beyond the individual clinician’s own ad hoc beliefs and practices, offices should have in place and properly administer systems that promote excellent communication about all aspects of treatment—including what is necessary and why and what can and cannot be accomplished by the practitioner within their mouth and within their budget—to circumvent the problems that can lead to “horror stories.”
“If systems are correct, there should be clarity about everything related to treatment—how long it will take, where the work will take place, how it will look,” Jameson says, stressing that one big key to overcoming problems is having a firm agreement about financing, which she says makes people more angry than anything else. “Much of what appears to be anger—which is a secondary emotion—is rooted in the primary emotion of fear, anxiety, or embarrassment,” she maintains.
Peltier considers the interaction between a dentist and a patient a two-way relationship based on trust and cooperation, and that dentists can modify their behavior to minimize the likelihood that they will find their patients difficult. This includes making an effort to listen and forming a relationship with the patient and establishing a way for them to signal that they are feeling pain. Gupta says it is important to stay firm with treatment but to make small adjustments based on patients’ needs. “The important thing in dentistry is for the dentist and patient to work like a team and for the patient to take ownership of self-care.” She adds that a little empathy can go a long way with patients who have had bad experiences in the past, many of who are fearful and distrustful.
Levy has a whole host of methods designed to accommodate patients’ physical and emotional issues, which are described below, and Ercoli schedules extra time to allow for the stop-start aspect of treating a patient with an exaggerated gag reflex. Jameson says dentists can also take a custom approach to dealing with patients based on their DISC personality type (See Sidebar, “Flex for Success with Different Personality Types”).
Dental Fears, Anxiety, & Phobias
Dental anxiety sends many patients and dentists alike to the psychotherapist’s office, explains Elaine Rodino, PhD, who notes that patients can be fearful for a variety of reasons. Fearful patients, she says, need to be understood by the dentist, who should ask questions such as: Why is the patient fearful? Is it fear of experiencing pain? Claustrophobia? Learning what the fear may be is essential to the dentist’s being able to deal with it, she maintains.
It is for precisely this reason that Levy has a “bag of tricks” at the ready once he has determined the source of the patient’s fear. In addition to relatively standard approaches such as the use of oral sedatives and/or hypnotics such as Valium, Halcion, Ativan, Versed, or chloral hydrate plus Atarax, he employs a variety of special tools and techniques. For the audiophobic, there are sound-reducing headphones, and treatment scheduled for when the office is quietest. For photophobic patients, there are headlamps that generate a tiny beam of light, in addition to having them wear black sunglasses. Those who are tactile-sensitive are given oral sedation to relax them and nitrous oxide to make them more comfortable and amnesic. His team approaches psychological hypersensitive gagging by placing salt on patients’ tongues, having them raise one foot, and concentrate on the raised foot. “They are so distracted that our success rate is over 95% with these patients,” Levy says. For those with abandonment anxieties, parents or caregivers in the operatory can hold their hand—or feet, if their hands are wrapped. For those with physical hypersensitive gag reflexes, they use topical or viscous Lidocaine. In addition, he says, some patients benefit from hypnosis, behavior modification, or desensitization visits. When these methods prove unsuccessful for a patient who is receptive and otherwise cooperative, there is general anesthesia. “We do our finest work on asleep patients who are not moving, talking, thrashing, wiggling, whimpering, answering their cell phone, pausing to go to the bathroom, or stopping us for 1,001 reasons,” claims Levy.
Ercoli, who treats a large number of fearful patients, makes an effort to build the trusting relationship he says is critical for successful treatment. He is frequently able to avoid the use of sedatives or nitrous oxide by talking, reassuring, and letting patients know step by step what to expect, thus alleviating the anxiety of not knowing.
One who does not use nitrous oxide or office sedation is Steven Perlman, DDS, MScD, DHL (hon) clinical professor of pediatric dentistry, Boston University Goldman School of Dental Medicine, who is also a consultant for Special Olympics in dentistry and the current president of the American Academy of Developmental Medicine and Dentistry. Calling himself “a behavior guidance guy,” Perlman instead establishes rules that enable him to do his job. His consent form makes clear his use of mouth props and immobilization techniques such as papoose boards, but there are also televisions in operatories to distract patients during treatment. “If my premise is that I’m never going to compromise care, I need to do what will enable me to deliver that care.” Perlman says a large proportion of his practice—which is limited to pediatrics, adolescents, and people with special needs—requires dealing with difficult parents, many of whom have already been banished from other practices. “Usually we’re the end-of-the-line practice, so they are already ready to accept whatever I say.” And some of what he has to say can be hard to accept, even for less-difficult situations. It is his policy not to have parents in the operatory—a “no-win situation” that he says is not helpful to the patient’s treatment. “Every study ever done shows that the blood pressure and anxiety level of the dentist are negatively impacted by the undermining presence of a hovering mother, as is the anxiety of the child who in turn is frightened by his mother’s behavior.” He is opposed to the use of general anesthesia except in medically necessary situations, performing such procedures only once or twice a month in the hospital. “Local anesthesia is always the safest; hospitalization is a last resort,” he says. He is unapologetic about his use of what he calls medical immobilization/protective stabilization. “Why is it okay for an emergency room doctor to put a child in a playground accident in an immobilization device while suturing up the cut, but not for someone with an acute dental problem causing pain and infection?”
Just Say No
Despite their best efforts to accommodate even the most challenging patients, there are times when all interviewed suggest the patient go elsewhere. Here Peltier objects to the term “dismiss” in favor of “part ways,” to recognize that the responsibility goes both ways. “No doctor is a good fit for all patients,” he says.
For Levy, it’s generally patients who insist on determining the treatment plan and the outcome, but will not sign a release-from-responsibility form. For Ercoli, it’s “somebody who really doesn’t belong in the dentist chair, but belongs in a psychiatrist’s or physician’s office or has such unrealistic expectations that they are impossible to satisfy.”
Descriptions of patients with unrealistic expectations—either to look like a movie star or their younger self—abounded. Ercoli recalls a patient named Michelle who wanted a smile like her namesake Michelle Pfeiffer, and another who, like the patient Levy described, presented with a number of temporary bridges and a desire to look as she did as a young woman. Gupta described a woman in her early 60s who lost all her teeth and resorbed all the bone in the lower jaw, causing her chin to protrude. Her request for complete dentures was reasonable; matching the picture she brought in from her high school yearbook was not.
Gupta also saw a patient who attempted to dictate a treatment plan that included extracting all her teeth and replacing them with a hybrid denture. “I prepared three different treatment plans for her, none of which included the removal of all the remaining teeth. She was adamant on getting the teeth extracted, and since I was not willing to do it, after discussing the plans with her for over an hour, we had to refuse treatment to her.”
Says Levy, “If I do not feel that I can meet their unrealistic expectations, I tell them so, shake their hand, and wish them well on their journey. Identifying them and establishing ground rules or dismissing them will reduce your headaches,” he concludes.
Flex For Success With Different Personality Types
Cathy Jameson is an educator, dentist’s wife, and has consulted on over 2,500 cases during her 20-plus years as a consultant to dental clients.
The four “DISC” personality types she describes—Dominant, Influencer, Steadfast, and Conscientious—are nothing new. More than 2,000 years ago, Hippocrates called them choleric, sanguine, melancholy, and phlegmatic, respectively, and educators have classified them in terms of colors—green, red, blue, and yellow, respectively.
Whatever they are called, understanding these types and “flexing” to accommodate the personalities they represent, says Jameson, is one key to better relationships and higher case acceptance rates. “The goal is to have a good experience and to have patients say yes to treatment and comply with recommendations/instructions,” she says and makes it clear that—as teachers of dentistry in the practice—it is the team members, not the patient, who must flex.
She describe these behavioral styles—much like astrological signs—in terms of their characteristics, desires, and fears, and explains how to use them to great advantage in the dental office.
According to Jameson, these hard-driving individuals are direct and decisive; they want results and control. They are time-conscious, assertive, competitive, decisive, and ambitious. They dislike inaction and take a logical approach to the challenges they seek. Professionally, they embrace difficult assignments and seek opportunities for advancement. They fear being taken advantage of by others.
To work effectively with dominant personalities, says Jameson, respect their time, their logical perspective, and their fear of being taken advantage of. Be brief and to the point, keeping socializing to a minimum, and responding to their questions with to-the-point answers, emphasizing efficiency and savings. Make them aware of the clinician’s qualifications and expertise, outline the possibilities, end results, and how it meets their desired results or bottom-line concern.
Jameson also advises asking Dominant personality types if there are time issues to be considered and to clearly explain how treatment will be conducted—eg, number of appointments and their length. “If they agree to treatment, they should be referred to the treatment coordinator to discuss the ‘investment’ and the options for payment,” she says.
Jameson describes this group as the “cheerleaders”—people who are talkative, expressive, and attention-seeking. They care about their appearance, social standing, and want recognition for their accomplishments. They enjoy being part of a team and want freedom of speech and favorable working conditions. They fear disharmony and loss of social approval.
To work effectively with Influencers, she says, discuss treatment in a friendly environment, asking open-ended questions and showing before-and-after photographs or testimonials of others with similar treatments. Compared to Dominants, they are less decisive and more concerned about appearance and the opinion of others. They are therefore likely to want more details, the opportunity to discuss the treatment options with a friend or partner, and will be most interested in photographs. Jameson suggests reflecting back to them the concerns about their teeth expressed during the initial consultation both to demonstrate that such concerns were heard and to use this information to motivate them.
These people are good listeners who like predictability, consistency, and a specific pattern of treatment, explains Jameson. They need security, appreciation, and to be able to identify with others. They are slow to change and need time to adjust; although they accept guidance, they need time to think about a decision, and they need assurance and support to overcome their fear of losing security. They don’t like surprises, she adds.
Patience is the key to helping them make treatment decisions. Helpful strategies include identifying their feelings and opinions by asking open-ended questions and explaining what will happen one step at a time. Ideas or departures from the status quo should be presented in a non-threatening manner, using a low-pressure approach and a quiet voice. Because of their concern about stability and fear of the unexpected, explanations should emphasize how treatments will either provide stability or prevent instability, and should provide detail—perhaps in steps—so they will know what to expect. According to Jameson, Steadfasts need more detail than Dominants or Influencers, as well as photographs to demonstrate their current condition and the need for or desirability of treatment.
Many C words—competent, compliant, calculating, correct—describe this group. Those in the Conscientious group are reserved, observant, analytical, and sticklers for quality, logic, and facts. They don’t like small talk or sudden changes, and are organized and calculating in their work—typically in number-crunching positions in banking or accounting—and fear criticism of it. They want personal attention, praise, deadlines, and controlled work environments with little total responsibility.
People who are Conscientious, says Jameson, require the most information—a complete treatment plan with visual support and financial options. Because they are so organized, they will care about the doctor’s organization, and are likely to respond best to well-prepared presentations of information. Therefore, she suggests the dentist arrive prepared with a case that sticks to business, focuses on the investment, and offers options with their respective pros and cons. It should be logical, with exact details and precise explanations. Any disagreement that might arise during the course of discussion, she warns, should be directed at the information, not the Conscientious person, who is thin-skinned about criticism.