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Liviu Oprea, MD, PhD

Associate Professor in Bioethics and behavioural Sciences


Successful medical care

what does successful mean?


Successful oral/medical care
 The ability to introduce yourself
 Listen to the patient concerns and problems,
 Explain procedures, treatment or ways of promoting
health
…
Difficulties in clinical situations
 Very talkative patients or those who remain almost
totally silent

 Patients who become over familial or dependent

 Patients who have very fixed opinions or beliefs about


their dental health, which is at odds with clinical
examination and knowledge (eg: a request for amalgam filings
to be replaced because fear of mercury poisoning)

 Patients who become tearful, distressed or anxious


Difficulties in clinical situations

 What does difficult


patients mean ???
Difficulties in clinical situations
 Patients who do not follow advice, such as oral
hygiene instruction

 Patients who make complaints: eg: if they had to


wait too long for treatment to be completed
Difficulties in clinical situations

 Patients who are inconsistent in giving their past


dental/medical history (eg: a partial history given when seen
first by student, and a fuller history provided to a senior member or
staff)

 Patients who need to be told something unpleasant or


negative (such as giving the patient the news that their tooth cannot
be saved, even after extensive attempts to restore it)
What are communication skills

 “The process by which information, meanings and


feelings are shared by persons throughout the
exchange of verbal and non-verbal messages”.
(Brooks and Health, 1985)
What specific skills should you posses to assist
yourself and your patients in the delivery of good
healthcare?
Two ideal qualities:

warmth
friendliness
What specific skills should you posses to assist
yourself and your patients in the delivery of good
healthcare?

 Patients’ suggestions of things a dentist can do to


reduce dental anxiety:
 Prevent pain
 Show friendliness
 Working quickly
 Have a calm manner
 Give moral support
 Reasure about pain
What specific skills should you posses to assist
yourself and your patients in the delivery of good
healthcare?
Four areas of complaints:
1. Many health professionals restrict their information
to a very narrow set of concerns. Patients often feel
that they are unable to express the problem they are
really anxious about

2. The information that is given to patients is often


inadequate (clinicians assume that patients know a
great deal about their bodies, but this in not entirely
true)
What specific skills should you posses to assist
yourself and your patients in the delivery of good
healthcare?
Four areas of complaints:
3. Clinicians are not always good at “sitting back” and
listening carefully

4. The emotional concerns of patients are rarely elicited


by the clinician
What are the instances with clear
communication issues

 Presenting oral hygiene instruction and dietary change


 Providing explanation to assist certain forms of
treatment (eg: advice on stopping smoking to allow surgical
procedure for periodontal disease)

 Giving bad news (eg: presenting the patients that teeth have to be
removed when they are keen to retain their natural dentition)

 Negotiating with a parent and child over treatment


procedures
 A positive patient story

 My new dentist spent most of her time just listening to


me for the first appointment and then decided not to
take any teeth out). I was surprised as all of me
previous dentist asked me a few standard questions –
age, previous treatment I’d had, how bad the pain was
and how long I had experienced the pain. The dentist I
go to see now is quite different. She asked me what I
thought the pain was, what I wanted her to do, what
effects previous extractions had had on the pain. What
I liked about her was that she wanted to know about
my ideas and made me feel good that I had been
listened to.
Advantages of good
communication skills
 Better diagnosis of your patients’ problems

 Increased adherence of patients to your


recommendation and advice

 Greater patient satisfaction with the care received

 Reduced patient complaints and litigation towards


your treatment interventions
Components of
communication skills
1. Information giving

2. Management of patient beliefs and


associated emotions
Information giving
 The need to understand the importance of providing
information

“I have a fair number of my patients whom I see every


months for a checkup examination and refer to my
hygienist for a prophylaxis. The levels of plaque appear
not to change. I try to support my hygienist by
explaining to the patient the need to maintain good
oral hygiene. I think they simply forget what we say in
practice?
Information giving
How patients memorize (or not) health information:
patient educational level is NOT strongly related to
the degree of recall. Other factors are more important:

 Clear relationship between the number of statements


presented to the amount recalled by the patient

 Patients often forget what they are told (the estimates


are 60%)
Information giving
How patients memorize (or not) health information:
patient educational level is NOT strongly related to
the degree of recall. Other factors are more important:

 The level of patients’ medical knowledge is related to


recall. This may be independent of educational
experience or attainment

 Very low or high levels of anxiety at the time of


providing information are predictive of poor recall
Information giving
How patients memorize (or not) health information:
patient educational level is NOT strongly related to
the degree of recall. Other factors are more important:

 Those statements which are stressed as being


important, and presented first (primacy effect) are
more likely to be remembered. Statements of the end
of the appointment are also likely to be remembered
Information giving
Statements that are “chunked” together (explicit
categorization) aid recall:
“I would like you to introduce 3 changes in your
household:
 The first is to do oral hygiene. I would like you to ensure that
your children are in fact brushing their teeth as long as they
say they are. In other words, can you be with them while they
are brushing to supervise the time that they brush…

 Second, I would like you to try and manage their sweet eating
so that they eat any sweets directly after their evening meal
with you. This is better than having them spread out at
various stages in the day”
Information giving
 “And finally, you’ll remember what I said earlier about
not being afraid to come and see me even if you think
there is nothing wring with your child’s teeth”
Information giving
 Other methods of information giving: leaflet or
booklets

 This depend of the type of patients you have

 Patients may prefer a more direct approach and receive all their
information from the dentist who is going to treat them
Management of patient beliefs
about illness and emotional factors
 Patients’ feelings associated with the problem (eg.
Anxiety about the invasiveness or the cost of any
treatment required)

 The settings/place in which the clinician meets the


patient quiet, private room, unlikely to be
disturbed
Non verbal behavior (NVB)
 The main function of NVB is to assist a verbal message
and provide it with greater clarity and strenght

 NVB can in some circumstances replace the use of a


verbal message (eg a carring touch)

 The control of a communication process can be


enhanced by the use of NVB
Non verbal behavior
 !!!!!!!!! Difficulties can arise with patients when dentist
says one thing, but then behaves in a totally
contradictory manner

 Eg: the dentist may have asked the patient to relate what
problems he has experienced. Even if this question may
have been asked when the dentist was facing the patient
 after the question the dentist then turns to look on the
shelf top behind the patient. The patient is not sure what
to do, whether to say that he has experienced some minor
pain in the lower arch, but then decides not to bother, as
the dentist seem not interested…
Components of non-verbal
communication
 Touch
 Proximity
 Posture and orientation
 Body movements and gestures
 Facial expression
 Gaze and eye contact
 Paralanguage
 General appearance
Touch
 Touch can be used as a means to comforting the
patient, and also as a means of controlling
 eg. The dentist may gently place his hand to one side
of the patient’s face and gently press against the
cheek of the patient to encourage him to turn his head

 The patient feel he is not being coerced to embark in a


procedure that he would otherwise not sanction

 Consistency of verbal invitation and gentle direction


Proximity
 The dentist has tacit permission to sit at close
proximity to the patient, during a dental procedure

 Social psychologists: 3 zones of proximity


 Intimate:
 includes actual body contact; occupies a spot up to 18 inches
from the body
 The majority of patients will accept that this very close
proximity is essential for the dentist to do his job
 The personal zone: for communicating with friends;
extends from 1 – 4 feet
 Social consultative zone – frequented by business
aquaintances - ranges from 4 /12 feet
Proximity

 Some patients may feel very uncomfortable and unable


to inhibit the aversion that such close contact
produces
Posture and orientation
 It is improtant for the dentist to face their patients
and observe the effects that their questions or advise
may have

 It enables the patient to assess the dentist on a


number of key qualities such as warmth , genuiness
and positive regard...
 Dentists who introduce themselves with their arms
folded and the head tilted back will give an aloof
impression
Body movement
 Hurried body movements should be avoided in close
proximity to patients

 Rapid movements increase uncertainity in the


patients -- > major component in the development
and maintenance of dental anxiety
Facial expression
 Provides excellent confirmation of the meaning of
information acquired verbally from the patient by the
clinician and vice versa

 With child patients, useful information can be drawn


from the patient’s eyes as an indicator of pain
Gaze and eye contact
 Duration of gaze and eye contact are powerful
indicators of arousal

 We tend to look more at the people we like

 The converse is also true – if we are aware that we are


not being looked at, then there is convert message that
individuals who avert their gaze are not interested in
us
Paralanguage
 Includes:
 Speed,
 Provide speech
 inflexion,
with an
 intonation, important extra-
 accent dimension to the
meaning of what
 volume
a person is saying
Paralanguage
 = how something is said, as opposed to what is said

 vocalisations are studied in terms of their tone,


pitch, volume, speed and accent
 Eg. a low volume of voice in talking to children can be
reinforcing and encourage attention to the message
the dentist wish to convey
Verbal behavior
 Clinical case: secondary referal from one hospital unit
to another
 Problem: edentulous following surgery to remove
squalos cell carcinoma

 the patient vividly remembers the clinicians at the


outpatient clinic saying that the patient’s mouth had
been cleaned up, as the “dirt” had been removed in the
initial surgery. The patient had been offended by the
word “dirt” and stated that this experience had been
worse that the initial major surgery itself to remove the
tumor and perform reconstruction.
Verbal behavior

 The importance of the appropriate selection of words


is vital when raising the issues of malignancy

 When in doubt, a helpful rule is to ask the patients


about how much he would prefer to learn from you
about his condition
Verbal behavior

 The dental situation in unique in patient – clinician


relationship

 Quite often the dentist ask the patient an important


question while the patient has his mouth open and
filled with instruments

 The patient may feel frustrated, save the question for


the end of consultation, and so, prolong the session
Verbal behavior

 The dentist has more responsibility to pace the


communication process than his colleagues in general
medical practice
Verbal behavior
 Dentist – patient interaction: stages:

1. Arrange the environment in a co-operative or user


friendly fashion

2. Appropriate greeting behavior: standing and meeting


the patient at the door, smiling, engaging in eye
contact, using “non –task ” comments (eg discussing
the weather briefly, commenting on a holyday the
patient may have had), offering a seat
Verbal behavior
 Dentist – patient interaction: stages:

3. Motivating the patient by indicating interest, giving


full attention and showing concern

4. Checking various details with the patient: name,


address, introducing oneself and the assistant, stating
the purpose of the visit, obtaining the patient’s
expectations and outlining what is going to happen
Verbal behavior

 A key part of verbal communication: LISTENING


 Passive listening: keeping quiet and letting the patient
speak

 Active listening: taking notes and analyzing what the


patient is saying
Appearance
 The clinician’s appearance has traditionally been
regarded as important in communicating a for of
respect to the patient.

 The wearing of gloves was considered a mark of


professionalism by respondents over the age of 40y

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