Listen to Complaint

     The biggest complaint patients have about their doctors, other than the cost of service, is the lack of communication with their doctor. I understand this is also a common complaint among many married couples. You must be a good listener if you want to become a good doctor.

     After the patient is seated and schmoozed I always look a new patient in the eyes and ask, "Why are you here?" I then write down their response, making a list if necessary. I have never heard a patient reply, "I'm here for a full mouth series of radiographs, study models, head and neck exam, periodontal probings, charting of decayed, missing and filled teeth and then to be checked off by possibly five different instructors." They usually reply, "I broke a tooth in the back," or "I'm here for a check-up." Patients are happy to see me listening, and writing down, why they came.

     The first component of record-making will focus on whether the concern is functional, cosmetic and/or painful. I will also discuss the patient's medical history and make notations in the chart, "PMH (past medical history)-discussed" and then list any medical conditions. I prefer to write "discussed" because it is inadequate medico-legally to just review a patient's medical history without actually discussing it with them to ensure they understand the questions. Notice again how important it is that patient's actually understand all that you are doing.

     I then ask the patient when they last went to the dentist and for what reason. I may note in the record, for example, "PDH (past dental history)-2 years for a prophy" and then inquire why they did not return to their prior dentist and are now visiting me. This can give you a lot of insight into the patient's emotional needs.

     Sometimes a patient may tell me that they have not been to the dentist for many years or I can see they are agitated sitting in the chair. If I notice this I usually sit back in my chair and in a supportive manner I tell patients about the most common reasons patients do not frequent the dentist: lack of time, lack of money, indifference, or fear.

     It is very common among people to get so caught up with work and family leaving little time to complete their necessary dental work. I will complete their dental work quickly and with a high level of skill. I just need to know the time-frame in which they are working.

     "A lot of people ignore the need for dental work without understanding that by ignoring a problem they usually create the need for more complex, costlier work later. Taking care of any problem earlier will always save money in the end." I prefer to avoid the use of the word "patients" because patients think of themselves as people, not patients. "If a lack of money is a barrier to receiving proper dental care we may discuss this when we discuss treatment options."

     "It is also not uncommon for someone not to go to the dentist because they don't have any pain so they reason they must be healthy." I then discuss how many diseases like heart disease, high blood pressure (don't use "hypertension"), diabetes, or cancer don't typically cause pain. The intention is not to suggest that dental disease is comparable to those diseases but just that most disease is not painful until it is in a later stage so that someone should never use the presence, or absence, of pain with any diagnostic certainty.

     Then I get to the big issue, fear. Without suggesting that the patient before me is actually "afraid" I generally discuss how fear is frequently a large component of why people don't seek dental care. I discuss the anatomic basis for fear as discussed in "greeting the patient." I then say, "I have found that the more powerful an individual is, either physically or professionally, the more uncomfortable they are going to a dentist. Though initially ironic, this is actually quite logical. A little, old lady is rarely afraid of dentistry because they are usually relatively powerless (I don't mean this negatively) in controlling their outside environment. On the other hand, a physically strong athletic type or successful executive might have gotten used to sensing a certain level of control over their environment. These people have the most difficulty giving up control and therefore experience the most fear of dentistry. Therefore, if fear may be (not "is") a component of why you have not been to the dentist recently you actually probably feel powerful in your daily life."

     "The way we help fearful patients cope with their dental work is by giving them control. We give them control over what we do, when we do it, how we do it, how much it will cost, what it will look like and how it will function. We also give them control over the potential of pain with a variety of medications (to be discussed later) both during and after any procedures." (I credit the concept to Martin Seligman's work on helplessness and depression that I learned at Penn.)

     I do not typically go over these four main reasons people don't frequent a dentist. If the patient replied, for example, that their last dental visit was eight months ago in San Diego just before they moved to New York then the whole conversation above would have been a waste of time. If, however, you begin to sense that fear may be a significant barrier to the patient receiving proper dental care, then the time is well worth the effort. After such a conversation you may tell a patient, "Okay, now you can take a deep breath since now you know you're concerns are pretty common."

     Getting back to the actual chief complaint, determine whether it is functional, cosmetic and/or painful. One needs to also learn the degree of this concern, e.g. how painful is the tooth.

     Next determine to what extent the patient's medical history and past dental history will impact treatment. Then determine what you must accomplish during this first visit to adequately (not necessarily completely, nor permanently) treat the patient's chief complaint. Lastly, make the appropriate records for treating the chief complaint only.

     Imagine going to a store to purchase a new shirt. While shopping, the salesperson commented that your pants are pretty ragged too and you really should buy new pants.

     Actually, your shirt is not so bad but your shoes are incredibly ugly. So buy new pants and shoes and come back next year for a new shirt. What would you do?

     I am not equating the significance of seeking dental treatment with that of buying clothes but seek to inform you that the emotional significance may be similar to some degree. In the example above, the salesperson could have provided you with a new shirt and emotionally supported how good you looked. Then he could have informed you that clothes for the new season will arrive in a few weeks. After seeing how much you love your new shirt, come back to see some really fabulous outfits.

     We must first give our patients what they want. Then, we attempt to teach them to want what they need. Before I begin making records, I repeat from my written notes the patient. s chief complaint and confirm that I understand specifically why they came.