After practicing dental hygiene for more than twenty years, I went to work in the office of Dr. Doug Roth who was attending courses at The Pankey Institute. He had a copy of Dr. Bob Barkley’s book, Successful Preventive Dental Practices. Reading that book was a revelation for me. Although I never knew Bob Barkley, his work so resonated for me that I had the feeling he had read my thoughts about working with patients.

I had believed for some time that more was possible in dentistry. I had worked with good dentists and felt as though I took good care of my patients in the time I was allowed to spend with them. We were kind, thorough in our exams, and conscientious in treatment recommendations. Sometimes they took our recommendations, and sometimes they did not. I did not think there was much we could do to change that.

As a result of Bob Barkley’s book and the courses Doug was taking at the Pankey Institute, we incorporated a new model for bringing new patients into the office. Instead of moving patients quickly through an exam and treatment recommendations, we invested time and attention to get to know patients in a different way before we recommended significant treatment. I had no idea of the depth of connection we could have with patients, and the impact we could have on their health and well-being!

We spent “engaged” time with patients over a variety of appointments. We came to understand that the clinical tasks we had to accomplish were a small part of caring for patients. We began to see every interaction, with every patient, as an opportunity to get to know them and what was important to them to help them make healthy choices.

Over time we discovered with our patients:

• The status of the dental health
• The challenges of their current conditions
• The implications of these conditions if nothing was done to intervene
• Interventions they and we could do to change the trajectory of disease.
• A possible preferred future of choice
• Considerations involved in various treatment choices.

When we met patients where they were instead of where we thought they “should be” we found that some were ready sooner than others. We stopped giving patients solutions to problems they did not yet own. We came to understand that if we gave patients the time and attention they needed to own their existing conditions they were more curious about what Dr. Barkley called their “Probable Future” and more likely to pursue a “Possible Future.”

Without this spirit of collaboration and intentional patient development, we cannot do our best work.

Our influence develops throughout a process in which the patient is learning, in touch with their body, and engaged in thinking about the implications of the various aspects of their oral health. Because the conditions we discover today and our patient’s choices will impact their future health, we have a moral obligation to share what our experience tells us is likely to happen (the probable future) if they do nothing or if they choose a stop-gap treatment.

It is also our responsibility to help them see a preferred future that is possible for them when they are ready.

By engaging them in the exam process, creating opportunities for them to experience learning about their health, and welcoming them into collaboration, we enable them to partner with us in shaping their future. We must help them understand the implications of any choice they might make including its limitations, so they are fully informed to make true choices.

We have been trained to be efficient, and most dental clinicians have pride in their efficiency. But by prioritizing being “effective” over being efficient we make better use of our time and theirs. We experience an increase in trust, in our patient’s confidence in their decisions, and a more comprehensive view of treatment. Patients begin to see dentistry as a vehicle to create optimal health, function, and esthetics. Patients are more likely to keep their appointments, follow through on suggestions, and pay for our care with gratitude.

When we invest time in the early stages of our relationships, everything down the road flows more easily.

Many times, patients have some sense about their overall health, but have no idea about what is going on in their mouths. They tell us they’ve never looked in their mouths. Our challenge is to engage them during the exam process in such a way that it raises their curiosity and awareness.

Our goal should be for patients to be so engaged in the exam that they continue to pay attention to their mouths, even when they leave our office. As they are driving home, we would like them to be touching their facial muscles. We would like them to be paying attention to how their teeth come together when they take out a nightguard in the morning. We would like them to notice if there are points of bleeding when they floss. As they go about their lives, we hope they pay more attention to all the things we talked about.

Think of engagement as being like the gears on a bicycle. If the gears on your bicycle are not engaged, the bike will not move forward. You may be inclined to pedal harder, but you are still going nowhere. Similarly, if a patient is not engaged, you might be inclined to give them more information. But you might as well stop talking because you are probably going nowhere.

Engagement has been described by educators as when the student is working at least as hard as the teacher.

We all know what patients look like when they are engaged. They ask questions, they touch their faces, they lean forward, or they point to images on the computer monitor. They give us signals that they are paying attention. On the other hand, when a patient’s eyes glaze over and they blankly nod, it’s a good indication they are not engaged. When you notice that polite smile, stop talking and look for a way to engage them in the process. You might ask them a question. “I know I’ve been giving you a lot of information, and I’m curious, what are your thoughts about what we have discovered so far?”

One of the things I like to do when I begin the exam process is to ask the patient to hold a mirror in case I have some questions for them as we go through the exam. Most patients will take the mirror and put it on their lap. I look for the first opportunity to ask any kind of question that involves the mirror. I might ask them to bring the mirror up to their face and show me in the mirror an area they mentioned as a concern. I might ask them to point to changes made in their mouth by orthodontics and restorations and inquire about how they feel about those changes. Once they do, they are more engaged and understand that what they are telling me has relevance. They begin to see themselves as part of the process with expertise about themselves.

We want to engage as many of the patient’s senses as we can…seeing…hearing…touching… tasting. As I examine the mouth, I might say, “I notice that when I slide the perio prob into this deeper space between the tooth and the gums, there is bleeding. Do you ever see or taste bleeding there?” Their personal involvement in the exam gives rise to questions that are opportunities for them to connect what is going on in their mouth with their self-care behaviors and the choices they will have about seeking treatment from us.

We don’t want our patients to just comply with our recommendations. We want them to be actively engaged in understanding, planning, and working toward improved health. We want them to feel responsible for their choices and to partner with us in improving their health.

Engagement leads patients to take ownership of their health and make healthy choices.

After the next exam or consultation you do with a patient, consider:

• How engaged was the patient?
• How much “work” were they doing relative to how hard you were working?
• What did you do to activate engagement?
• If you could do it all over again, what “one more” question could you have asked the patient?

In dentistry, we’re clear about the connections among the teeth, the muscles, the bone, and the joints—and how all these pieces are related to esthetics. We understand how those pieces fit together. Unfortunately, most patients don’t come to us with that understanding.

Dr. Bob Barkley used to talk about patients not understanding “the web”—the connection of how all the pieces come together.

Just as with a delicate spider web, if you touch any one aspect of it, you change everything. Bob Barkley would say to his patients, “I know you are concerned about that one tooth. That’s your job to be concerned about that one tooth. My job is figure out and to help you understand how what’s happening with that one tooth is related to everything else that is going on in your mouth.”

The exam is a process by which we can do exactly that. We can help our patients understand the connections in their mouths. The exam is also an opportunity to encourage our patients to have confidence in us. Confidence building starts with the new patient exam and continues in subsequent interactions. The more thorough the examination we do, the more in touch we are with what is really happening in our patients’ mouths and the more confident patients will feel about our ability to help them.

Our thoroughness and knowledge aren’t the only aspects of the exam that develop patients’ confidence in us. The gentler we are in our touch and the more careful to include the patient or others in the room during exams are important. These aspects of the exam communicate our character and the way we tend to approach our work. Patients anticipate our care and approach will be similarly open and comfortable during future consultations and procedures.

People don’t take risks when they don’t feel confident. Unfortunately, many patients do not have confidence in making decisions for themselves when they sit in a dental chair. They think of significant dentistry as a risk. For best long-term results and positive relationships, we always want the patient to feel as strong and confident about their choices as they can.

Repeated comfortable interactions are needed for them to develop their confidence. Every time we find something good in their mouth, every time we point out health such as healthy gum tissue or a beautiful restoration, and areas not needing restoration, we are reinforcing healthy choices they made in the past. This can be a confidence booster to help them move forward in making next choices.

The examination process is an opportunity for the clinician to:

• Understand what the patient is experiencing emotionally and physically,
• Provide sensory learning experiences (see Art of the Examination: Part 1),
• Help the patient draw connections for deeper understanding of their health
• Explore options for what the patient might choose to do.

The examination is an opportunity for the patient to develop understanding of:

• The clinician’s ability to help them.
• The current condition of their teeth and other oral structures.
• The impact on them of what they are learning.
• The choices they can make to improve their health.

Every examination is a next opportunity to develop our patients’ confidence in us and in their ability to make healthy choices for themselves.

All dental schools teach a system for doing a clinical examination. The goal is typically to gather as much information about current clinical conditions as possible, as efficiently as possible. It is an important aspect of patient care. The science of the exam is useful, but it misses the art of the examination. In my experience, it is often a missed opportunity

In dentistry, we are always trying to figure out the best way to influence our patients to make healthy choices for themselves. When I left Hygiene school, I thought it would be simple to influence patients. I thought that if I did a good examination, a good diagnosis, and then made a good presentation, patients would go ahead and do the treatment.

What I experienced when I was in practice was different. Over time, multiple conversations, and multiple interactions—in their own time and in their own way, patients would move forward with treatment. Sometimes it seemed random, but what I’ve come to understand now is that every interaction was an opportunity to influence the patient.

Every single interaction, with every single patient, by every single member of the dental team is an opportunity to influence.

I think most of us have learned over the years to be skillful at providing information. We know how to “Teach and Tell” what we are finding and recommending. But there is an aspect of that process that has to do with experience. What we have not always paid attention to is how we can go beyond information to create learning experiences for our patients.

When I see a baby touching grass, I imagine that the experience of learning about grass through the senses is entirely different than learning by being told about grass. Creating opportunities for people to interact physically with their own bodies is an opportunity we have in a number of different situations. We can do this during a consultation, but we really have this opportunity during an examination.

If we place priority on effectiveness over efficiency, we will do our exams with the intention of creating physical-sensory experiences, which can be as simple as having them touch their muscles as they touch their teeth together, sliding their jaw forward and side to side, finding a relaxed jaw position, tapping their teeth together, clenching, feeling fremitus with their tongue or finger, feeling the difficulty of flossing between tightly packed teeth, and taking us on a tour of their mouth in a mirror while telling us about their concerns. It’s natural to say, “Tell me more about that. Show me where.”

Consider the new patient exam as the initiation of an experiential learning process to influence our patients to make healthy choices.

The new patient exam is not “the one” opportunity we will have to influence patients. We’ll have many more opportunities, but it sets the tone for every conversation you will have with your patients about their health, about the conditions present in their mouth, about the implications of what is going on in their mouth, and some of the choices they might be able to make.

Job one is to engage the patient in discovering just how intriguing their mouth is and why the health of its various components matter for long-term comfort, function, beauty, and overall health.

Ask One More Question

One of the ways I have learned to Stay in the Question is to practice asking one more question before I give information. Learning to ask one more question has helped me to be more effective in several ways

1. The practice of asking one more question helps us save time.

My experience is that we spend a lot of time giving patients information they may not want or need. We can waste our time and theirs by giving information they have not asked for.

There was a time when if a patient asked me if x-rays were “really” necessary, I would go on at great length about the value of the radiographs, what we could see on them, and what we might miss if we didn’t take them. But I learned to respond, “It sounds like you might have some concerns about having x-rays,” and ask, “What is your concern?” By asking one more question, I was able to answer the patient’s question or concern very precisely and quickly.

2. Staying in the questions helps us understand what the patient wants from us.

Patients don’t always know how to communicate with us to get their needs met. They ask what they know how to ask. Sometimes their question is “Will my insurance cover that?” Sometimes their question is “How long will it last?” or “Will it hurt?”

Asking a follow up question to any question or concern they express allows us to better understand their needs and expectations. If a patient asks, “Will it hurt?” I could reassure them I will be as gentle as possible. Alternatively, I could say, “It sounds like you are concerned about the pain of this procedure. Have you had a painful dental experience in the past?” Responding to a specific fear will always be more powerful than a general reassurance.

3. Asking one more question allows us to give information clearly, to give information that is useful to them.

After seeing patients over years, it is easy to fall into giving the same information repeatedly. We all have our scripts we fall back on that describe a particular disease or procedure. Having a ready-made script may seem efficient but in the long run it can cause us to miss opportunities to be more effective with our patients. We can spend a lot of time giving them reasons why we think they should have treatment instead of providing more precise information relevant to their needs and their wants.

Aristotle said, “The fool persuades me with his reasons. The wise man persuades me with my own.” We don’t need to guess how to persuade our patients. I’ve learned that, when I stay in the question, patients tell me exactly what they need from me to be able to make decisions.

4. Asking one more question creates an opportunity to build trust.

There was a time when I thought having all the answers for my patients would make me seem competent and gain their trust. I’ve come to understand that I will never have all the answers and that, in dentistry, it is just as important for patients to trust our motives as it is for them to trust our competence. When we take their questions and concerns seriously, follow up with genuine curiosity, and listen deeply to their responses, they are more likely to feel our care and concern. They are more likely to trust that what we want is what is best for them.

Staying in the question — staying curious about what more you can learn about each dental patient and the intention to help each patient be more curious about their own situation, enables dentists and dental hygienists to be more effective in helping their patients.

What Do You Think You Know?

The next time you are reviewing the chart of a patient you are frustrated with, try this exercise. Instead of going too quickly to thinking, “What is wrong with this person? Why don’t they get it?” – ask yourself these three questions:

1. What do you know about this patient and their situation, specifically because they told you this? They actually said it.
2. What do you think you know? This has to do with the guesses you have, your intuition about what is going on. What do you think the patient has implied by what they said? Recognize which of your thoughts are guesses because those assumptions might or might not be true. If you act based on what is not true, you may miss opportunities to learn more about what is important to your patient. Asking yourself what you think you know is a way of challenging your assumptions.
3. What do you want to know? What are you curious about? How can you take some of your “think you know” thoughts and move them into the category of “what you do know” about your patient.

The more you do this exercise, the more you become aware of the difference between what you know and what you think you know, and the more curious you will become about your patients. The more I have done this exercise, the more I have come to know that what I do know is small compared to what I do not know. I sometimes I realize I know very little about what is important to them.

Is the Patient Curious to Learn About Their Situation?

I have come to realize that the first question the patient asks is just the first step in their learning process. Sometimes they need help framing some of their more important questions. Or sometimes, a question is their attempt to share a little of their story, their struggles, their fears, their embarrassment. Often, I realize they have emotional discomfort I can address with empathy. In that moment, empathy is more effective in helping and leading the patient to higher health than the clinical information I could provide them.

Understanding that most patients have some level of anxiety about their oral health and oral health visits, I have learned to pause and ask a question before plowing ahead with information they may not want or need — or may not “hear” if they are anxious.

For example, if I see wear patterns on teeth when I do an examination, I could tell the patient what I see. I could say, “I see you grind your teeth.” But that type of statement is often perceived as accusing, not empathetic. What I have found to be more effective is to show the patient what I see. If the patient does not say anything that indicates she would like more information, I might ask her, “How long has that wear pattern been there?” or “What do you think has caused it?” I never want to deprive her of information. I want to give information when she has a little more curiosity — when she wants to know it and will hear it.

Sparking curiosity with a question often leads the patient to ask a question that reflects what is most important to them at that time. Discovering what is most important to them enables us to optimally make use of our time during that visit. We can provide information that is important to them, that they want. Or we can focus on providing the empathy they need to develop a relationship of trust.

The art of helping our patients develop ownership of their present condition and their desires for their dental health is built on the foundation of listening. But much of the time, we do all the talking and provide all the information.

Several years ago, my friend and I were coaching a young hygienist when her patient asked how she could get her teenage son to spend more effort caring for his teeth. I was ready to dazzle them with all the tips I had learned over my 20+ years in Hygiene but my friend Linda cautioned us to “stay in the question.” She was curious to know what the mother in the chair was really asking. That was the first time I became aware of the concept of staying in the question.

The model I learned in my clinical training—the model of teach and tell, really isn’t enough to help patients make choices about their dental care. And over the years, I learned that when I assumed I knew what a patient meant by a question and gave information I thought they wanted… I was wrong. My assumptions got in the way of my ability to really help my patients.

Are our patients asking for help or for information?

When I learned to combine the ability to stay in the question with my knowledge about dental health and dental care, all my conversations became a bit easier. I have come to realize that that mother with a teenage son, like so many of our patients, was asking for HELP but not information.

Today I can think of several questions I might have asked that mom before I jumped in to giving her information. I might have asked, “Well, what have you tried so far?” Or I might have asked, “What motivates your son in other areas of his life?” I might have asked, “What is he doing to care for his teeth?” I might have asked all those questions but asking even one of those questions, might have enabled me to better help.

Sometimes asking just one question before offering information is enough to open the door to real learning.

Staying in the question is both a skill and an attitude.

We need to skillfully ask authentic questions that are not designed to manipulate people into doing what we want them to do. If the questions help us understand our patients better, they are authentic questions. If the questions help them talk through and move through any barriers they perceive, they are authentic questions. If the questions open their minds to possibilities, they are authentic questions.

But staying in the question is not just about asking questions. It’s about an attitude of curiosity, of coming to the conversation with a desire to know more. It’s about releasing the attitude that we know everything we need to know to help the patient move forward.

Staying the question requires a genuine belief that our patients have information that we need to help them better.

What would you like to build your relationships upon in your practice? With all the attention that is paid to dental insurance, it sometimes seems as though that becomes the foundation of our relationships with patients. When this is the basis of our relationship, the moment the plan changes, the patient may be looking for another dental office. Do we want to have our relationship based on such a fragile platform?

When I think about what we could have at the foundation and how we could make this happen, several things come to mind.

Compassion as the Basis

Basing a relationship on compassion can begin with the very first phone call. When a new patient calls, compassion can be expressed by something as simple as, “What prompted you to call us today? I hope you are not experiencing any discomfort.” Right out the gate, you are putting out there that you care about their comfort.

For a new or an existing patient, you might to say something like, “I’d like to make sure we schedule enough time to do this very thoroughly…very gently, and that we provide you with the best possible service so you are as comfortable as you can be.”

When you talk with patients about conditions you are seeing in their mouths, you can express concern as simply as saying, “I see a crack in this tooth, and I am concerned that, as it gets larger, you may experience some pain. Have you experienced any pain there?”

Mutual Trust as the Basis

On the very first call, you can begin to base your relationship on mutual trust and respect. You might do this by saying something like, “I’d like to schedule enough time for you to get to know us and for us to get to know you. When we learn what is important to you, we can help you make choices that are in your best interest. We’ll want to know what your previous experiences have been in dentistry because we want to provide you with the best possible experience in this practice.”

During Hygiene appointments, you might say something like this, “As I look in your mouth, it appears to me that over the years, you’ve gone to the dentist regularly and done everything you could to take care of yourself. You’ve chosen to have treatment when it was recommended. I believe that if you have the right information and you have some support in working through the process, we can help you make good choices for yourself in the future.”

If the patient is not in pain, you might say something like, “You’re in a really good position right now. We’ve got time to study the information we’ve gathered and to learn about your preferences. The doctor will want to go over all the information we’ve gathered today and spend time thinking about your oral health circumstances and options. If you decide later to have treatment, you will be fully informed about your options so you can make the decision that is right for you.”

Shared Values as the Basis

When we discover shared values in conversation, there is a powerful connection between us and the patient. If a patient mentions a filling has lasted for decades, you might say something like, “It seems to me that you like to have your dentistry last as long as possible?” And if the patient says yes, you might say, “Excellent, we’ll take that into consideration when we think about options for you.” Give them opportunities for discovering together with you what is most important to them.

The foundation you intentionally build on compassion, mutual trust, and shared values will enable you to expand conversations you have with patients about insurance and the cost of care. You will be able to assure them you will do whatever you can to make the dentistry they value affordable for them.

The Least Understood Part of Dr. Pankey’s Cross

I’ve always thought that the least understood and least appreciated aspect of Dr. Pankey’s cross of life is the directive to “Know Yourself.” It seems more interesting and exciting to get into learning about your work and your patients. And applying that knowledge makes all the sense in the world. Many high achieving people are happy to dedicate themselves to a lifetime of learning about their work.

What about learning about ourselves? My experience is that it’s easier to believe we have “done that.” We take a psychological instrument and label ourselves as “Driver” or “Amiable.” Check! We survey our values and identify the top three. Check! We write a vision or mission statement. Check! How much more is there to learn?

I have come to understand that, over time, the self-discovery process of knowing yourself can be the most challenging and most rewarding aspect of your work. Knowing yourself is what makes you not only a better dentist, but a more effective leader, a more engaged family and community member, and a more fulfilled person. So, when I was asked to speak about that at the Pankey Institute’s Annual meeting I was both delighted and a bit intimidated. It is such a big topic!

“But, What about Self-Absorption?”

The idea of knowing yourself can have a connotation of self-absorption, a self-serving focus inward. This thought has arisen in our evening discussions at the Institute. We tend to think it is more appropriate to focus outward on our patients, our team, and our work. We want to facilitate their growth and their learning about how to become healthier. It can be difficult to see the value of that inner self-discovery focus. But Parker J. Palmer, whose writing has informed my work over many years wrote:

“. . . When I do not know myself, I cannot know who my students are. I will see them through a glass darkly, in the shadows of my unexamined life, and when I cannot see them clearly, I cannot teach them well.”

That lens through which we see others is an essential part of who we are. What I have learned so far is that my lens includes filters of impatience, and judgment, and assumptions about what I think I know. I have my blind spots. But my lens also includes compassion, and love, and understanding.

After 40 Years, Even New Discoveries

After 40 years in service of others, I am still learning about myself. As I learn to know myself, I am better able to take a step back and look at my filters, not just through them. I’m learning to question and understand where they fit and where they do not. I find it very interesting how on my best days I can see both the filter and the lens. With intention, I practice questioning my assumptions and suspending my judgment. Sometimes I can even laugh at the stories I make up about people and situations! And often I can also see the gifts I bring; the perspective, the compassion. Those are the times when I can bring all of myself to my work.

I serve better and I am better for knowing myself.

Mary will be presenting on Know Yourself at the Pankey 50th Anniversary Annual Meeting this year on Key Biscayne, Fl September 13,14.

It’s important to consider your hygienists as autonomous skilled professionals independent from your management. Of course, as the leader you must provide guidance, but you should still defer to their training in their specific field.

A Hygienist’s Expertise

This is one of the hardest parts about managing a team – letting go of the reigns a little. But you don’t have to entertain a free for all to provide some freedom. If a hygienist has made it clear to you that they have both clinical and behavioral skills, then it’s your job to open up a dialogue.

You should discuss with them what you will individually bring to an exam. Find out what they feel comfortable recognizing and diagnosing, that way you can both be on the same page. Don’t rely on the antiquated belief that hygienists only know how to recognize. They are also fully capable of diagnostic techniques.

In hygiene school, they will have thoroughly reviewed the signs and symptoms of multiple conditions. But for them, their education tends toward directing them to call the problem to the dentist’s attention.

The key to all of this is to only offer advice in your area of expertise. That goes for both hygienists and dentists. As with most things, individuals vary. Dentists and hygienists will have different qualifications, therefore providing different perspectives in the practice. No matter our level, we must offer our opinions as opinions and be willing to listen to the thoughts of others.

Diagnosing versus recognizing comes down to semantics, while both are very different from the actual treatment planning designed by the clinician. It’s a hygienist’s responsibility to serve the patient’s needs to the best of their ability based on their skill level and judgement.

What do you consider a hygienist’s purview in the dental practice? We’d like to know what you think!