I had a great reminder recently while I was working with a patient that listening to patients’ intuitions and beliefs about their own dental health and care can be valuable. I’ve had this experience with many of my patients. Sometimes that value is clinical, and sometimes it is in increased patient understanding and relationship development.

I treat a lot of patients who have chronic TMD…oral facial pain…occlusal muscle disorders. You have them, too, in your dental practice. We try to help them understand that there is no “treatment,” but we have management strategies. Even when patients know this, it is frustrating for them when they have flare ups.

My patient had been comfortable and symptom free for the better part of a year, which was a long period for her. Recently, though, she had started waking up with headaches and muscle tension in her masseters and temporalis. She came in to talk about “What now?” And the answer to “What now?” is always “What has worked in the past?” We walked back on our options.

She wondered, “Can you add some material to my appliance? I always feel better at a slightly open vertical.”

The question didn’t surprise me. She’s been a dental patient for a lot of years and knows the meaning of “open vertical.” My first gut reaction was to dismiss her suggestion because it ran counter to what I know about the science and my clinical experience with other patients. I honestly didn’t want to change her appliance. But I intentionally put a pause on that resistance and sought clarification from her about what she has experienced.

Over the years, it has amazed me how knowledgeable patients are about their own dental health. They are receiving physiological data that so often they don’t know how to describe. Assessing the validity of what patients describe can be a challenge, but I’ve learned the value of acknowledging the information and asking the patient to tell me more. I ask, “Why do you think that? What have you experienced in the past that has led you to that belief?” Often, I can access the data and understand the validity of the information to help the patient.

When I don’t have a really good idea of what to do next and the TMD patient has an intuitive idea, I’ve come to respect their intuition and do what they suggest. Many, many times I have no evidence to explain why it works but their intuition works. And when it doesn’t work, it’s still okay because the patient has been validated. We’ve demonstrated we’re in a partnership in their care, and we move on to try something else.

I’ve learned to stop and recognize there must be something behind intuitions patients share. Seeking to learn more about their intuitions has led to trying new types of care and always deeper relationships with patients.

We had another interesting week at the dental office when a patient (I’ll call Ron) came in. Ron has been a patient of mine for over 20 years and is nearing 80. Whenever I saw him, we would have interesting conversations about what he was doing and thinking about doing next. He was the kind of person I love to be around, always positive with a “can-do” attitude.

This time was different. I hadn’t seen Ron in over three years, because he suffered a heart attack which led to some other complications. He came in using a cane.

When it was time for my hygiene check, Julie came to me and said, “I don’t know what’s going on with Ron, but he was really hard for me to work with today. I tried to get as much accomplished as I could. I’m sorry.”

Ron was previously very health-centered but now he was behaving like he wasn’t. Do values change in that short a period? No, but a person’s priorities might, particularly when they have developed a distorted perspective due to some traumatic events.

When I entered the room, Ron’s attitude perked up. He was positive and respectful — he was honoring our long history of mutual respect. He updated me on what happened and how he was doing. Not only were his physical disabilities frustrating, but he had rarely left the house for over a year.

Following my exam, we discussed an area of decay and several cracked teeth — all restorable with crowns. He responded that he was old and wasn’t sure how much longer he would be around. He asked, “Is there an inexpensive way to fix this? I don’t want to spend a lot of money on my mouth.”

Dentists hear this every day, but in this case, I knew the REAL Ron. I knew it was his depression speaking to me. I told him it would make sense for us to develop a Phase 1 plan, meaning, “Let’s remove the decay and get everything stabilized like they would do for you in the ER if you had an emergency, and then we can talk later about restoring things back to the way they need to be — strong and secure.”

“I don’t think I want any restoration work,” he replied.

Then, I said, “Ron, I know how much you love to eat fine food, and it would be tragic if, in your last decade, you were limited to eating only soft food or you had to fumble around with a partial denture that catches food around it all the time. Like I said, let’s focus on Phase 1 and then talk about restoration later. We have time on our side.”

“Ok,” he said, “I can go along with that.” He needed to feel like he was in control.

I finished by using words that would resonate with him, “You know Ron, despite these things that need to be addressed, you have great bone around your teeth and a great smile, so there are good reasons to restore things and finish out strongly. If you were an old, uninspiring ‘84 Oldsmobile, I’d say there is no point in restoring things, but you’re like a 1956 Corvette barn find that’s still in good condition. You’re worth it. Let’s save the conversation about restoration for another day when you are feeling better. I’m so glad that you came in, I miss talking to you.”

Ron’s eyes lit up. He smiled and said, “Yea, maybe you’re right. I can’t move like a Corvette any longer, but I understand what you are saying. I really appreciate it.”

One evening I was seated next to a new acquaintance at a dinner party. As we began the conversation, I learned Bob was a retired CFO of a manufacturing company with $250 million in sales. He had traveled extensively and had had many experiences in dental offices.

In our conversation, Bob discovered I was a dentist teaching at The Pankey Institute. I thought I would move the conversation off of dentistry and have the opportunity to climb into the mind of a CFO of a $250 million dollar company, so when he asked what I taught, I responded with “I teach Finance.” He looked surprised and a bit disinterested, but he said, “You know, the thing that impresses me most, about dentists, is how quickly they make decisions.”

Trying to find the compliment in the statement, he had just made and hoping he thought dentists to be of high intelligence, I queried, “Quick decisions?” He went on to tell me, and sometimes show me between bites of food, the crowns I had already noticed. He said, “It always impressed me, when I went into the dental office with a broken tooth, how the dentist would have a quick look around and then tell me I needed a crown. Sometimes he was ready to do it on the spot!”

Other things had come out in our conversation. He was an accomplished golfer with a six handicap. He had three homes, and each home had an identical set of golf clubs. All were recently updated, matched, swing-weighted custom sets. My mind was spinning as I thought about the gap between those matched sets of clubs and his unmatched set of teeth! How could I get his attention?

Doctor Pankey would often say to me, “Communicate with others by making your examples relevant to the other person’s experience or frame of reference.” The light bulb came on, and I said, “Tell me about how you made decisions as a CFO in your business.”

“Well, I take a good look at the short and long term impact of the decisions, the cost of capital necessary – both short and long term, and the risk/reward potential to the bottom line of the company.”

Now I was in full swing, “Sounds like you study the problem and/or opportunity with reflection and quite a bit of detail. You slow down and take the necessary time to uncover the best decision.”

“Well, yes, of course, they would be important decisions, and they would take time!” Bob replied.

“Quite honestly, Bob, that is exactly what I and others are attempting to teach dentists at The Pankey Institute. We are asking dentists to intentionally slow down and become more reflective, affective, and effective with their patients.” I could see he was thinking about this.

“Bob, let’s compare you and your teeth to your sets of golf clubs.” He was intently listening. “It’s as if, when you were a young man, God gave you a set of new golf clubs. We, as dentists, call them teeth. You used them through the years as you refined your golf game and in time you broke the 9-iron. You went to the pro shop and tried to get a new one. It was a 9-iron, of course, but the grip, the shaft and the swing weight were not quite the same as your original set. It was okay, because you knew how to adjust if you remembered to accommodate for the differences.

“As time went on, you had the same experience with your 7-iron, the 4-iron, the pitching wedge, and your favorite wood. In time, you were adjusting your swing and muscles every time you swung a club. You noticed there were times when certain muscles would get sore and even the soreness would get in the way of your swing chewing. Finally, you decided to get refitted with a whole new set of clubs. You went to a professional who put you through a whole series of tests and thorough evaluations to diagnose and plan the best solution, which fit your uniqueness. And, you not only got one completely new set of golf clubs, you got three.

“Many dentists would see you as a very busy man who wants to get out of the dental office with dispatch. They respond in a crisis mode to your crisis events. But, like clubs, teeth need to be customized and “matched” to work together so you aren’t constantly accommodating as teeth break and are restored. What we are encouraging dentists to do is to slow down and be as thorough as you would be in your decision making in your business. It’s better for you—actually better for all concerned.”

Bob’s face lit up, “So that’s what you teach?” “That’s what I teach,” I responded

With that “aha” smile, Bob said, “Would you be so kind as to give me your business card with the name of a dentist who thinks like you do? In fact, I’d like three – one for each of the locations of my golf clubs!”

Doctor L.D. Pankey would often say to me, “Communicate with others by making your examples relevant to the other person’s experience or frame of reference.”

Years ago, I had been asked by a young dentist to come to his office and help him with the implementation of his new learning with occlusion applied to bite splints and equilibration. I suggested he line up a few patients for us to work on together during my visit. When we arrived at his office early in the morning to talk about the patients we were going to see together over the next two days, I asked him to bring me up to speed on where he was in treatment with the patients and the conversations he had had with them. We also looked at full mouth models, models of bite splints, and radiographs. I asked him what he wanted me to do with the first patient who was coming in that morning.

He said, “I want to watch you sell him a bite splint!” A little surprised, I asked him to tell me about the patient. He said he was a new acquaintance. They played golf together and occasionally gambled as they played to keep their interest up in the game. They also gave each other a hard time about handicap ratings. He mentioned he felt a bit embarrassed because he thought he knew what was best for his new friend and had kind of hustled his friend on the golf course to be a patient. Now he was feeling a bit guilty about having his new friend come in as a patient, and he could not bring himself to a have conversation concerning the benefits of a bite splint.

Charlie (the friend) appeared, and the dentist introduced me. Charlie and I stood about the same height. We looked each other in the eye, and we smiled at each other – a good beginning. In my mind, I was repeating slowly to myself, “Find a relevant connection.”

I said, “Thanks for taking the time to come in and meet me on such a beautiful Spring day, as I pointed to a comfortable chair for him to sit in.”

He offered something about how golf could be a bit boring if you played it too much. Still looking for a relevant connection, since my “stated task” was to sell him a bite splint, I asked him about his work, and he said he was retired from directing filmed commercials. I asked him what he did with his new found time aside from golf. He smiled a big smile and said he ran about five to seven miles a day. I smiled as I remembered the years when I ran three to five miles a day during the week and seven to ten miles on weekends. A light bulb went on, in my head, and I knew a question I could ask to engage him and tweak his curiosity.

I asked, “How often do you buy new running shoes?” And without hesitation, he said, “Every four hundred miles.” I then asked, “How did you discover that interval?”

He reached down with his right hand and rubbed the lateral surface of his right leg from the mid-thigh, across the lateral surface of his knee, to the lateral surface of his calf, while telling me of the discomfort he would experience in his muscles when the bottoms of his running shoes became worn.

I made the statement, “You must run with the traffic!” Surprised, he asked, “How do you know that?”

I told him I experienced the same thing when I ran on a road with the traffic, especially when the road had a bit of a “crown” on its surface. I thought I had found a relevant connection, and I let it sink in a bit. Then, I told him his dentist friend wanted to offer him a new pair of shoes for the top of his teeth in the form of a removable bite splint. It would be like getting a new pair of running shoes. It would be professionally custom fitted to the tops of his teeth, which would please your chewing muscles and create greater comfort, just like a new pair of running shoes pleased his leg muscles and knee joint.

Charlie looked at his dentist friend and then at me before standing up. With a big smile he said, “I will make an appointment with the receptionist.” Hmmm… Isn’t that Interesting!

Here I share abridged excerpts from my newest book The Porch: A Dental Fable to illustrate why the new patient exam is sacred time that sets the stage for trust.

In this story, Tom Parker, DDS has been invited to shadow a second-generation dentist by the name of Paul Wilson, who has been in practice many years in a small town in upstate New York. Paul is a close friend of Tom’s mentor Henry, and both Paul and Henry have been immersed in opening the eyes of dentists to the possibility of practicing in an intentionally virtuous way that is enriching for both patients and dentists.

Upon arrival at Paul’s dental office, Tom notes that Paul displays photos of his family and dogs, pictures related to his love of skiing and golf, and pictures that indicate he is as a person of prominence in his community. Tom feels like he is back in time to another era.

Paul tells Tom the first patient is a new one so Tom will see what a blank slate looks like for the doctor and patient. When Paul is finished, he escorts Tom into his private office and asks him what he thinks so far.

“To be honest, Paul, you did it just the way Henry taught me.”

“Okay, but what didn’t you see. You know, what was invisible to you?”

“What do you mean?”

“I mean the intangibles. The things we can’t see or touch or even explain sometimes — like love. Let me explain what the positive psychologist Barbara Fredrickson calls the cocoon of self-absorption. Most of us spend our days focused on ourselves. It’s just our default…Frederickson says love appears ‘anytime two or more people, even strangers connect over a shared positive emotion, be it mild or strong.’ The doctor-patient relationship is a dyad in which love can be present…The virtues of love, empathy, kindness, compassion, and gratitude take time.”

“I think Henry mentioned that trust is spelled T.I.M.E.”

“Yes, we like to teach that. And that is why we ritualize the comprehensive examination, so we can leave the cocoon of self-absorption and become other-focused. That is why we ritualize slow dentistry.”

“Slow dentistry…I like that. I also noticed that the first thing you did was thank Gloria for coming in.”

“Congratulations, Tom, good observation. Gratitude is another virtue that is most important for our well-being. Being grateful rather than feeling entitled or taking others for granted is important. My dad taught me that years ago. Every morning he would greet his team and tell them how thankful he was for them being with him. Science tells us that gratitude is a great way to improve our health, happiness, and general well-being. So, I ritualize my greeting, but I really do mean it. I must earn the right to treat them. Did you notice how much attention I was paying to Gloria? It’s a tricky thing. It’s more than just listening.”

“Yes, I have seen active listening demonstrated before, but what you were doing was different.”

“I’m sure Henry has told you there is no instant pudding. We all need to work on our attention. Love is attention. It’s the highest form of love there is. When we learn to pay attention with no expectation of reward, with no agenda, this is the rarest form of generosity. People can spot bogus attention in a heartbeat. Your wife and kids know when you’re not paying attention. Patients know, too. That is why we make the examination sacred time without interruption.

“People want to feel that they are the only one in the room. I always begin with a very open-ended question, for example, ‘What you are going through with your health?’ or ‘What is it that made dental care a priority now?’ I don’t keep a list of questions. I use different ones. Some land well. Others fall flat, but I keep trying, always looking for levels of comfort. The point is to not just acknowledge their presence but to truly notice their presence. This takes another level of awareness. We need to learn their stories. We need to learn their goals, not only their dental goals but their overall health and wellness goals. They want to know that we are here for them in every way.”

Tom’s face lights up in an Aha moment as he realizes love is operationalized through attention that is selfless. The examination is sacred time in which we pay attention – with no expectation of reward.

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.

Over the past few months, I’ve had a series of coaching sessions with frustrated dentists due to many of their exchanges with team members not being as effective as they had hoped. The dentists were confident they had been clear about their expectations, and yet there was still lagging or even absent implementation of the anticipated behavioral and system changes.

“Maybe this is not the right team member! How can they not just do what I ask them to do?”

Of course, I appreciate how disconcerting this can be, AND I want to challenge the notion that a single conversation can lead to effective change.

I imagine we can agree that most of your patients are in the midst of their own developmental process, as dental offices have quality systems in place to support this idea. A patient comes in for a hygiene appointment and they are routinely scheduled to return in 3 or 6 months to follow up, monitor for changes, and (hopefully) celebrate new levels of health. We are used to the idea of having a return date, better known as a “recall appointment.” More often than not this system works. Over time, as the recall appointments continue, trust levels increase along with deepening relationships and even case acceptance.

The question I pose is this: How can you as a leader apply this same principle to coaching your team members? I like to call this system a Conversational Recall.

What if at the end of a coaching conversation, even a short one, you create an opportunity to revisit with the team member to assess progress, problem solve any obstacles, and set a time for yet another Conversational Recall? My own experience tells me that sustained change typically occurs by implementing small changes over time. Staying connected with a team member by offering ongoing feedback and support may very well be the difference between you being frustrated by unmet expectations and your ability to celebrate high performance and heightened levels of engagement.

One aspect of leadership is setting each team member up for success. You can do this by investing time and energy, walking alongside them, and committing to following up as a pathway to letting each person know that you care. One of the greatest ways to inspire change is to demonstrate to your team members that you both value what they have to bring and that you believe in them…sometimes even more than they believe in themselves.

Another aspect of quality leadership may just lie in your ability to be congruent in all areas of your practice; do for your team what you do for your patients—if not more. Care for your team like you care for your patients—if not more. The rewards for everyone involved could be incredible!

If you watch one episode of Gordon Ramsay’s Kitchen Nightmares, you will see a repeating theme. Previously great restaurants have come close to shutting their door, because the owners’ passion for maintaining high standards has waned. Diners have dropped them from their A list, their B list, maybe even their C list. Without a dramatic makeover and grand opening, diners are not going to come through the door.

Bring this forward to 2020 and the pandemic. Patrons… clients… customers… have legitimate concerns about moving forward with their lives. Dental teams are doubling down on conversations with patients, along with adopting and adapting to many changes in how they practice. And, then, there is another problem I am seeing in all businesses, not just dental practices. The government gave money to employees to “not work.” Now when they are needed (especially in dental practices and labs), employees want to stay out not only for more “free lunch” but also out of health concerns of their own. They don’t want to take coronavirus back to their family members at risk.

Some of this comes down to the history of the business and how they practiced before and the culture they created…that went way beyond “money.” I’m not saying this is true of all dental practices and less so in the relationship-based practices, The Pankey Institute and other thought leaders promote. But, practicing every day consistently at the quality level of the past takes tremendous commitment. The moral compass of the practice leader—the dentist, must continue to show courage, trust, respect, authenticity, integrity, communication, education and growth, excellence, resilience, purpose, and alignment. Whew! That’s a tall order when you are feeling stressed and exhausted.

It’s no wonder if some of your pre-pandemic passion for spending time with individual patients has waned. When I came out of dental school in 1973, Paul Simon had not yet written his monumental song Slip Slidin’ Away, but within my first decade of practice, I knew the song well and already sensed that life was not on the trajectory I wanted. My passion for dentistry had waned.

We work our jobs
Collect our pay
Believe we’re gliding down the highway
When in fact we’re slip slidin’ away

With inspiration at Pankey and Dawson, wide-wide reading, and encouraging colleagues, I found my way… my passion… my balance… my joie de vivre in dentistry. I discovered how to not only conserve my personal energy but also generate more energy through personal contemplation time and daily exercise. The greatest discovery I made was that my practice of dentistry actually centered around one specific system: the comprehensive patient examination and the meaningful conversations I had with patients during the exam.

The One Thing to look out for is the quality of your comprehensive patient exam. Is it at the highest level?

The comprehensive examination is the “one procedure” or process that gives the dentist the opportunity to express and display his or her leadership “virtues.” Don’t let it slip slide away.

Conversation is where the human side of health care takes place. Continue to spend extra minutes in conversation. The meaningful moments you share with your patients will energize you and help you get through current stressful days. Just remember that having a meaningful conversation, in many cases, requires us to let our guards down and become vulnerable. It means sharing our philosophy and showing our human side… maybe even how challenging dentistry is right now… and yet still so rewarding.