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!

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.

When I bought my dental practice in Glendale, Arizona, eight years ago, they were offering patients a choice of flavors for topical anesthetic. I truthfully thought it was silly and that we would stop doing it. With experience, however, I came to realize that giving a choice was valuable for both patients and team members. Today we are still offering a choice of flavors.

When a patient is seated, the dental assistant will say, “As you know, as part of the process for getting you numb, we will be using a topical anesthetic. We have five flavors and you get to tell me which flavor you would like to use today.”

It is really interesting to listen to the dialog, but also to realize what is happening for the patient. The choice gives the patient an opportunity to settle into a conversation and something to focus on other than that they will be getting an injection and the logistics of that.

The process almost creates a fun, quirky conversation, as the patient thinks about the choices. Sometimes patients say, “You choose, and I’ll guess which one it is. Let’s see if it really tastes like that.” When patients pose themselves this challenge, the whole time I am giving the injection, they are trying to figure out which flavor of topical we have used.

Sometimes patients ask, “Which flavor is your favorite?” or “What do other patients like most?” In this case, we talk about it.

We have the mint flavors everyone else has but we also rotate in cherry, strawberry, bubble gum and pina colada. In summer, we offer watermelon. At any one time, we typically have five flavors and they vary throughout the year. A patient who has come in a few times, may even start the conversation with, “Do you have any new flavors for me to try today?”

One of my favorite conversations is whether the pina colada actually has rum in it and how funny it would be if we could just use the rum. An ice-breaker conversation such as this is a great way for us to ease the tension at the front end of an appointment that will require anesthetic. It truly adds an element of fun that has become for us a practice distinguisher.

As the Pankey community begins to re-open its practices, reports indicate that most patients are responding with high levels of trust and gratitude. This represents a clear indication that the investments we’ve made in building truly helping relationships with others are paying back significant dividends at a most critical moment. Relationship-based / health-centered dental practices are designed to give the kind of meaningful caring and support that relationship-starved people truly need as they venture back out into this brave new world. 

The truly person-centered Pankey practice model aligns well with research which shows longevity and happiness aren’t just linked to healthy diets, habits, and genetics, but also to the consistent presence of positive social engagement. My mother frequently spoke of these types of happy people as being “givers.” She’d say, “They are givers – not just takers, and they pass this attribute along to their children, because, well, that’s just who they are.” 

Abe Maslow called these types of personalities “B-Loving” individuals—individuals who self-actualize through their unconditional love of others. These are the folks who buck today’s meta-trend of consuming more, contributing less, and living a silo-type of existence. And we look forward to seeing them on our schedules, enjoy spending time with them, and feel a tremendous sense of loss when they finally pass.  These folks are the ones who intuitively know that the loving attention they give to others, no matter how simple or brief, is an ever-expanding positive experience that yields out significant benefits to themselves as well. 

When you add up all of those moments, hour after hour, day after day, year after year, you end up with the smiling and joking Betty or Bob. They’re the ones who are the first to give you a hug when you’ve had a bad day or experienced a personal tragedy. And they’re the ones who alter the course of our lives through a laugh, a smile, by demonstrating strength, courage, and irrepressible hope. In short, they are miracle makers. 

As practitioners of relationship-based / health-centered dentistry, we need to remind ourselves that we’re miracle makers as well, because we’re also in a perfect position to listen intentionally, care more deeply, and help more significantly. But that’s only possible when we choose to see dentistry as being a helping profession and not just about teeth, technology, production – and now PPE! 

On a personal level, I’ve found myself sharing my feelings about what we’ve experienced with my team and patients, and I’m finding myself opening-up on an emotional level more each day. As a result, we’ve ascended to yet another tier of caring as a team.  We’ve used this communal tragedy as an opportunity to strengthen our social bonds through love and understanding instead of allowing fear to drive us further apart.  Abe Maslow would likely say that we’re self-actualizing on the individual, group, and community levels through B-Love. This represents a key realization, because in spite of all the new stress which has been thrown into the middle of our lives, we’ve been able to see the huge practice development opportunity the situation has created for us.   

Those of us who have grown technically, intellectually, and spiritually through The Pankey Institute have “givers” hearts (just go to one Pankey Alumni meeting and you’ll understand exactly what I’m talking about). Consequently, this communal tragedy plays right to our natural strengths, inclinations, and existing practice structures. So, in spite of all of the changes surrounding us, it’s time to confidently step forward and demonstrate principle-centered leadership. And by so doing, we’ll be holding fast to what we already know is true – that the secret to living is in the giving. 

It may not be this week. It may be next before you have a practice continuation plan in place and have communicated fully with your team and patients. When you do find you have some time, I encourage you to sit back and think about everything you have experienced over the last month and what new learning you have discovered. Then reach out to colleagues and talk over your learning. Continue sharing with each other throughout this time of social distancing. 

I am mindful of a quote from Carl R. Rogers: “The true wonder of learning is discovering for yourself.”  

Starting out in my career, I felt well trained technically, yet I must have subtly believed I was a “hardware” salesperson. Or, maybe it had to do with my tendency to be introverted. Whatever the reason, I found it easier to talk “hardware and technique” than to listen well and then help patients clarify their health objectives and the benefits they were seeking in their dental health care experience.  

I went to a workshop led by Carl R. Rogers titled Client-Centered Therapy. This workshop was significantly different than any of my previous educational experiences. It was a participatory experience. It took some time for me to assimilate his educational concepts into my life and practice, and I noticed right off that I had retained more from a workshop experience and could apply my understanding of what I had learned. When I returned to my office, I attempted to create a participatory learning experience for my patients. I learned from these early attempts more about learning and witnessed behavioral changes in myself and my patients.  

I sought out many other workshops at this time in my life. One was Parent Effectiveness Training, facilitated by a local devotee of Dr. Thomas Gordon. Then, I became reacquainted with Dr. Karl Olson, the retired President of North Park University where I had done my undergraduate schooling prior to going to Northwestern University Dental School.  

Olson had joined forces with Bruce Larson and Heidi Frost of Faith-At-Work and created The Leadership Training Institute, which focused on discovering your leadership potential through three separate weeks of “experiential learning.” The first week was focused on Know Yourself, the second-week focus was Know Yourself in a Small Group, and the third-week experience was focused on Designing Small Group Experiences for Others. Each of these three weeks was separated by six months of intentional application and reflection, which created a powerful learning period of discovering myself.  

From my point of view, there is nothing more rewarding than a learning experience in which one can become aware of one’s own learning in “the moment” or upon reflection. So, now that you have been thrust into participating in Knowing Yourself, your practice, your team, and your patients on a new level where there is a concern for everyone’s safety and wellbeing on an elevated scale take time to reflect on what you learned in “special moments” of the past month.  

Are any of your discoveries blog-worthy to stay in communication with your patients? They will appreciate your personal “touch.” 

Making a comment in response to this blog is one way you can encourage a “continuing conversation” of Pankey participants’ “new awarenesses.” 

We are bombarded weekly with ads for this or that course in “airway management” or “how to make money treating sleep apnea.” And, we are dealing with airway management every day whether we like it or not.  

Who has not had a patient come in with a worn dentition who claims, “Doc, I can’t ever remember grinding my teeth.” How about the patient who keeps fracturing restorations and says the same thing? You might want to question these folks or their partners about sleep habits. It is very likely you will find they are members of the population with some form of sleep-disordered breathing.  

Do you remember why we learned to fabricate and adjust bite splints?  

Have you had parents ask you about what it means when they can hear their young child grinding his or her teeth at night? Childhood bruxing is almost always a symptom of some sort of airway issue. What is happening in a child who presents with proclined incisors and an anterior tongue position? Do you think putting the child in headgear is going to solve the underlying reason the tongue has to be forward so they can breathe? 

We don’t have to treat all these issues, but we certainly should be able to communicate with our specialists and medical community for appropriate diagnosis and treatment of underlying issues that have a direct impact on the success or failure of our restorative care. 

The American Sleep Apnea Association estimates that 22 million Americans suffer from sleep apnea. Since we see our patient base, on average, two times a year, it makes sense that we should be doing at least a basic screening for sleep-disordered breathing. This can be anything from mild snoring to serious sleep apnea.  

Basic diagnostics would include paying attention to a person’s body mass index, neck size, asking whether they snore, and providing the Epworth sleepiness scale as part of your standard health history. Be aware that some folks with the worst sleep apnea or narcolepsy are not overweight. These are often the very fit appearing folks who are serious bruxers. 

If you really want to get involved in treating these people, you need to get more education.

Either at The Pankey Institute or somewhere that has a multi–day course. You need to commit to going into the process deeply, as there is much to learn and treatment is not simple. You will quickly learn that unless you develop great systems and team members, it is not an easy way to make money. However, you will be truly saving lives. 

If that does not sound right for you, commit to being a good diagnostician and develop an excellent referral network with some ENT doctors in your area. Most of these doctors are looking desperately for a dental colleague with whom they can discuss cases and develop treatments beyond just the use of CPAP. If you can refer just one child for early treatment each year and help prevent a heart attack or stroke for a person with undiagnosed sleep apnea, you will have done great service whether you get involved in active treatment or not. 

(more…)

Every one of you knows from your own experience with care providers that you want to have complete trust in them before accepting their recommended treatment. Your dental patients are no different, and that trust is affected by their entire experience with everyone on your care team. The dental experience in relationship–based practices increases this desire, because listening well to others is one of your priorities. Patients become at ease confiding their concerns with you and celebrating high points in their life with you. In your dental practice, listening well and acts of kindness generate positive emotions and positive memories of their dental experience.  

The Golden Rule 

Under daily situational stress, personal psychological stress, and oftentimes lingering physiological stress from the day before, preoccupation with internal concerns gets in the way of being truly present for the patient. The benefits of discussing this occasionally within team meetings foster a continuing positive culture of everyone striving to intentionally apply the Golden Rule with patients.  

When that aspiration is sustained and everyone on the team “takes care of” patients by “treating others as you would want to be treated,” the emotions experienced by patients are positive and support treatment acceptance. And, the genuine care you give others has a way of stepping down your own stress with the release of oxytocin.  

I’m speaking to all team members from the front to back when I say, “Practicing being truly present for patients until it becomes a natural habit is one of the greatest things you can do for them, yourself, your fellow team members, and the business.” 

A Few Extra Minutes  

If appointment times are increased by five to ten minutes, the clinical care team has more opportunity to converse with patients without stress developing, and in just a few more minutes a lot can happen. Conversations between care team members and patients help establish trust. These conversations also disclose patient feelings, concerns and unanswered questions. The sharing of this information with other team members can be used to create an optimal patient experience in this and future appointments.  

It takes just a minute more to share this information appropriately in handoffs to tee up the doctor-patient conversation about treatment and to support scheduling the next visit before the patient leaves. By the latter, I mean the business team at the front and the patient always need to be prepared for the end of the appointment when the follow-up treatment fee is presented and scheduled. This preparation includes communicating the why behind the treatment and true concern for the patient’s welfare.  

Same Page, Same Language 

Patient confidence grows when every team member is on the same page, is aware of the patient’s expressed goals and concerns, supports the treatment plan with why it is recommended and enthuses about the expertise of the practice. Using the same language helps too.  

In a relationship-based practice that focusses on these details, this is possible, and more treatment is accepted. If team members stop occasionally to ask themselves, “How was that handoff,” you will discover ways to improve how everyone “takes care of” patients through shared knowledge, empathy, and language. And knowing the Pankey community as I do, I see in my mind’s eye care teams around the world coming together at the end of the day to say, “Nailed it!” 

When the art and science of dentistry are reduced down to primarily being about production and code mining, its spiritual dimension is easily lost. Spend a few minutes on some dental social media sites, and you will quickly see this truth in black and white. 

Dr. L.D. Pankey warned us about this problem.

The key to becoming a truly successful professional isn’t just about mastering the technical skills and endlessly chasing after the siren songs of our materialistic culture. Such narrow pursuits are ultimately hollow and do not represent enough to carry us through life as a fully developed person. And they do not represent enough to carry us through life’s inevitable tragedies and periods of significant suffering.  

Creating a habit of connecting with our patients in deeply meaningful ways, helps us to form the emotional antibodies we will need to carry us through the inevitable not-so-good times, the times when all the money and material possessions in the world can’t solve our problem. These are the times when only love, support, and reciprocated empathy can start the process of healing our wounds. 

Never forget this central truth.

Chasing after the next new and shiny object may not be the best solution for our challenging situation today. The best solution may very well be sitting right in front of us in the form of a deeply caring patient.
 

L.D. Pankey, when talking about the assimilation of knowledge would say, “First you get it in your hands, then your head, and finally in your heart,” meaning objective understanding and competence was only a step in becoming a complete dentist. 
 
This, of course, was a hard message to hear as a young clinician, because after rapidly proceeding through Pete Dawson’s curriculum, purchasing three Denar articulators, and then going on to The Pankey Institute, I felt that I was ready to start practicing as a “comprehensive dentist.” 
 
But unfortunately, most of my patients and the citizens of my berg didn’t get the memo. Most of them just looked at me suspiciously, while others left. Fortunately, a few of them allowed me to perform my “complete exam,” collect study models and take 35mm slide photography. And then, I’d spend hours waxing up cases, and preparing a thorough written report containing all of my findings and recommendations. Finally, I’d make  a “case presentation” appointment and unveil the brilliance of my understanding of complete dentistry–about which I was sure the patient would be impressed and then have no alternative but to say “yes” to my plan for them.

From there, it was easy for me to visualize a completely organized schedule full of people who had said “yes,” and a projected level of income of my choice based upon how hard I wanted to work, and the number of hours I was willing to commit to being at the office. It all sounded so perfectly logical, and it all fits quite well with my left brain driven in the world view of dentistry.

But things didn’t work out that way very often. And since that time, I’ve have spoken and consulted with literally hundreds of dentists who’ve experienced similar frustrations. Many of them told me that they eventually gave up on their effort to try and practice comprehensive dentistry. Others took their practice to near bankruptcy via their determination.

You see, most of us missed Dr. Pankey’s message the first time we heard it, or even after the next two or three times.

We failed to recognize that the concept of complete care also hinged on how each patient felt, what they wanted for themselves, and what the solution would mean to them on an emotional level.

It was only after this difficult realization that things began to improve for me and my practice. The work of Carl Rogers, Bob Barkley, Lynn Carlisle, Avrom King, Sandy Roth, Mary Osborne, and many others, helped me to make some critical adjustments regarding how I was communicating with my patients–and perhaps even more critically– when.

Patient-centered dentistry is just that, patient-centered, not treatment centered.

This means we must first come to appreciate each person without imposing our beliefs and expectations upon them. This is a process that involves feelings first (their feelings not ours) before cognition–and before the discussion of any solutions. We must first be able to grasp the contextual meaning of the dentistry in each person’s life, and by so doing, better appreciate their perspective.

When we become better at doing this, we’ll feel that our knowledge has finally reached our hearts and the hearts of our patients as well. And it’s only at that moment that things will start to become easier and our patient’s behavior more predictable. It’s only at that moment that the “yes” to comprehensive dentistry will happen on a regular basis.