Laura Harkin, DMD, MAGD 

Let’s delve deeper into the preclinical interview! 

It’s helpful to understand a patient’s perception of their overall health and oral health, as well as what type of restorative dentistry they’re hoping to have and why they feel the way they currently do.  

Sometimes, an integral family member has influenced the timing of care. For instance, you may hear, “My grandchildren are making fun of my teeth” or “My wife asked me to get my teeth fixed.” From this response, I know that I will need to be sure my patient personally desires treatment before rendering it. I’m also anxious to understand what type of restorative dentistry a patient is considering. For example, are they open to removable prosthetics, fixed crown and bridgework, or implantology? 

Recently a new patient came to my office with an emergency. Tooth #5 presented with the buccal wall broken to the gumline and a moderate-sized, retained, amalgam filling. He immediately said, “I do not want bridgework.” I listened quietly until he elaborated by saying, “When I had this front tooth replaced by my other dentist, I had to take it in and out, and I just found that so irritating.”  

I finally understood that he was referring to a flipper but calling it bridgework. So, it’s important to listen and ask questions when someone seems close-minded about having a certain modality of treatment. Delve deeper into the conversation because it may simply be confusion surrounding dental terminology. 

For the grandparents who ask for a better smile, I’d like to understand their thoughts on the scope of treatment and their expectations. Are they looking for a white, straight, Hollywood smile or a more natural appearance with a little bit of play in the lateral incisors? Are they mainly concerned about stains, gaps, or a missing tooth? Are there other problems they’re aware of such as tooth sensitivity, inflamed gums, or the need for a crown? This input is very important as we continue conversation with co-discovery throughout the clinical exam, diagnostic records, and treatment planning phase. 

Learn to count on your chairside for pertinent information. 

I’m fortunate to always have my assistant, Cindy, beside me for preclinical conversations, comprehensive examinations, and restorative procedures. Sometimes, Cindy interprets a patient’s statement or component of conversation differently than me. She may hear a message that I missed or read body language of which I wasn’t aware. Sometimes, auxiliary conversations between patient and assistant take place after I’ve left the room to complete a hygiene check.  

At the end of the day or in the morning huddle, we always take time to discuss interactions with our patients. Together as a team, we’re more efficient at acquiring accurate information so that we may approach the road to health most effectively for each individual. 

Determine if trust is present. 

As I’m getting to know a patient and before I choose to begin restorative treatment, I seek to understand if trust is present in our doctor/patient relationship. New patients often share past dental experiences, and, unfortunately, some have lost trust in dentistry itself. This may be warranted due to improper care, but it may also be due to a lack of understanding or unclarified expectations regarding a given procedure or material choice.  

It’s not unusual, particularly when a patient is considering a large scope of treatment, to serve as a second or third opinion. Building trust and waiting to be asked for our skills are key necessities before moving forward in irreversible therapy.  

The comprehensive examination, periodontal therapy, splint therapy, and gathering of records are all appointments during which opportunities exist to get to know our patients. True trust often takes time to establish, but the reward reaped is frequently one of empathy, friendship, and the ability to do our best work. 

The Pre-Clinical Interview – Part 1 

Laura Harkin, DMD, MAGD 

I am a third-generation, restorative dentist in New Holland, Pennsylvania, which may be best known for its blue, New Holland tractors. I own my grandfather’s and father’s dental practice where I am the sole provider for approximately 1,000 patients. My dental team consists of two hygienists, two assistants, and two front office administrators. 

I graduated from dental school in 2008 after short careers both in the actuarial sciences and as a stay-at-home mom. In 2010, I purchased my practice and signed up for my first course at The Pankey Institute. Note, my father also studied at the Institute when it first opened its doors in the early 70’s. One of my greatest challenges, early in my career, was learning how to diagnose oral conditions, develop and present treatment plans, and execute that treatment via phases. I found it quite overwhelming to simultaneously manage multiple, complex cases. Now, I love sharing my experience and the approach I’ve found works best for me. 

Above all, I’ve learned that in the midst of daily pressures in dentistry, we need to maintain our own health and strength to properly treat our patients and lead our teams. Surrounding ourselves with knowledgeable, positive, and compassionate colleagues helps! 

Knowing ourselves is as important as knowing our patient. 

Dr. L. D. Pankey’s Cross of Dentistry supports the belief that knowing oneself is of equal importance to knowing a patient whom we choose to treat. This challenge forever evolves because no person remains unchanged with time. I frequently evaluate my strengths and weaknesses as a provider, team leader, and mentor. At the same time, I ask myself what aspects of patient care and business management I excel at and most love to do. I can then choose my specialist team accordingly and empower my office team to best support me. 

Together we ultimately provide a better product and higher level of care. 

To prepare specifically for the treatment planning process, my team helps me gather key information and clinical records from a patient for a comprehensive evaluation. After a thorough analysis, I carefully craft written documentation which will help educate my patient, my team, and the specialist team I’ve chosen. An added benefit is its ability to serve as legal documentation.  

I always ask a team member to join me during treatment plan presentations. They bring another set of ears and eyes so that we may better understand a patient’s motivating factors as well as the challenges they may face in receiving treatment. We encourage open and honest conversations and understand that treatment plans evolve to fit the needs of individuals. 

How do we get to know our patients? 

In addition to gathering a thorough health history and dental history, we are seeking to learn more about our patient’s chief complaint, perception of their current state of oral health, desires for treatment, and barriers to care. 

We listen intently for clues to identify a patient’s communication style. I’ve always heard that we have two ears and one mouth for a reason. I practiced with my father for two years and once, after observing me, he said, “Laura, you do far too much talking. You need to really listen to what your patients are sharing.”  

I’ve had to develop the skill of active listening. To stay in the question and become comfortable with silence takes practice. Some observations that I try to make in order to effectively communicate and build a relationship with a patient are as follows: 

• Do they seem to enjoy conversing or are they responding with short answers in order to get through the interview quickly? 
• Do they readily ask questions and express thoughts, or are they quiet and need to be invited and prompted to share? 
• Are they amiable? 
• Are they distrustful or fearful due to past dental experiences? 

We need to intentionally verbalize our empathy when we’re in conversation with a patient to help them recognize that they’re being both heard and understood. 

It is beneficial to understand a patient’s background. For example, what have they done in life? What do they love to do? Who is important in their life? Sharing in these conversations will help build a rapport, lead to improved doctor/patient communication, and can help to begin a trusting relationship. 

Does the patient have limitations such as the ability to drive to appointments, afford dentistry, or find time for treatment? Do they need to discuss their oral health condition and treatment options with a trusted family member before making a decision? 

Understanding these answers helps us to not only provide respectful and resourceful solutions but also limit inaccurate assumptions. This knowledge is especially helpful in my third-generation practice, where I have many elderly patients who are dealing with health issues, multiple medical appointments, and scheduled drivers. Their desire is to simply make a careful decision for an oral rehabilitation which fits their objectives and abilities. 

Do we hear the desire for treatment? When speaking with an existing patient, I can often recognize signs of interest to move forward with previously recommended treatment. At that point in time, I often ask, “Why now?” The answer helps me clarify their chief concern(s) so that we can move forward fittingly. 

In Part 2 of this series, we will explore additional techniques to clarify our patient’s desire for oral health and long-term, oral stability. 

Do You Know Your Team’s Threshold? 

Robyn Reis, Dental Practice Coach 

While visiting a dental practice that had amazing hospitality and incredible relationships with its patients, I observed a doctor’s presentation to a patient who was in his forties and who had been saving for a smile makeover for a long time. The doctor did an amazing job with his presentation of what was possible and the phases of treatment. The patient was very excited, even teary-eyed.  

The patient wanted to get started and asked about the cost. The doctor said, “You know what? My team at the front are experts in figuring that out.” So, the patient was taken to the front and handed over beautifully. In a few minutes, he was presented with the treatment plan on paper with the approximate dollar amounts. In phases, they would do the full mouth. All seemed to be going well until it wasn’t. 

Intrinsically, everyone has a monetary threshold that up to a certain point, you have no problem with the amount. It’s something within your range of expectations and easy to say yes. When you cross that threshold, anxiety may creep in and for sure, you become uncomfortable.  This is what I witnessed in a matter of moments. 

I observed the front office team member look uncomfortable after glancing at the paperwork, despite being experienced with treatment presentations. The clinical assistant who had been part of the diagnosis and treatment planning process, would also help with scheduling and any questions. 

Together, they gave the patient the opportunity to ask questions after reviewing the plan again. The full mouth restoration was going to be in the neighborhood of $25,000. The first phase would be about $18,000. They offered CareCredit financing. The patient said, “It’s only $25,000 and I have $20,000 saved. This is wonderful! I don’t know how I will pay the other $5,000, but I know I have the means. It’s only $25,000.”  

The team appeared somewhat shocked because they were obviously uncomfortable with quoting that amount. This treatment plan crossed their personal thresholds. They suggested the patient go home and sleep on it “because this was a big investment.” The patient was so committed to moving forward that, despite their advice, he scheduled his first appointment. He would call them back once he figured out how to pay the remaining balance, knowing insurance would contribute very little. 

What I also found interesting was that neither team member asked for a deposit. No money was exchanged to reserve an extended appointment. The patient could back out and the doctor’s time spent on the case work-up would be uncompensated. In my experience, making a signed financial agreement would be the responsible step to take at this stage.  

This example illustrates the discomfort many dental teams feel about asking for a deposit if the treatment estimate crosses their personal threshold. Of course, dental teams will want to explain what can be done to make treatment more affordable and the financing options that are available. But it is beneficial for team members to understand their personal threshold and to become comfortable saying, “Grab your checkbook or pull out your credit card, Mr. Jones. Here’s what your investment is going to be to get started.”  

What’s your threshold? This is a great team exercise you can do at your next meeting because a patient might ask anyone they interact with about the cost of dentistry, and what options you offer for the dentistry they want.  Every team member will benefit from considering their personal threshold and discussing it — even role-playing — to become comfortable with the best ways to manage these questions. Depending on the situation, it could be referring the patient to the treatment coordinator or to the financial administrator to have a comfortable conversation. 

It is my belief that when patients are excited about what the treatment results will be and they want to move forward, it’s the right time to ask the patient to make a financial commitment to get the process started. 

There is a practice in Ohio I recently work with, in which the dentist and a young hygienist were having a chat about the idea of restorative partnership. When she first heard the idea, her reply was beautiful. She said, “Oh you want me to learn about treatment planting,” and I thought that was just the coolest thing ever because that is what we get to do when we think about developing patients over time. We are planting ideas…planting seeds that we can grow.

When I was still working as a hygienist, I found I was good at talking with patients about what was going on in their mouths… what I saw… what the possibilities were. And I even enjoyed dreaming with patients about what their mouth could be like if they chose to do dentistry proactively rather than reactively. So, it is interesting to me how many hygienists become nervous about the idea of talking about dentistry with patients.

This nervousness exists because we have been taught in and out of hygiene school that it is illegal for hygienists to diagnose. This one barrier has become an incredible obstacle to having conversations about current conditions and possibilities with patients. It does not need to be this way.

When I think about restorative partnership, now, I think of it as treatment planting! The doctor diagnoses and discusses the potential of treatment with the patient. And during recall appointments, the hygienist has amazing opportunity to plant seeds during encouraging conversations. A restorative partner deeply appreciates the developmental path that dental patients are often on and looks for opportunities to plant seeds of awareness, curiosity, and of course, possibilities.

Wouldn’t it be cool if a patient came in one day and said, “You know, we’ve been talking about this idea of comprehensive care… we’ve been talking about the idea of restoring this quadrant… and I want to go ahead with it.” Wouldn’t it be exciting if suddenly what you have been talking about blooms like a beautiful flower?

If you have been thinking about having a conversation with your team members about restorative partnership, starting the conversation around “planting seeds” would be enormously helpful. Think about looking at cases together…creating learning opportunities in your office, where you can start sharing more of your knowledge about what it takes to work in a patient’s mouth, examining photographs together and talking about what you see, talking about the implications and consequences of not having treatment done, and what the benefits could be of thinking about treatment.

The restorative choice is always in the patient’s hands, and what I find to be most exciting about the restorative partnership is the partnership that we, as dental professionals, get to develop with our patients.

In Part 1, I discussed combining Hard Skills and Soft Skills to wisely and intentionally produce the best outcomes. Soft skills are necessary to establish rapport, work with emotional intelligence, listen actively, and do outcomes based thinking. Hard skills are necessary to produce excellent clinical results. 

In Part 2, I would like you to consider “there is no single specific thing that will differentiate your practice and make it successful.” Our work life and personal life are based on balance. Whether you use the Pankey model of Work, Play, Love and Worship or Stephen Covey’s model, balance is the key.   

As a professional, there is an expectation among your clients and peers that you and those around you will own and maintain excellence in the hard skills of your calling, but the aforementioned soft skills are also essential. Our family, clients, and staff also deserve to be part of the other three parts of the cross of life. For example: 

• Pre-block days off in the schedule just like you book productive time at work. Your most productive time will be when you come back to work after a vacation.  
• Take the staff to a Study Club event for fun.  
• Support your staff having a volleyball team just like you support your kids’ soccer team.  
• Be respectful of personal events in your employee’s family lives. Support from you when times are tough will be repaid many times over.   
• Whether formally or in private take time to be thankful for the blessing of your family, your career and those who trust and support you.   

James Allen, in his book As A Man Thinketh, emphasized the incredible power of positive attitude and abundance thinking. When we find our staff doing something good and we compliment them, there is ten times the power of “constructive criticism.” When we hear laughter in the office, it is a good thing. Stress is lower among happy people. When we take time to train staff to take intra-oral photos and then trust them to do it right, we are all winners.   

The leader in your life and practice is you. Think deeply about the life you want to live and how that will affect those around you. When you learn to see the glass of life as half full and not half empty, you are making progress. When you then are willing to share your glass with others, you are ready for success. 

There have been numerous articles lately about the growing importance of “soft skills” (behaviorally adept process) in the development of a successful dental practice. Where have these writers been living for the past forty years?  

In the early 1980’s one of the key points of The Pankey Institute Continuum courses was the proper balance of skills at work and in life. L.D. Pankey learned that from studying the Greek philosophers. L.D. often said, “You can’t deliver what you don’t have on the shelf.” He was talking about more than occlusion and crown margins. He was talking about the ability to understand and work with our family, clients and our staff. So, what is more important – Hard Skills or Soft Skills? 

Hard Skills/Soft Skills Combination 

Over the course of my career, we have been blessed with a myriad of technical breakthroughs. Does anyone remember the joys and frustrations of early composites like Adaptic? Today the strength, color, and marginal integrity of resin restoratives gives us the ability to do dentistry we never imagined in 1976. Our diagnostic and imaging tools have made life better by being both user-friendly and patient-friendly. We have implants that really work, bone regeneration, and much more.   

This generates some hard questions. Are we as a professional staying current and taking advantage of these breakthroughs? Are we doing a thorough diagnosis and comprehensive treatment plan on all our clients? Are we taking the time to understand the outcomes desired by our patients and then educating them on the options that exist today? These are Hard Skills/Soft Skills combinations. Well managed, they will make any practice “special” in the eyes of clients new and old. 

We do not have to be able to provide all the technical aspects of our profession.  We should, however, know about them and be able to understand where they might be used to our client’s advantage. We must then be able to educate our clients about the potential value of a service and know where to send them to have it delivered with care and quality should they choose to do so.   

If you own a CEREC unit does that mean you will never again do a cast gold onlay? Truly mastering the capacity of your CEREC is a daunting task. It is a hard skill you can be proud of. However, if your practice begins to revolve around only Emax restorations you have missed the point. Your clients deserve a comprehensive exam and diagnosis. Their treatment plan should be based on the whole field of dentistry and the outcomes that they desire at this point in time. This is a hard skill and soft skill combination. 

A Balance 

If you and your staff develop the soft skills necessary to establish rapport, work with emotional intelligence, listen actively, and do outcomes based on thinking, then delivering the hard skills with excellence will be easier and more fun.