Human relationships is a much studied subject with a vast variety of opinions. As dentists we deal with patients on a daily basis and this interactive realtionship comes into play. Our guest for this months Opinion column, Dr. Marvin Mansky, discusses this factor and studies on how it works towards a successfull dental practice.

The Relationship Factor: A Practical Guide to Successful Relationships

In order to provide competent and responsible dental care, the dental team must develop a connected and supportive relationship with each patient. Successful relationships provide the basis for greater patient satisfaction for the services received from the dentist and in turn, offer significant personal and financial rewards for the dentist. Some of the benefits of successful relationships are decreased dentist and patient anxiety, increased new patient referrals, improved patient retention, and more successful treatment acceptance needed for private fee-for-service practice growth.

Conversely, unsatisfactory dentist-patient interactions lead to increased anxiety and stress for both patient and dentist. Patients accept less treatment, patient turnover is high, and patient referrals are low. In addition, practices with poor dentist-patient relationships help foster a belief by patients that managed care practices can provide dental care equal to care provided by fee-for-service practices.

There are four requirements a patient needs fulfilled for a successful dentist-patient relationship. The patient needs to:

* Feel connected with the dentist and know that his or her best interest is the dentist's main concern
* Know the dentist can focus attention on each moment of the treatment and interaction
* Feel relaxed and anxiety-free in the dental environment
* Know that his or her dentist is competent

The more capable a doctor and staff are in satisfying these interrelated requirements the more enriched the doctor-patient relationship will be. Multiple technical, administrative and business functions compete for a dentist's time. Therefore, requirements for developing successful relationships should be simple, easy-to-repeat techniques that are consistently effective.

What is a Connected Relationship?

Many years ago, Dr. Bob Barkley, the early missionary for preventive dentistry, taught that the quality of relationship with a patient is more important than the treatment provided at any point in time.

An empathic connection, or connected relationship, develops from the willingness of people to be in a close relationship with each other. Understanding what another person thinks and feels characterizes connected relationships. Other relationship building blocks are mutual awareness, concern, respect, and honesty. The communication must be empathetic, convey attentiveness and have a common language.

Basic to understanding the patient's need to feel connected to the dentist is the need to understand the underlying significance of the mouth. Leon Lefer, DDS, MD, a psychiatrist and formerly a practicing dentist, speaks about this importance. At birth, the tongue, needed for nursing, is the only fully developed organ. For the first two months of life, the mouth functions more completely than any other organ. The infant's survival, the pleasure derived from nursing, the ability to communicate and the infant's first explorations of the surrounding world depend on the mouth's proper functioning. During the same developmental period, infants are helpless, cannot adequately express themselves, can be hurt, and are at the effect of others. It is easy, therefore, to see that the mouth becomes profoundly important in the development of the unconscious.

This brings up some questions about how the developmental importance of the mouth in conjunction with the infant's helplessness affects how a person deals with dental situations:

* How do both a person's unconscious emotional memories of early helplessness and the early significance of the mouth affect him or her when in a dental situation later in life?
* How do differing degrees of control needed by different people affect anxiety levels?
* How does the dentist as an authority figure, with power to cause pain to a patient who feels helpless, influence the patient's perception of dental treatment?
* How is the relationship with the dentist affected if significant people in a person's early life were abusive, dishonest, or uncaring?
* How does a person who has difficulty with intimacy deal with the physical closeness and contact integral to most dentist-patient interactions?

Patients come to us with unique personalities and histories. They often feel vulnerable and anxious. They frequently express frustration because they do not feel understood. When new patients are queried about previous dental experiences they frequently recount experiences of not being heard, being talked at, and of being ignored:

"The doctor rushed from room to room."

"He would take calls from his stockbroker in the middle of my treatment."

"She did not pay attention to my concerns."

"She got upset when I asked questions."

"He talked about subjects I had no interest in. It made me very angry."

"He hurt me and did not seem to care."

"The doctor clearly did not respect my time."

It is easy to see why some patients say their previous experiences were difficult.

Why is a connected relationship important?

Both patient and health care provider benefit from sharing in a connected relationship. Each person feels understood. The patient feels safe and protected. The treating professional wants to do the best he or she can for the patient. When connected, the healthcare professional can better perceive and react to moment-to-moment changes in a patient's attitude and awareness. Moreover, the dentist and staff can provide a more competent service that reflects each patient's unique personality.

From the point of view of patient management, a connected relationship increases trust and effective communication. The dentist will be more aware of the patient responses to presented information. A patient will be more open to listening and learning. A common shared vision is more easily developed and the patient is more willing to take actions that serve his interest. Patients more readily accept treatment and refer others to an office where he or she feels connected.

Why is it difficult for dentists to build connected relationships?

Understanding what another person thinks and feels strengthens connections between people. There are two main roadblocks to understanding what others think or feel. One is that we do not think of asking. The second is that we do not know how to ask.

A dental school curriculum is intensively technique oriented. Unfortunately, students often do not receive adequate training in understanding the complex interactions that characterize the dentist-patient interchange because of curricula time restraints and lack of faculty interest. After graduation, the dentist's conversation with a patient is mostly one way, with the dentist speaking to a person whose filled mouth does not allow effective responses; in essence, the doctor talks at the patient. Because of this, the dentist does not generally learn the patient's thoughts or feelings. Consequently, the dentist frequently speaks to a patient based on his or her own assumptions and frame of reference. The expectation is that a patient will understand, agree to and comply with what the dentist thinks the patient should understand, agree to, comply to. Effective empathetic listening and communication approaches for eliciting patient responses are not a part of the dentist's training. Because of this, the dentist generally accepts a patient's "yes" or positive appearing nods as acceptance or acquiescence to his recommendations and ideas. Moreover, when he or she later discovers his patient did not accept the recommendations, the dentist frequently becomes upset, anxious, feels misunderstood, becomes authoritarian and may eventually 'burn out'.

A simple approach to building a connected relationship

The following is a simple question that can dramatically change the traditional one way line of communication so frequently characteristic of dentist-patient relationships:

"When you think about ______________, what are you thinking?"

The underline in the previous sentence is for asking about any of the patient's thoughts or feelings the dentist is interested in understanding. This question elicits immediate and honest responses from almost everyone. This question seems to eliminate any barrier between what a person thinks and what he or she says.

A following are a few examples of this question using this structure, with some variations, that are pertinent to a dental practice:

* When you think about seeing a new dentist, what thoughts come to mind?
* When you think about the problems you have, what are you saying to yourself?
* When you think about the treatment I am proposing, what thoughts come to mind?
* When you think about the fees for your treatment, what are you thinking?
* When you think about sitting in the dental chair, what comes to mind?
* When you think about how you would like your teeth to look, what are you thinking?

What is significant is that the patient's answer is the start of a conversation that relates directly to what that patient is interested in and concerned about. Knowing the patient's thoughts and feelings allows the dentist to respond in a way that is meaningful to the patient. Because the dentist's response pertains to the patient's concerns, it is it easier for the patient to assimilate concepts and recommendations. In addition, the dentist can appropriately customize the treatment presentation for each patient.

Another variation of the question used to elicit a patient's thoughts can reveal what the patient is feeling. For example:

"When you think about the treatment I am proposing, what are you feeling?" "When you thought about making this first appointment with our office, what feelings came up for you?"

It is surprising how open people will be if you give them the chance. Questions by a dentist in his or her search for understanding, which allow a person to explain him or herself, are more appreciated by the patient than inaccurate or even reasonably accurate assumptions made and stated by the dentist.

Be aware, however, that many people are not as comfortable expressing feelings or are not always sure what they are feeling, but most people do know what they are thinking.

It is valuable to know the patient's thoughts about his or her problems, recommended treatment, fees, and attitudes about dental health. It is also valuable to know how the patient feels the office is serving him or her. These issues are easier to explore if the dentist is comfortable with people and interested in his patient as a person. It is also helpful if the dentist feels comfortable occasionally sharing information about his own life.

Additional attitudes and techniques that enhance the doctor-patient relationship Recognize it is heroic for highly fearful people to visit a dental office Be committed to making every interaction with a patient a positive one Be convinced that the treatment you provide is in your patient's best interest and fits in with his preferences and lifestyle Respect and acknowledge the patient's concerns Offer full explanations before and during treatment Warn patients if pain is anticipated Coach patient in coping with pain and anxiety Don't appear rushed Offer patients the opportunity to take breaks or stop treatment at any time Demonstration personal warmth from the dentist

Make it comfortable for the patient to discuss any problem he or she has with the office Dentistry is a difficult profession. Excellence in business, staff management, patient management, and systems development are critical and time consuming, yet peripheral to providing dental care. The burden of difficult relationships accounts for much of the stress experienced by dentists. With improved doctor-patient interactions, decreased stress levels, personal growth, practice development, and the quality of care dramatically improve. Connecting with another person is exciting and offers many rewards.