Part 1:
Communication in the Office
All great writers have a built‐in, infallible crap detector.
Ernest Hemingway
Communication is key to successful dental practice. Dentists must communicate with staff members to ensure the office operates effectively. They must communicate with vendors and other professionals to ensure excellent patient treatment. And they must communicate with patients to inform them of their needs and to gain acceptance for treatment options. A successful practitioner must be a great communicator. This part discusses the communication process and how dentists can improve their patient communication process and abilities.
Communication, in its most basic form, is simply the transfer of information from one person to another. This seems simple on the surface. However, digging deeper into the process, communication involves speaking, writing, thinking, and a heavy dose of psychology. It involves transmitting not just facts but also ideas, opinions, emotions, and attitudes. It is the primary method of forming interpersonal relationships. For example, to formulate a treatment plan for a patient, the dentist needs to understand their frame of reference, wants, needs, and desires. The only way to find this out is through interpersonal communication. Although many forms of communication are used in the office, face‐to‐face communication is the most common. It is also the richest method for processing issues, especially those with high uncertainty or a large emotional component to the decision. Other communication channels, such as letters, email, or telephone calls, do not share the depth of understanding that someone gains from face‐to‐face communication.
THE COMMUNICATION PROCESS
The communication process is a shared experience between two or more people, with importance given to sending and receiving information. All interpersonal behavior involves communication, either intentional or not, because most actions convey some meaning. Communication involves eight key elements. All eight must work for there to be an effective sharing of ideas. The important point in understanding this process is that any of the eight steps may be the cause when communication fails. If someone understands the steps, they can decrease problems in the process.
- Sender
The sender is the person who wants to transmit the idea or information to another person. A dentist may offer an idea, or the patient may want to express an emotion, fact, or concern to the dentist. The role of sender and receiver shifts back and forth as communication progresses.
- Encoding
Encoding happens when the sender translates the communication into a language the receiver will (hopefully) understand. If practitioners use too much dental jargon that the patients cannot comprehend, their failure to properly encode may harm the communication process.
- Message
The message is the result of the encoding process. It is the idea that the sender wants to send to the receiver. It may be information, a feeling, a value, a belief, or an attitude.
- Medium
The medium is the process that carries the message. The most obvious is the meaning of the spoken words. Other examples include text messages, emails, tone of voice, or body language.
- Receiver
The receiver is the recipient of the message. Receivers decode and interpret messages, developing their own meaning for the message. This may be different from the sender’s meaning.
- Decoding
Decoding happens when the receiver translates the message into their “language.” They must interpret the direct words and any additional messages the medium carries. Because some media, such as face‐to‐face oral communication, are much richer (i.e. they contain more additional information), they also incorporate more room for misinterpretation and error. The receiver’s perception of what was said is a reality for them. Therefore, their values, attitudes, beliefs, and concerns all influence the receiver’s perception of the message.
- Feedback
Feedback occurs when the receiver responds to the message. A direct response (verbal reply, facial expression) allows the sender to assess whether the receiver received the message and if it had the intended result.
- Noise
Noise is a factor in the system that distorts the intended message. The receiver may not accurately interpret the message if there is too much distortion. Examples include physical noise in the conversational space, such as other people talking, and psychological noise, such as fear, different frames of reference, and preconceived notions by the communicators.
METHODS OF ORAL COMMUNICATION
People use several ways of communicating in face‐to‐face situations. Verbal communication (either written or oral) is the most obvious. However, how someone present verbal communication tells the receiver about their state of mind during the process. Perceptive people use these cues to come to a deeper understanding of what the sender meant to say, as opposed to what they actually said. This means that people have both intentional communication (e.g. the meaning of the words) and unintentional communication (e.g. the unease exhibited by nervous fidgeting during the conversation). The best communication occurs when these two match. Although this sounds simple, the process becomes muddied by people’s perceptions, cultural and family histories, state of mind, and current conditions.
VERBAL COMMUNICATION
Verbal communication is the most common form of professional–patient communication in dental offices. Too often, dentists assume that when they say something, the other person understands what they said, why they said it, and the nuances of what they said. This involves the two sides of speaking and listening. People use verbal communication to transmit or obtain information, share experiences, or bring about change in another person. Depending on the purpose of the conversation, they rely on different elements. As noted, the dental practitioner needs to practice appropriate techniques for sending and receiving verbal communication. Sending involves speaking. Receiving involves the equally important listening function.
SPEAKING FUNCTION (SENDING INFORMATION)
Word Choice
The words that someone uses may have different meanings to someone else. This occurs especially when people discuss a topic that is familiar to them but unfamiliar to the other person, or if someone has preconceived ideas about the topic. For example, dentists are familiar and comfortable with endodontics, but many patients fear the dreaded “root canal.” Patients may have heard stories or jokes that have given them preconceived ideas about how horrible the procedure is. So, a dentist using the more technical term endodontic procedure over the emotionally laden term root canal may avoid a negative reaction from a patient. Box 24.1 gives several other common dental office terms that may generate negative responses from non‐dental people. The more non‐dental terms dentists and their staff can use, the less likely it is that they will generate negative emotional responses from patients.
Effective Self‐Disclosure
Self‐disclosure occurs when a person intentionally gives information (verbally or non‐verbally) to someone else about themselves. Self‐disclosure is important because it conveys openness. Openness is one requirement for developing a trusting relationship. Trust is an element that is necessary for a patient to communicate effectively and accept proposed treatment.
People can see self‐disclosure in the response statements “Really? I’ve had a similar experience” or “I’ve often felt the same way.” When a practitioner shares that experience or feeling with the patient, the patient understands that the dentist’s opinions may come from a similar reference and, therefore, be more valid.
Effective Feedback
The only way to know if the patient received and processed a dentist’s message with the same meaning as was meant is for the dentist to ask. A simple question such as “Does that make sense?” or “Do you have any questions?” asks for a response that tells the practitioner if the patient understands what they said. Several other techniques also test for understanding. Parroting is a simple repetition of what the person said, and paraphrasing does the same thing, only rephrasing what the person said in the listener’s own words. Both are good ways to encourage additional discussion of an issue.
Listening Function (Receiving Information)
As busy professionals, dentists become accustomed to talking but not listening to patients. However, listening is only half the communication process. To be an effective listener, a dentist must stop talking and listen. (This can be difficult for some people!) Dentists also must listen for more than facts by keenly observing the patient during the conversation.
Each person uses several levels or types of listening in their role as a practitioner. They shift between the types depending on the purpose of the conversation they are holding.
Listening for Content
The basic level of listening is to hear and comprehend the meaning of what the other person said. This requires that people have an appropriate vocabulary and understand the rules of grammar and syntax to understand what others are saying. Some words carry more importance than others. Understanding the content requires that people rank key facts from the long stream of words that make up many conversations. When a practitioner listens to a patient’s medical history, they must initially listen for the simple, factual content of what the patient says. Once the dentist gathers this information, they can move to higher levels of evaluation and interpretation.
Listening for Interpretation
The next level of listening is where a person makes judgments about what the other person says. People listen to decide if the other person is telling the truth, how strongly they believe what they are saying, and if they have other hidden agendas. When people interpret what they hear, they must also listen visually. When someone notices the cues that body language provides, it helps them assess if what another said verbally is congruent with what they said through actions and mannerisms. This type of listening is important as dentists interview patients about their wants, needs, and desires in dental treatment. If dentists try to persuade a patient to change their health behaviors, that patient will use interpretive listening as they weigh the pros and cons of the dentist’s position to decide if it makes sense for them.
Relationship Listening
Sometimes the reason that people listen is to develop or maintain a relationship. (Lovers talk for hours about things that would bore them when listening to someone else.) In relationship listening, a person tries to learn more about the other person, how they think, what they enjoy, and what motivates them. This type of listening is vital in developing both business and personal relationships. Before a patient commits to an extensive treatment plan, they must believe that the practitioner is looking out for their interests, not the dentist’s. For a dentist to gain that level of trust takes time to build a relationship.
Therapeutic Listening
In therapeutic listening, people gain an understanding of how others are feeling. The purpose is to use this personal relationship to help the other change or develop. To get others to expose these deeper and more sensitive parts of themselves, people need to show understanding and empathy toward them, not just in words but in how they ask questions. Practitioners must be sensitive to the patient’s unease in a way that encourages self‐disclosure. A typical example in the dental office is discussing treatment history with a dental‐phobic patient. These patients are often embarrassed about their dental condition and behavior in the dental setting. Through therapeutic listening, a dentist may find the root of the dental aversion and help the patient respond appropriately.
Active Listening
Active listening is a process that uses different types of listening. This process intends to improve understanding between speaker and listener. The listener frequently checks with the speaker to be sure that their interpretation of what the speaker said is what the speaker intended.
Active listening focuses attention on the speaker. The listener must be sure to listen fully, not think of other things, such as what they will ask next. The listener also observes the speaker’s behavior and body language, incorporating those into the content and interpretation of the conversation. Having listened, the listener then paraphrases the speaker’s words, not necessarily agreeing but simply checking what the speaker said. In emotionally charged conversations, the listener must recognize those emotional bases. The active listener often describes their observation of the underlying emotion (“You seem to feel angry” or “I sense that you feel frustrated. Why is that?”). This validates the speaker’s emotional statement in a non‐judgmental way. It allows and encourages the speaker to discuss their emotions in a positive fashion for the conversation and leads to effective therapy.
VERBAL COMMUNICATION BARRIERS
People have often heard someone say during an argument “What you heard is not what I said.” This points to a breakdown in the communication process. Several common reasons that oral communications fail in the dental office (barriers to communication) include the following:
- Different frames of reference occur when people have different and valid views of similar issues. These come from different backgrounds, experiences, and values. For example, dentists value excellent oral health. Some of their patients may not share that view. If a dentist discusses treatment options based on their frame of reference, they may not “get through” to the patient because of this different frame of reference.
- Selective perception occurs when people hear what they want to hear, blocking out information that conflicts with their beliefs and values.
- Value judgments occur when the receiver decides the value of the message before they receive the entire message.
- Semantic problems occur when words and terms have one meaning to one person and a different (or no) meaning to the other. If practitioners use too much dental jargon or words too casually (root canals can have a negative meaning for many patients), they may impede communication.
- Poor listening skills can occur, especially under times of stress. Many patients find the dental office to be a stressful environment. Others may be in severe pain or worried about a diagnosis or the cost of a procedure. This can make effective listening difficult for them.
- Verbal–non‐verbal incongruity occurs when the verbal message does not match the non‐verbal message sent. If a practitioner shakes their head back and forth but verbally says “Yes,” the patient will become confused. More subtle incongruities exist when a practitioner fidgets while trying to sound confident or grins when telling a patient bad news about the patient’s dental condition.
IMPROVING VERBAL COMMUNICATION
Dentists can improve interpersonal oral communication in the dental office by using the following techniques:
- Follow up on messages to be sure the listener received them correctly. The simplest way is for the practitioner to ask the patient if they are clear about what is happening. This verbal feedback assures the dentist that the patient received and properly interpreted the message.
- Simplify language by not using too many professional terms. A dentist may find it helpful to make a list of dental terms and acceptable alternatives in daily communication.
- Watch body language. The dentist must be aware of the body language they project and take time to read the body language of patients. If a patient is sitting cross‐armed with their lips pursed, they are probably not accepting the dentist’s message, regardless of the verbal response. (There is more on body language in the next section of this chapter.)
- Work on effective listening skills. These are skills that people can learn and improve if they take the time and make an effort.
- Ensure that non‐verbal messages support verbal messages. If these are not congruent, the listener will hear the worse one.
NON‐VERBAL COMMUNICATION
Communication is the transfer of information from one person to another. This is usually thought of as simply the spoken word. However, face‐to‐face communication carries much more information than simply words. People can view the other’s facial expression and hear their tone of voice or the emphasis they place on particular words or points in a way that is not possible if there is no personal encounter (e.g. think of an email message that is factual without any embellishment). Psychologists estimate that as much as 85% of the information conveyed in face‐to‐face communication is non‐verbal. People use these non‐verbal cues to learn additional meaning and emotional background. By examining the context of the communication, people validate or refute what was said verbally. They examine the other’s body language, or what the person has said beyond the simple spoken word, to have a richer communication encounter. People do this continually and subconsciously. Even someone who is inactive or silent may be sending an intended or unintended message: that they are bored, depressed, or angry.
People must also remember that the other person is assessing them similarly. Therefore, the dentist must be careful of the non‐verbal messages they send to others (patients and staff) and manage that part of the communication process.
Verbal and non‐verbal information is related. Non‐verbal information is usually the more powerful of the two. When they are congruent, the non‐verbal message reinforces the verbal message. When they are not congruent, cognitive dissonance indicates that something is wrong. (Think of a person who has anger in their words and voice but is calm and smiling.) Cultural and gender differences play a role in non‐verbal cues as well.
POSTURE
A person’s posture clearly states how they feel about themselves. An upright but relaxed posture shows confidence and honesty. Slumping suggests lower self‐esteem. Crossing arms may feel like a relaxed position, but to observers it can indicate that a person is shutting themselves out. Fidgeting (including twisting hair, drumming fingers, or examining fingernails) shows boredom or nervousness.
EYE CONTACT
Direct eye contact suggests honesty and openness, especially when speaking to someone else. A person looking down or away while speaking shows boredom. To be effective, people must try to make eye contact for the first and last 15 seconds of a conversation. This creates a feeling of concern and honesty that it is difficult to gain otherwise. However, eye contact should not be held for too long, because others will see that as hostile.
PHYSICAL CONTACT
People expect to be touched when they visit a dentist. However, they expect a “therapeutic” or “professional” touch, not an aggressive or sexual touch. Dentists still must respect a patient’s personal zones, only entering the closer zone when they are invited. Hand‐shaking is a ritualistic way to move from a social to a personal zone. (A person’s emotional state is often shown by their hand. Are they cold and clammy? Warm? Sweaty?) A pat on the shoulder is a less ritualistic way of making a symbolic connection with someone.
FACIAL EXPRESSION
Facial expressions give away a person’s emotions. People can read surprise, happiness, anger, or other emotions by carefully watching a patient’s facial expression. Squinting can be read as aggression. Facial pallor or blushing can also share an emotional state.
TONE OF VOICE
The tone of someone’s voice can be a giveaway to their emotional state. People can show (or see) anger, fear, boredom, or happiness depending on how they emphasize words and their tone. Practitioners see this when a patient talks with them or when a dentist or a staff member talks with patients. For example, consider the children’s game where the speaker emphasizes a different word in the same sentence – entirely different meanings result:
- I love my job.
- I love my job.
- I love my job.
- I love my job.
Because no one knows how they sound to someone else, dentists should record themselves talking with a patient, then listen to the tape privately to evaluate their vocal delivery. That allows them to develop one or two specific things to work on. If they have difficulty speaking with patients, they should consider getting a voice coach, who will help them develop their tone and method of oral delivery.
PROXEMICS (PERSONAL SPACE)
Proxemics is the study of space and how people relate to space. Understanding people’s comfort zones can help a dentist influence their communication and professional relationships with their patients.
Everyone has a personal space that surrounds them. The social relationship that someone has with another person defines this space. Psychologists have proposed that the reasons may lie in evolutionary behavior. When a person keeps another person at a distance, they cannot surprise with an attack. As people are invited closer, it becomes easier to talk with them. When people are brought even closer, intimacy or affection is being invited. Someone may deliberately threaten another by invading their space without invitation. Anytime someone enters a personal zone without invitation, it creates anxiety for the person whose space is invaded. This is seen as a threatening action. Some people do this intentionally to signal that they are more powerful.
Box 24.2 lists the comfort zones. The public zone is generally more than 12 ft. When people encounter each other in public, their tendency is to leave space between them. When adequate space cannot be left, people begin to feel uneasy. The social zone allows a connection with other people. People can talk with others but still keep them at a distance. Friendly people in a social setting adopt this distance. The personal zone is one in which people who know each other may directly converse. When each person is close enough to touch the other, they are in the intimate zone. They can harm or touch each other in intimate ways. There must be significant trust for the two to be comfortable in this area.
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