18: Gaining Case Acceptance

Chapter 18

Gaining Case Acceptance

Part 1: Communication in the Office

All great writers have a built in, infallible crap detector.

Ernest Hemingway

At the completion of this part, the student will be able to:
1. Describe the steps in the communication process.
2. Describe the common methods of communication in the dental office.
3. Describe the types of nonverbal communication.
4. Describe how proxemics affects patient interactions.
5. Describe how patient position affects patient interactions.
6. Describe the oral communication process.
7. Define common barriers to communication.
8. Describe the types of listening.
9. Describe how to deal with common “problem patient” communication issues in the dental practice.

active listening
body language
content listening
effective feedback
interpretive listening
intimate zone
oral communication
personal zone
public zone
relationship listening
selective perception
semantic problems
social zone
therapeutic listening
value judgments
verbal/nonverbal incongruity
written communication

This part presents guidelines for communicating in the office.

Communication is a key to successful dental practice. Dentists must communicate with staff members to be sure that the office operates effectively. They must communicate with vendors and other professionals to ensure excellent patient treatment. And dentists must communicate with patients to inform them of their needs and to gain acceptance for treatment options. A successful dentist has to 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 more deeply 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, we need to understand their frame of reference, their 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 that have a high degree of uncertainty or a large emotional component to the decision. Other channels of communicating, such as letters, e-mail, or telephone calls, do not share the depth of understanding is gained from face-to-face communication.

The Communication Process

The communication process is a shared experience ­between two or more people with importance given to both sending and receiving information. Really, 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 when communication fails, any of the eight steps may be the cause. If someone understands the steps, he or she can decrease problems in the process.

1. The sender is the person who wants to transmit the idea or information to another. A dentist may wish to offer an idea, or his or her patient may want to express an emotion, fact, or concern with the dentist. The role of the sender and receiver shifts back and forth as communication progresses.
2. Encoding happens when the sender translates the communication into a language that the receiver will (hopefully) understand. If dentists use too much dental jargon that the patients cannot comprehend, their failure to properly encode may harm the communication process.
3. 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, value, belief, or attitude.
4. The medium is how the message is carried. The most obvious is the meaning of the spoken words. Other examples include text massages, e-mails, tone of voice, or body language.
5. The receiver is the recipient of the message. Receivers decode and interpret messages developing their own meaning of the message. This may be different from the sender’s meaning.
6. Decoding happens when the receiver translates the message into their “language.” They must interpret the direct words plus any additional messages carried by the medium. Because some media, such as face-to-face oral communication, are much more rich (i.e., they contain more additional information), they also have 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.
7. Feedback occurs when the receiver responds to the message. A direct response (verbal reply, facial expression) allows the sender to assess whether the message was received and if it had the intended result.
8. Noises are factors in the system that distort 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 Communicating

People use several ways of communicating in face-to-face situations. Verbal communication (either written or oral) is the most obvious. However, how people present the 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 was meant to be said, as opposed to what was actually said. This means that people have both an intentional communication (e.g., the meaning of the words) and an unintentional communication (e.g., the unease exhibited by nervous fidgeting during the conversation). The best communication occurs when these two match, when people communicate effectively what they want to communicate. Although this sounds simple, the process becomes muddied by peoples’ perceptions, cultural and family histories, state of mind, and current condition.

Nonverbal 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 the words. People can view the other’s facial expression and hear the tone of the voice or the emphasis of words or points that are not present without a personal encounter (e.g., think of a simple e-mail message and how simply factual it is without embellishment). Psychologists estimate that as much as 85 percent of the information conveyed in face-to-face communication is nonverbal. People use these nonverbal cues to learn additional meaning and emotional background. By examining the context of the communication, people validate or refute what was said verbally. People examine the other’s body language, or what the person has said beyond the simple spoken word, so that they have a richer communication encounter. People do this continually and subconsciously. Even a person who is inactive or silent may be sending an intended or unintended message: that he or she is bored, depressed, or angry.

People also must remember that the other person is assessing them in the same way. Therefore, people must be careful of the nonverbal messages that they send to others (patients and staff) and manage that part of the communication process as well.

Verbal and nonverbal information is related. Nonverbal are usually the more powerful of the two. When they are congruent, the nonverbal message ­reinforces the verbal message. When they are not ­congruent, there is a cognitive dissonance that indicates that something is wrong. (Think of the person who has anger in his or her words and voice but is calm and ­smiling in his face.) Cultural and gender differences play a role in nonverbal cues also.


A person’s posture gives a strong statement on how he or she feels about himself or herself. 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 suggest that a person is shutting them out. Fidgeting (including ­twisting hair, drumming fingers, or examining fingernails) shows boredom or nervousness to patients.

Eye Contact

Direct eye contact suggests honestly and openness, especially when a person is speaking to someone else. A person looking down or away while speaking shows boredom. To be effective, people should try to make eye contact for the first and last 15 seconds of a conversation. It creates a feeling of concern and honesty that cannot be gained otherwise. However, a person should not overdo eye contact because if it is held too long, others will see it as hostile.

Physical Contact

People expect to be touched when they visit the dentist. However, they expect a “therapeutic” or “professional” touch, not an aggressive or sexual touch. So dentists still must respect a patient’s personal zones, only entering the closer zone when invited. Hand-shaking is a ritualistic way to move from a social to a personal zone. (A person’s emotional state can be indicated 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 a person.

Facial Expression

Facial expressions give away a person’s emotions. A ­pallor shows fear. Squinting shows aggression. People can read surprise, happiness, anger, or a host of other ­emotions by carefully watching a patient’s facial expression.

Tone of Voice

The tone of someone’s voice can also be a giveaway to his or her emotional state. People can show (or see) anger, fear, boredom, or happiness depending on how they emphasize words and the tone of their voice. Dentists see this when a patient talks with them, or when the 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 he or she sounds outside to someone else, the dentist should record himself or herself talking with a patient. Then the dentist should listen to the tape private and honestly evaluate his or her own vocal delivery. Then the dentist should develop one or two specific things to work on. If a dentist has difficult time speaking with patients, he or she should ­consider getting a voice coach. The coach will help the dentist develop the 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 communication and professional relationships with his or her patients.

Everyone has a personal space that surrounds them. The social relationship that someone has with the other person defines this space. Psychologists have proposed that the reasons may lie in people’s evolutionary behavior. When unknown people are kept at a distance, they cannot surprise attack. As people are invited closer, it becomes easier to talk with them. When people are invited closer, intimacy or affection is invited. When people are acting, they 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.

The public zone is generally more than 12 feet. When people are encountered in public, the tendency is to leave space between each other. When adequate space can not be left, people begin to feel uneasy. The next 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 a 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.

The sizes of these zones vary by culture (Latin Americans and Middle Easterners have smaller personal spaces), by gender (women have smaller spaces), and by personality. People who come from different cultures may have different views of personal space. For example, males in some cultures find it unnerving to have a woman touch them or be proactive in invading their space.

In the dental office, dentists see each of these spaces. Patients sit as far from each other as possible in the reception room. In the operatory, they must be prepared for their intimate space to be invaded. Dentists then go further by touching them and invading their bodies, by putting their hands in the patients’ mouths. This can be disconcerting, especially for someone who is not accustomed to dental visits. The dentist should reduce space gradually: meeting the patient, shaking hands, and gradually decreasing space before starting dental procedures. Patients who are lying in the supine position in the dental chair are in an exposed and vulnerable position. (Dogs roll on their backs, exposing their bellies to show submission.) When a dentist discusses treatment options with a patient, he or she should have the discussion with the patient in the upright position with eyes level or in a treatment conference room. This is a coequal position that promotes trust and open conversation.

Box 18.1 Personal Zones
Public zone more than 12 feet
Social zone is between 4 and 12 feet
Personal zone is between 1 1/2 and 4 feet
Intimate zone is less than 1 1/2 feet

Verbal Communication

Verbal communication is the most common form of professional–patient communication dental offices. Too often dentists assume that when they say something, the other person understands what is said, why it was said, and the nuances of what was said. It 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, people rely on different elements.

Word Choice

Particular words that people use may have different meaning to others. This occurs especially when people are discussing a familiar topic with a person who is unfamiliar, or 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 terms endodontic procedure over the emotionally laden term root canal may avoid a negative reaction by a patient. Table 18.1 gives several other common dental office terms that may generate negative responses from nondental people. The more nondental terms dentists and their staff can use, the less likely they are to generate negative emotional responses from patients.

Table 18.1 Word choice in the office

Dental Term Nondental Term
Waiting room Reception area
Operatory Treatment area
Price Fee
Investing Paying
Oral exam Check-up
Recall Routine visit

Types of Listening

As busy professionals, dentists become accustomed to talking, but not listening to patients. However, listening is half the communication process. To be an effective listener, dentists have to stop talking and listen. (This can be difficult for some people!) Dentists also must listen for more than facts by keenly observing patients during the conversation.

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 18: Gaining Case Acceptance
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