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Factors affecting the psychological collection and identification of the fearful dental patient

Arthur A. Weiner

INTRODUCTION

The assessment and identification of dental fear and anxiety, although it appears deceptively simple, can actually be rather difficult. Although dentistry is a technically oriented profession, the way a dentist communicates can significantly influence the behavior of his or her patients. The dental situation does not generally favor two-way conversation. The dentist is often seen as an individual carrying on a one-sided conversation with the patient, who is unable to participate.

Communication is a two-way street. The dentist needs not only to have the ability to receive messages from, but also to convey information, to the patient. The ability to receive a patient’s verbal and nonverbal messages is of paramount importance in developing rapport and mutual trust. When a practitioner fails at this, it can lead to mistrust, anger-increased fear and anxiety and eventual avoidance. Collection of information concerning a patient’s past and present history should ensure that the dental practitioner acquires a complete understanding of the needs and dental problems of his or her patients. But this is not often emphasized or even taught within the dental curriculum.

The identification of this multifaceted emotion we call fear requires the accumulation of complete and accurate information in order to ensure that the desired result is achieved. The essential components are:

• enhanced communication-listening skills;
• a positive dentist-patient interpersonal relationship;
• rapport building and establishing trust;
• good interviewing skills;
• empathy; and
• willingness to cooperate and learn to overcome one’s fears.

The most critical and potent component of effective communication is not speaking, but rather listening. Listening is far more potent a tool then speaking. Listening not only helps determine what is heard, but more significantly, what is often said after the hearing. When the dental practitioner begins to listen effectively to what the patient is saying, he or she has taken the first steps toward understanding the thoughts, feelings, goals, and needs of that patient. It is the initial building block of a doctor–patient relationship, one built on mutual trust and rapport.

PREREQUISITE COMPONENTS FOR ENHANCED COMMUNICATION SKILLS

Good active listening skills are largely comprised of “attention skills.” These imply a direct interest of the part of the listener practitioner. Attention skills include:^1,2

Eye contact: Eye contact is the principal means of expressing involvement. Establishing and maintaining eye contact throughout a conversation is an essential listening skill. It should be steady, frequent, and focused on the face and eyes of the speaker. However, one should also avoid prolonged eye contact, which can be intimidating, especially in some cultures. Eye contact and facial expressions are fairly reliable indicators of how good the speaker–listener contact is, and may indicate the quality of the information being communicated. If eye contact is lessened by the patient, it may be difficult for the dentist to acquire adequate information without these nonverbal cues.³

Body orientation: This pertains to the degree to which one’s shoulders and legs are turned in the direction of the speaker. Bodily facing the speaker is the correct position.

Posture: The listener’s body posture conveys important messages concerning interest and attention. A listener should maintain a slight forward lean. To do so communicates a positive attitude and interest, while leaning back often implies a negative attitude and disinterest on the part of the listener.

Silence: Silence is an extremely effective listening tool. Silence on the part of a dentist during a conversation, especially during the initial consult and interview, often gives patients the time to formulate their thoughts and facilitates continued communication. A listener should avoid interruptions.

Following cues: “Cues” are verbal and nonverbal behaviors that occur in response to a patient’s statements and can reinforce the patient’s desire to continue communicating. For example, the listener could make such statements like “That’s interesting,” or I’d like to hear more about that.” Vocal interjections such as “really?” and the use of facial expressions that denote interest serve to convey interest and empathy. Nodding the head occasionally indicates that the listener is interested in what the patient is saying. A timely smile can indicate a genuine feeling, implying “I’ m looking forward to working with you,” or “it’s a privilege to have met with you.”

Establishing appropriate distance: A distance of 3–4 ft (36–48″) is considered to be an appropriate distance for interpersonal communication. Closer distances make evoke feelings of intrusion, while a greater distance may imply a lack of interest and involvement.

Eliminating distracting behaviors: Many practitioners have personal habits that can be distracting and annoying to a patient. Pencil tapping, continuous shifting of positions, nervous movement of the hands and feet, playing with objects, or glancing at watches should all be avoided. These may indicate to the patient that the consultation is taking up too much valuable time. Conduct the interviews and consults in a setting where telephone calls will not be a distraction.

The physical environment: The environment or room for the consult or interview should make it easy for both the patient and dentist to give their undivided attention to one another. It should provide sufficient privacy so that a patient’s conversation cannot be overheard. It should be well lit, pleasant, and comfortable.

Attending to content, not the delivery. Most patients are not good speakers, and often they are anxious and frightened. Some may have an unpleasant voice, while others may have speech defects. Ensuring positive and successful communication requires a deliberate attempt to attend to what the patient is saying, despite the manner in which it is said.

Listening to feelings: While factual knowledge is essential for proper diagnosis and treatment, it is also important that a dentist listen for affective and attitudinal messages. Very often feelings, concerns, and attitudes are expressed in offhand remarks, asides, and by-the-ways. A patient may often insert casual comments to his or her messages to see how the dentist will respond. A lack of response to these messages may be interpreted by the patient as a lack of interest on the part of the practitioner. Practitioners must constantly be alert for such cues.

Attending to nonverbal forms of communication. Patients communicate through nonverbal channels, as well as verbal ones. Nonverbal behavior is influenced by many factors, including personality, culture, and time context, to name a few. Most of what a patient feels and thinks are communicated through gestures, tone of voice, and body actions. Positive and effective listening necessitates that a listener pay as much attention to nonverbal forms of communication as to the spoken words of the patient.

Nonverbal behaviors are potent cues in the communication process because they lend context to the patient’s words, thoughts, and feelings. They also reveal the distress and discomfort patients may be experiencing during treatment. The value for the dentist of attending to these non verbal messages has been shown to including the following;

• Yields a more accurate understanding of what the patient feels and needs.
• Helps provide a determination of the emotional flavor behind the patient’s words or feelings. Did you hear an angry “no” or a questioning “no”?
• Helps to provide feedback to the patient demonstrates that the dentist is an interested and attentive listener/observer.
• Demonstrates to the patient that a non verbal communication links exists, which can be reassuring to the patient, and helps reveal that the dentist is concerned.
• Helps regulate the flow of speech, conveys emotional feeling and thoughts, and most importantly, helps build and maintain a positive relationship.

When the dentist uses positive nonverbal communication (smiles, nods, gestures, facial expressions), he or she demonstrates a capacity to understand, listen, and identify with the feelings and concerns of their patient.

• Avoid questions or words that might cause emotional arousal such as “drill,” “scrape,” “needle,” and “grind.”
• Develop calming statements such as “Try not to let it upset you” or “Try to relax, it is not as bad as you think it is.” Some individuals prefer to be called by their full first name rather than by a shortened version or nickname (William instead of Bill). Some individuals become antagonized by the shortened use of their name. Try to avoid the overuse of technical jargon. Such language can intimidate patients and cause them to withdraw and avoid giving needed information.

Reflective listening and response: In any given point in a conversation in reflective listening, the dentist combines both verbal and nonverbal information captured and feeds back to the patient in his or her own words the patient’s expressed or implied feelings, in an effort to reiterate correctly what the patient perceives the message to be. The goal is to provide the patient with specific feedback about the dentist’s understanding of the needs, goals, and concerns of the patient. It allows the patient the opportunity to correct any misinterpretations and avoid any misunderstandings. It can also be utilized when a treatment plan is presented to a patient, allowing patients to present their interpretation of the suggested treatment plan in their own words, and correct any misunderstandings that may have risen during the practitioner’s explanation.

With this technique, you can reinforce the patient’s emotional state, clarify vague statements, and help the patient assess and take ownership of his or her feelings. Remember, feelings can often color content. The art of listening is essential to establishing a positive working relationship between patient and dentist. Affective responses such as “You seem anxious,” “You seem concerned and uncomfortable,” or “I can understand why you would feel anxious and upset” can elicit responses providing valuable information that may help complete the picture and explain a patient’s negative and emotional behavior, fear, and cognitions more fully.

Provide positive feedback: Refrain from using language that discourages rather than encourage solutions to an ongoing problem. Avoid responding to the patient solely when the individual’s response illustrates a past negative response or behavior. Provide positive feedback to counteract the patient’s negative outlook; it helps to motivate and promote a brighter outlook. For example, during a new patient consultation, the patient stated that “all her previous dentists were only interested if she had insurance, did not provide her with sufficient information or answer her questions fully, never explained the risks and benefits of what was to be done, and were always in a rush to get started.” Try using the I statement technique to communicate a positive attitude and counteract the patient’s negative experiences. For example, “I am very sorry you have experienced these past difficulties. I do not practice like that. Each of my patients is adequately informed each visit. Before I start, I give each of my patients the opportunity to ask any and all questions they may have. I believe we all forget sometimes, information previously given, and many times, I myself am guilty of momentary lapses. Please be assured if I at any time seem to be rushing or you have any question, I want you to feel free to interrupt me; in fact my staff and I insist upon it.” The idea is to communicate to the patient that you are a different type of person, more caring and responsive to the needs and feelings of your patients. It allows them to feel they will be a part of the overall treatment.

Clinical chairside implication

• The reflective listening/response technique can help insure treatment compliance in that it permits (1) a checking the accuracy of information and (2) the elimination of misunderstandings through the giving and receiving of feedback by all parties involved. It can be a potent factor in assuring treatment compliance and building trust.

I know that many times during this text, I can be accused of repetition, but I always remember one of my first dental school professors saying:

Repetition is the mother of learning.

I feel so strongly about many of the ideas and concepts this text advocates that I feel no quilt in constantly restating them.

ESTABLISHING A POSITIVE PATIENT–DENTIST RELATIONSHIP²

Key elements in creating a positive patient– dentist interpersonal relationship are:

• Establishing rapport and trust;
• utilizing two-way communication—verbal and nonverbal;
• understanding a patient’s perception of control, relative to past dental experiences and effects on fear levels; and
• accommodating initial patient-dentist priority differences.

Creating rapport

Rapport is a relationship that must be established early in the cycle of dental treatment. Most individuals, especially fearful and mistrustful ones, form their impressions of a practitioner within the first few minutes of their encounter. Therefore, early communication should consist of listening to the concerns and needs of the patient.

A patient’s perception of a practitioner as warm, caring, and empathetic helps build trust and rapport. Patients should be made to feel comfortable, and encouraged to ask questions and interrupt at any time should they become confused and not understand what the practitioner is trying to communicate. Avoid embarrassing or belittling the patient over lack of care or poor oral hygiene. Do not appear to rush, and be alert to nonverbal cues. Sometimes an individual’s verbal message may convey conviction while their gestures, facial expressions and tone of voice may indicate a sense of doubt.

During the initial consultation, get to know to the patient. Try to establish a mutual connection. For example, ask “How long you have lived in the area?” The dentist can respond, “Well, I have also lived here for some time.” Ask “What high school did you go to? Great, I went there also.” “When did you graduate?” “Who was your dentist when you were growing up? Really? He was mine also.” Try to make a connection, through your children, college, soccer, Little League, anything that can equal a shared similarity, or common background. It helps create a friendly beginning to what may potentially be a long association.

Clinical chairside implication

• Communication and rapport are essential for understanding and trust.
• Listen; listening builds trust, the foundation of all successful relationships. The more you listen, the more people will trust you and feel that you are genuinely interested in their well being. The greater the trust and rapport, the greater the likelihood a patient will agree to a recommended treatment plan.

Past studies cited below, which were concerned with communication between patient and dentists and the many interpersonal variables that can be found in the patient–dentist encounter, demonstrate an increased attention by the profession to this particular interaction.^4–8

In the establishment of a positive dentist– patient relationship, the dental practitioner must possess certain interpersonal skills, including active listening and the ability to capture both verbal and nonverbal cues, such as displayed and repressed emotions. Patients use these two forms of expression to display their feelings and concerns and inner emotions. It is a way in which a patient expresses their problems, and often reveal any hidden fears. The dentist must be able to recognize these cues and be responsive to them. They may appear as nervousness, fear, shame, and distrust. Some of these emotional cues may be in the form of body language: sitting at the edge of the chair, for example, or nervous rubbing of hands, or crying at the thought of having to discuss treatment. Patients may manifest shame, not wishing the dentist to look in their mouth and see the condition of their teeth.

To establish and maintain this relationship between patient and doctor, the dentist is required to be sensitive to the patient’s communication or lack of it, and to be skillful in recognizing these emotional expressions, verbal or nonverbal, that the patient is sending during conversation. The dentist must also play the role of a sympathetic human being, displaying empathy, respect, and an air of understanding. If the dentist fails at this, he or she could fail to gain a complete understanding of the patient’s overall dental problems. There are some patients who are distrustful of dentists or dentistry in general and who want to control the entire consultation in order to learn more about who the practitioner is. Some may constantly blame a previous clinician for their poor oral health, while others may hide their fears during the initial consultation, either because they do not want or are unable to express or verbalize their fears and anxieties to the dentist. Also, some individuals repress expressing their anxieties as a strategy for coping with their discomfort, while others joke and minimize their fears as a way to hide their shame and embarrassment.

In 2000, Karoly and Kulich,⁹ in their study of the dentist–patient consultation in a clinic specializing in dental phobic patients, suggested, regarding to the dentist’s interpersonal skills and as role as a clinician, that the healthcare provider must listen intently to the patient’s concerns, learn from the patient, teach the patient, and be open and nonjudgmental in order to understand the patient’s complaints and dental problems. They also concluded that the practitioner’s overall interpersonal skills must consist of demonstrating empathy and paying attention to both what patients say and also what they are often unable to express verbally but convey through nonverbal forms of communication. The dentist must continuously offer encouragement and understanding.^10–12

TWO-WAY COMMUNICATION^2,13–16

The dental practitioner is often characterized as an individual who usually carries on a one-way conversation, either asking questions, then interrupting before the speaker has completed a response, or making conversation with a patient whose mouth is filled with a variety of equipment and accessories, preventing a reply. Two-way communication between patient and dentist is essential because the patient needs to know that he or she can exercise some degree of control over situations perceived to be threatening. Patients should be informed, each time they present for either a consultation or treatment, that it is perfectly acceptable to interrupt if they feel any unpleasant discomfort during treatment or have any questions needed for clarification during a consult. In the treatment phase, always:

• Inform patient what you wish to do.
• Explain the reason for doing it.
• Ask if any questions or concerns exist before starting.
• If the patient requests, inform how m/>
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