The Treatment Plan Trap

Dentists love to fix things. I know several dentists who find doing dentistry therapeutic, like pottery or painting. They can get lost in the details of making everything work perfectly and beautifully and experience what Mihaly Csikszentmihalyi referred to as flow (where performing an activity results in energy, enjoyment and a loss of the sensation of time passing.) Dentists are like craftsmen, creating something useful, functional and esthetic out of all manner of materials from porcelain to plastic to enamel itself. Is it no wonder that the joy of dentistry can at times get in the way of the dentist getting the chance to create? The dentists desire to have another opportunity to fix stimulates an excitement to get started. This excitement leads the dentist to rush past the patient’s acceptance of the situation and on to presenting their plan to solve the problem. Here, the dentist steps on the gas instead of applying gentle pressure to the breaks which would be more prudent.

When what the dentist wants to do is not in sync with what the patient wants or understands, frustrations surface. Unfortunately, too often dentists get frustrated with the person attached to the canvas that they are so eager to engage. This frustration is not typically due to a personality conflict between the two individuals, but rather to the patient’s inability to travel the path from condition to valued solution as quickly as the dentist would like. Think of traffic on a snowy day when you are anxious to get to your destination. The conditions are frustrating, but speeding up is not the answer. In dentistry it in common to lose the patient in the process of treatment planning. This loss is primarily a result of a sort of conditioning that dentists get through their formal dental education, where the accuracy of a treatment plan is valued higher than the fit of the treatment plan for the patient. It would be so much quicker if dentists could just do what they know is best. Those days are long past, no longer are dentists afforded the trust and leeway to do anything that they think is in the best interest of the patient. Today, the patient has to come on board; this is reality and it is a good thing.

Dr. Carlisle writes about the expert trap in his compelling book “Motivational Interviewing in Dentistry.” Dr. Carlisle references that even the term “patient” can create a rift in the treatment planning process, where the patient is deemed less than the doctor. It is true that a doctor-patient relationship has historically been a largely hierarchical relationship. The doctor is the expert the patient knows next to nothing about what must be done to fix the problem, so the doctor decides in a paternalistic fashion that she knows best how to fix the problem. At times this is exactly right, if you have a gunshot wound to the leg that is bleeding profusely, you want the doctor to diagnose the problem quickly and act decisively, no need for any discussion-save the life doctor. Unfortunately, this mindset carries on to all manner of decision making where that patient’s opinions about treatment range from important to critical to making a choice that the patient will appreciate.

Over the past four years, I have had the opportunity to participate in the professional growth and development of dozens of dentists. I have found an almost universal desire to focus on “the” what dentistry they (the dentist) want to do as opposed to the disease. All of these dentists make a diagnosis but within a millisecond of making the diagnosis they have also decided what they want to do to fix the problem. Often the dentist will develop a treatment plan away from the patient. When they return their attention to the patient, they confidently tell the patient their plan. The plan is often appropriate; it is also often left undone. It isn’t that the dentist hasn’t explained the merits of their plan well enough that leads to the oh so polite, “well I need to think about this and talk it over with my husband.” No, it is not the quality of the plan, it is the fact that too many dots are left unconnected for the patient to pass over the dreaded abyss of “maybe.”

There are two critical skills underdeveloped in dentists. First, is counseling and second is collaboration, neither is intuitive to a person trained in how to fix precisely that which is broken. After all, why would an expert need to learn how to collaborate with an untrained person, or counsel them?

There can be no doubt that most dental disease is a lifestyle disease. Our diets and our hygiene habits contribute to most forms of diseases of the gums and teeth. Lifestyle is tricky. People are slow to make changes to lifestyle and are defensive when anyone, even those with the purest intention, questions the choices that people have made. As Dr. Carlisle states in his book, many people are ambivalent to their dental health and an enthusiastic dentist who wants the opportunity to fix all the damage that the patient’s lifestyle created is not always received well. Time is one part of the answer to this dilemma. As Stephan Covey used to say, “with people, slow is fast and fast is slow.” How many dentists in their eagerness to share all the splendor of an intricate plan speed over many issues and zero in on the solution to the problem that the patient has yet to embrace? For a thorough lesson in entering into “helper” relationships with your patients, I recommend reading “Motivational Interviewing in Dentistry.”

The second skill of collaboration also takes time, but less than you might imagine. Separating diagnosis from treatment planning is an essential step in collaboration—a millisecond is not enough time. Not only is it prudent to case acceptance to separate the two, but it is also easy. There is only one diagnosis for a condition (true a tooth might have multiple things wrong, but the amalgamation of all of the conditions is the diagnosis.) The dentist has an obligation to diagnosis everything that their knowledge, training, and experiences have taught them to be true. In actual practice one way to accomplish the separation of diagnosis from treatment plan is to go tooth-by-tooth, system-by-system interactively with the patient. Mrs. Jones, this tooth has a crack on this side next to the silver filling that is failing, it also has decay on this side and has a lot of wear on the top of the tooth. By doing this, you have made a diagnosis in lay terms that your assistant can translate into the chart; i.e. #3 distal fracture, recurrent occlusal decay, mesial decay, attrition. The diagnosis goes into the chart. You have finished your first tooth. Avoid the unyielding desire to tell Mrs. Jones this tooth needs a crown. If you must hint at what needs to be done, you can say “this tooth has problems, and we will want to discuss what we can do to solve those problems after I have looked at everything else and I can accurately help you make a choice about the best way to address the issues. Don’t tell you assistant zirconia crown and build up, or wink at them or anything, move on, resist the urge to solve the one problem until you know all the problems. Once you know the extent of all the problems, now is the time to begin collaboration.

Collaboration is part of being in a helping relationship. As you were going tooth-by-tooth, system-by-system you should have been looking for clues about what the patient is thinking. Periodically, check in by asking what they think of what you just discovered and or how they are feeling about their mouth. When finished with your examination and you have your problem list, I find it helpful to ask some questions. One of my favorites is, “Mrs. Jones we identified several issues in your mouth, is there anywhere in particular that you were hoping to address first or that you are most concerned with?” If the answer is yes, follow her lead and begin discussing solutions based on what is now a richer understanding of the patient’s situation. If the answer is “no” or worse yet “you’re the doctor” it is time for another question. “Would it be ok with you if I focused on the area where I feel you are at the most risk.” If there are many of these areas or I am uncertain, I will acknowledge the challenge of her case and ask permission to spend time with her case privately where I can work through the consequences of different alternatives before presenting any options. Again remember Covey “Slow is fast and fast is slow” If I give a complicated and expensive plan in its entirety the first time I have met someone, the odds of me getting to yes is in the single digits.” But, if I focus on a limited area, perhaps only treating it in a palliative way, this allows the patient to experience my care, skill, judgment and touch. Now I can invite the patient back to discuss possibilities. When they return, the chances are much greater that I will earn the opportunity to participate in that client’s care in a more significant way in the future. Once you have done one thing, even something small like a filling or impressions for diagnostic casts you have become that patient’s dentist. Getting to yes isn’t about getting to do more, getting to yes is about helping patients solve their dental disease dilemma. The patients who leave the chair with a beautiful treatment plan and feel overwhelmed, defeated and lost are certainly not well served.

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