Kevin Lewis shares the results of research into interactions between clinicians and patients, and discusses their relevance to dentistry when it comes to building rapport within the limited time of appointments…
Time pressures have been shown to be one of the main causes of stress in any workplace, and few would deny that they are also the enemy of any aspiration to provide high-quality dentistry. The most obvious manifestation of this is seen in the NHS – especially within the deeply unsatisfactory UDA arrangements in England and Wales, but also within the fee-per-item system that preceded it (and which still exists in Scotland and Northern Ireland). In such systems, it is a simple enough exercise to extrapolate a fee or income to a representation of the amount of a dentist’s time it will pay for.
And whatever that total amount of time adds up to, it needs to cover not just the time for the actual clinical procedure(s), but all the associated discussions in relation to the consent process, pre- and post-operative instructions, the likely cost of treatment, and all of the human interaction involved. Dentists – sometimes out of necessity – become adept at using potential ‘down’ time within an appointment, to fit in some of these essential aspects of patient care without extending the length of appointments unnecessarily. But we may be overlooking the difference between talking ‘at’ a supine and perhaps anxious patient from above and behind them where they cannot see us (and in mid-procedure), as opposed to talking face-to-face ‘with’ a patient in the natural way that is possible in most medical consultations.
The difference two minutes can make
But one of the less obvious casualties of time pressure is the development of rapport between dentist and patient. Part of this relies upon having not just the skill, but also the time and predisposition to listen effectively to what the patient is saying, to understand more about them and what matters to them, how they are feeling and what they are thinking. Communicating care, interest, compassion and concern for the patient’s well-being develops the trust which is the very foundation of rapport. While it is easy enough to appreciate that all of this takes time, the evidence from medical consultations throws up some interesting surprises about how much extra time needs to be invested in order to make a difference – and the best ways to use it.
One remarkable study by Levinson and Roter in the US¹ revealed that a clinician’s tone of voice and the extent to which they allow patients to speak without interruptions, was found to have a huge impact on the likelihood of being sued. The actual content of what was said during consultations mattered a lot less than the way in which it was delivered. Physicians who had never been sued spent, on average, slightly longer with patients – a difference of just two or three minutes per consultation.
“One remarkable study by Levinson and Roter in the US¹ revealed that a clinician’s tone of voice and the extent to which they allow patients to speak without interruptions, was found to have a huge impact on the likelihood of being sued.”
When you can’t or won’t invest that additional two – three minutes, there is a risk of being more prone to interrupting patients, less likely to invite questions from them, and overly keen to bring an appointment to a timely conclusion. Hickson’s landmark study² identified some recurring characteristics of (in that case) obstetricians who had frequently been sued, which tended not to be demonstrated amongst their colleagues who had never been sued. For example:
- An unwillingness to listen
- An appearance of not having sufficient time for their patients, or of being rushed
- An impression of detachment, disinterest or lack of respect for the patient – and especially if coupled with any sense of arrogance on the part of the clinician
- A perceived lack of care and concern
- No ‘small talk’.
In separate studies, Hickson and his co-workers3 demonstrated that physician attitudes and behaviours, and the way patients perceived them, were closely related to the nature and frequency of complaints and litigation.
The damaging impact of interrupting
Rhoades, McFarland and Finch4, and other researchers, have highlighted a disturbing tendency for some clinicians to interrupt patients surprisingly early in the patient’s attempt to tell their story – the first interruption typically occurring after as little as 12 seconds and often within eight seconds in a study which spanned both medical GP practice and hospital interns. 25% of the interruptions were of the most damaging kind – talking ‘over’ the patient, i.e. the clinician started talking before the patient has finished talking. Training in effective listening, coupled with the availability of a little extra time, may make this less likely.
This compelling research evidence should not be dismissed on the basis that it comes from the USA and relates to medical consultations. We do face the particular handicap that dental procedures take place in the mouth, but perhaps that fact makes an even stronger case that we must somehow find some other quality time within an appointment to allow us to talk with our patients in normal, human interactions in which we can harness the full range of communication tools. Even a little extra time could make a huge difference, if we put it to good use.
For example, DiMatteo and co-workers5 looked at whether or not it was possible to predict patient satisfaction and tolerance of adverse outcomes. In a study of 500 patients, split between those who had sued their physician and those who had not, the conclusions were that:
- Patients noticed and responded to the non-verbal communication of the physician
- Patients formed views about the physician and his/her skills and level of care, based on their interpretation of that ‘body language’
- Physicians with the best non-verbal communication skills tended to engender significantly higher levels of patient satisfaction – reflected in fewer complaints and litigation
- When deciding whether or not to litigate, a dissatisfied patient would be strongly influenced by how they felt about the physician, as well as the actual treatment outcome.
“The ability to invest an extra few minutes into a consultation, and using that time to maximum effect in terms of your overall communication with the patient – consciously developing rapport, active listening and your ‘body language’ being especially important – is the best way to protect yourself against complaints, litigation and other dento-legal challenges.”
Being skilled at dentistry in a clinical and technical sense is not enough. The ability to invest an extra few minutes into a consultation, and using that time to maximum effect in terms of your overall communication with the patient – consciously developing rapport, active listening and your ‘body language’ being especially important – is the best way to protect yourself against complaints, litigation and other dento-legal challenges. At the same time, it is a great practice builder anyway – so every second counts, in more ways than one.
¹ Levinson W, Roter DL. Physician-Patient Communication. JAMA 1997.277;5533-559.
² Hickson GB, Wright Clayton E, et al. Obstetricians; Prior Malpractice Experience and Patients’ satisfaction with Care JAMA. 1994; 272:1583-1587.
3 Patient complaints and malpractice risk. Hickson et al JAMA 2002 v287 i22 p2951(7).
4 Rhoades, McFarland, Finch & Johnson. Speaking and interruptions during Primary Care office visits. Fam Med 2001 July-Aug; 33(7) 528-532.
5 DiMatteo M.R., Taranta A, et al. Predicting patient satisfaction from physician’s non-verbal communication skills. Med Care 1980;18 (4): 376-87.