Knowing your patient, Part I, The role of empathy in practicing dentistry
This is another in a series of master's articles. Harold Wirth was the best at talking or writing about "Knowing your patient". It was a treasure to hear L.D. Pankey and Harold Wirth present the philosophy. Read on for what a master says.
This article appeared in Continuum '80 and is used with the permission of The Pankey Institute.
Knowing your patient - Part I - The Role of Empathy
Knowing your patient is one arm of the Cross of Dentistry, Dr. Pankey’s application of the Cross of Life to our profession. In my opinion the most difficult part of that cross is “Know Yourself” and the most neglected is “Know Your Patient.”
The first is the prerequisite of the second: To know your patient you must first know yourself. The better you know yourself, the better you can analyze yourself, and the more astute you will be in understanding another person.
Of course, understanding implies communication, an art often thought to consist primarily of carefully chosen words and appropriate tone of voice. However, the crucial element in communication between dentist and his patient has nothing to do with vocabulary or voice. Those qualities have their roles, but it is how you feel that ultimately determines success or failure.
In my opinion the most difficult part of that cross is 'Know Yourself' and the most neglected is 'Know Your Patient'.
--Harold Wirth, DDS
A good patient is one to whom the dentist can relate; a bad one is one to whom he’s not able to relate. It’s up to the dentist to adjust his personality to the patient, though most try to make it work the other way around. Getting to know your patient is rewarding, stimulating, and fun – it’s also an important challenge.
The Role of Empathy
The best communication in any relationship is based upon empathy. The Golden Rule says ”Do unto others as you would have them do unto you.” The Empathic Golden Rule says, “Do unto others as if you were the other person.” Freely translated, the rule enjoins us to know that person, take the time to get to know him so we can think as he thinks, feel as he feels.
Many dentists find this difficult, usually because they’re reluctant to ask questions beyond the “name-age-date” level. This is at best superficial and leaves you treating a stranger represented by a set of labels and statistics, you must engage in the sort of interpersonal exchange that has been termed “preclinical examination” or “history taking,” but I choose to call “the interview.”
Anyone can take a history; handing the patient a form to fill out will accomplish that. An interview, on the other hand, must be conducted by someone trained - self-trained-in the art of relaxing his subject, getting to know him, turning him from frightened adversary into a conversational companion.
It sounds awesome; it sounds difficult. It probably is the most important part of the dentist - patient relationship. If you’re talking with a patient and can identify to the extent of thinking, “If I were he, knowing what I know about dentistry, how would I want to be treated?” then you have achieved empathy. This is the beginning of trust.
Once achieved, empathy communicates itself almost automatically, with a minimum of words. The patient will sense your empathy and tell you anything you want to know.
The interview should be a continuing process rather than a single encounter. Every time you see the patient, your relationship - and the empathy you have taken care to establish - can be reinforced. A friendly inquiry may be sufficient:” How are you doing?” “Have you been comfortable?” “Are you enjoying your meals - or does chewing cause you pain?” The interview should be a continued attempt to know how the patient feels.
No two people experience physical sensations in exactly the same way. The dentist may think the patient should not have had much pain, but that person’s pain threshold is unique, individual unto him. He may have suffered a great deal of physical distress. The only way you can absorb these aspects of a person is to maintain and deepen the level of care you project at the initial interview.
Watch for little signs and symptoms: Is the patient nervous? Apprehensive? Tense? No one is at his best when he goes to the dentist. He may have survived more serious traumas in the past, but on that day the dental appointment is his low point. The determining factor is not just fear - all patients have some apprehension - it’s the degree of fear that make you strangers. Strive to make every patient a friend.
If you can follow the adage that you should never treat a stranger, that you should know the patient, you’ll be surprised at the difference it will make.
What is the basis for fear? Often, it’s the unknown. As knowledge grows, it produces trust, a strong counterweight to fear. For this reason I try to use knowledge to incorporate trust into my relationship with every patient. It becomes the love aspect in the Cross of Life: Work, Play, Love, Worship.
If you love your patients, in the sense that his well being contributes to your own, you care. The patients know you care - you probably couldn’t hide it if you wanted to. The exchange of feelings inevitably leads to trust. And care and trust dissolve fear.
The sociologic changes I have observed in more than half a century of practice are so awesome they frighten me. Trust and care are practically obsolete. The prevalent feeling today is that nobody cares about you; you can’t trust anyone. You haven’t even the luxury of neutrality - suspicion and distrust have become second nature to even the most optimistic of us.
Trust has become so scarce a commodity that any dentist who earns a reputation for caring and being trustworthy will quickly acquire as many patients as he can handle. Why? Because people still cherish the values that seem to have been lost and are overjoyed to learn that care and trust still exists.
Knowing your patient may begin as a one sided effort on your part, but it soon becomes mutual. If you project your trust to the patient, he will - subconsciously at first feed it right back to you. He will begin to care about you and trust you as you care about him and trust him. Soon like a reversible equation, you will be automatically exchanging the essential elements of a mutually sustained relationship.
Unfortunately, some dentists tend to destroy trust even before it has a chance to take hold. They ask for a down payment, saying, in effect, “I don’t trust you.” They ask for another part of the fee at a prearranged interval, again saying, “I don’t trust you.” They are not selective, neglecting to get to know which patients are conscientious and which must be periodically prodded. Indiscriminately treating all patients as poor credit risks does a good deal to precipitate distrust or increase whatever skepticism already exists.
There are some obvious characteristics in patients - in people in general - that are projected. If you really care, you can begin to recognize them in advance. Such little things as the way a person dresses and walks, or his choice of words and tone of voice,
can give you a head start.
Very generally, the outward manifestations of personality can be divided into three categories: A given person is seen as an introvert (shy and withdrawn), and extrovert (gregarious and verbose), or am ambivert (a combination of introvert and extrovert), often a balance, occasionally a see-saw of extremes. Its important to recognize each of these in the dental office. Many a dental appointment is made in good faith, only to be broken at the last minute. The dentist doesn’t understand why it may very well have been because he failed to pay attention to the type of person with whom he was dealing.
Though we all see an occasional shrinking violet or bellowing loudmouth, these extremes are just that—poles at the opposing ends of a long range or personality amalgams. About 85 percent of people are ambivert, both extroverted and introverted—but not necessarily in equal proportions. A given person may be more introverted under some circumstances and more extroverted under others. And, as if to compensate for each other in a delicate psychological balancing act, opposites tend to attract.
The ambivert who favors his introverted side is likely to marry a more extroverted person - even though the spouse, too, is an ambivert. But someone makes the decisions in every family, and it’s not necessarily the man.
In the dentist’s office, it’s not necessarily the patient. If you make your case presentation and receive acceptance from a introverted ambivert, you may be wasting time and inviting stress for all concerned. If such a patient goes home and timidly tries to reiterate what he or she was told or heard or understood, the decision-maker, the extrovert, may respond with an emphatic “No!” Result: The whole series of appointments may be cancelled. It happens all the time. But that problem is not difficult to handle because its resolution all comes back to knowing your patient.
For example, suppose the patient is a married woman. If she gives me any reason to suspect that she is not the decision - maker in the family, I’ll say, “The next time you come I’ll have all the information together, radiographs and diagnostic casts, the result of my clinical examination, and I’ll have a treatment plan worked out for you. When I present that plan I’d like to have your husband here with you so we can all agree on and understand the best way to proceed. He’s welcome. Maybe you should arrange an appointment that’s convenient for both of you.”
This is a very simple way to learn who makes the decisions. If the woman says, “That’s not necessary. I’ve made up my mind, and its going to be all right,” then I know I’m talking to the right person. On the other hand, she might blanch at the suggestion, saying, “oh, no, my husband never goes to the doctor, never goes to the dentist. I’m always the one in trouble. He’s very busy. He just doesn’t understand this kind of thing.”
The husband won’t come. But I’d better get him sometime because she’s afraid to even tell him. And if she’s that afraid, there’s going to be confrontation somewhere along the line, because there’s going to be a fee involved. A lot of unpleasantness can be prevented by settling the matter at the outset. But you have to keep the communication free-flowing.
The interview needn’t be lengthy or complex. Its aim is education, empathy, and the beginning of mutual trust. You don’t have to give each patient a 300-point questionnaire. Your not interested in that much detail. A skilled interviewer can obtain all the necessary information in 15 or 20 minutes. Thirty minutes is a long time. And I consider this to be the most profitable 15, 20, or 30 minutes the dentist can possibly spend with his patient.
Part II will follow