Dr George Wright, Deputy Dental Director at Dental Protection, explores some causes of difficult interactions and basic strategies for handling them
For many, difficult interactions with patients remain an unattractive occupational hazard and one that can challenge even the most experienced of practitioners. Dental Protection regularly receives calls from members seeking advice on either preparing for an expected difficult interaction or dealing with the fallout from one. It will come as no surprise that the way in which a difficult interaction is handled can prove pivotal in how the patient responds.
A well-managed interaction, even following a significant disagreement or conflict, can strengthen the professional relationship. However, without careful navigation, a difficult interaction can easily escalate and precipitate a patient complaint, while also increasing the risk to the dental professional of aggression or violence from the patient.
However, it is important to recognise that with all the will in the world, some dentist-patient relationships may break down irrevocably and will require careful management to ensure a transition of care that is in the patient’s best interests.
What makes an interaction ‘difficult’?
The literature, along with our own experiences, tell us that generally, the source of any difficulty lies in one or more of four interrelating domains: the patient, the dental professional, the patient’s clinical condition, and the systems in which we work.
On any normal day, we may be able to take difficulties arising in one, or even two, of these domains within our stride. But the more domains that come into play, the more difficult it is to manage the interaction effectively – partly because we may have fewer positives to draw on to provide a counterbalance. Consider, for example, the ‘perfect storm’ of having a high-treatment need patient presenting with dental anxiety, being 20 minutes late for a 30-minute new patient examination on a day when you are short-staffed, the computers are malfunctioning, and you didn’t sleep well the previous night as your young child was unwell. Taken in isolation, many of us would be able to work unaffected by any one of these factors. However, the cumulative effect of these when they all come into play can create an entirely different context for the patient’s appointment.
Patient factors can include unrealistic expectations, differing interpretations of the same situation, extreme emotion (for example, dental phobia), or the patient’s inflexibility in relation to alternative treatment options. I recall from my own clinical practice a patient presenting with multiple missing anterior teeth and severe periodontal disease, who wished to have their teeth replaced with a 7-unit bridge. Careful discussion with the patient yielded nothing in terms of their acceptance of the situation or what in my view were the available options (none of which were a lengthy bridge supported by two grade 3 mobile premolars).
A patient’s clinical presentation and condition can also add a layer of unwelcome complexity, which might leave us feeling uncomfortable. Anecdotally at least, dentists report difficulty interacting with patients when they feel the patient’s pain is non-dental in origin or, for example, those patients with complex medical histories taking multiple medications.
System factors play a significant role in modern healthcare and are a source of frustration to many. Unfortunately, many of these factors sit outside our immediate sphere of influence and it is important to focus on the factors that can be controlled.
Research has shown in medicine that doctors[AT1] are often less empathic with patients when there are system factors causing difficulties, rather than other factors, and work on human factors in other industries such as aviation has also reached similar conclusions. For those not working in private practice, there are additional systems and process considerations that can further challenge even the most resilient practitioner. Members contacting Dental Protection for advice following a difficult interaction with a patient will often refer to systems and process factors as contributing to why an interaction evolved as it did. These might include factors such as time pressures, interruptions, availability of resources, and equipment issues.
It is interesting to note that although all dentists recognise difficult patients, individual dentists are likely to vary as to which patients they would identify as such, or the degree to which they would rate them as difficult. So, identifying and rating the difficulty is not objective, and as dentists, we ourselves form part of the equation.
An interesting study conducted in Australia identified that when asked, dentists believe that they are practising good patient-centred consultations “all the time”. Any failure or difficulty in the consultation is thus seen as an external or an ‘other’-related problem, rather than it being directly dentist related.
Dentists had no difficulty in identifying barriers to patient-centred care that arise due to systems or processes. What was less obvious to them were the behavioural factors in themselves, the patients, or the dental team that also could give rise to difficult interactions. Yet it is easier to influence the behavioural factors than it is to influence systems and processes. So, it is worth focusing on the factors that are under our control and that can be improved to reduce the risk of complaint or claim.
Sometimes it can be just a personality clash, but often it’s something in the situation that triggers our ‘hot buttons’, which may activate our prejudices, stereotyping, and assumptions. We may also have been profoundly affected in a negative way by our interactions with patients who have presented or behaved in a similar way to the patient before, and this may significantly influence our attitude and ability to handle the interaction.
Examples include the patient who is always cancelling appointments, the patient who does not pay on time, or the patient who only uses you in an emergency. Our degree of training in handling difficult interactions is also a major factor.
It is interesting that people in service industries receive a lot of training around handling difficult situations. Do we, as healthcare professionals, receive the same level of training?
Our own resilience can be affected by our own emotional baggage and a patient that might not otherwise have created a problem becomes a ‘difficult’ patient. This might also explain why difficult patients to one person might be easy-to-manage patients to another. All of this is harder when we are Hungry, Angry, Late, Tired, Energy depleted, Distracted.
Choosing your response
Dental research has shown that the impact of difficult interactions contributes to stress, and this creates long-term physiological and psychological phenomena if not managed correctly. Difficult interactions tend to create a feeling of discomfort. The original work of Corah and O’Shea on dentists’ perception of problem behaviours in patients listed various behaviours that can be very annoying for dentists. These included patients devaluing, being critical of, or questioning a dentist’s performance. Because such behaviours are likely to result in feelings of personal assault on the dentist’s part, they are likely to have a deleterious effect on the patient-dentist relationship.
It is helpful to be aware of your own warning signs – signs that your emotions are starting to affect your behaviours. For example, what do you do when you get angry? The consultation is a dynamic interactive process, and patients and dentists will respond to each other’s behaviour in ways that will either help or hinder the interaction.
An interesting study by Thierer, Handleman and Black in 2001 assessed the relationship between dentist communication behaviour and their perception of patient attributes such as likeability, manageability, and prognosis. The result suggested that dentists alter their communication behaviour depending on their assessment of various patient qualities.
There are already branches of communication that look specifically at these situations, for example neurolinguistic programming, which recognises that people have different filters through which they see the same situation, which predetermines their reaction. Is your reaction different when you like or dislike a patient or with someone who fails to attend an appointment? It is an innate human trait that if you don’t like someone, you will often show it.
Effective skills and strategies
Making a careful and considered diagnosis of the difficulty is a critical step in having an effective response. One of the most effective strategies in managing a difficult interaction is to recognise our own reaction. Our automatic reaction may be telling us things like “this person is a nuisance” or “this person is uninterested in their oral health”. Such reactions may be correct or incorrect, however, they are not helping us to manage the situation. On the contrary, they may be interfering with our self-control and self-confidence, and our ability to demonstrate the necessary support skills.
Various support skills can help to effectively manage a difficult patient interaction. The first of these is active listening, which involves two key components: open-ended questions to encourage the patient to tell their story, and reflection of content back to the patient, including short summaries and acknowledgement of emotions. We try to give a considered response. This may take some time but trying to objectively define the problem, name it, and externalise it from the patient and the dental professional can provide the backdrop to managing it effectively. It may be useful for the dental professional to take time out by, for example, reviewing radiographs or records while quietly going through this analysis of the difficulty.
One of the problems in a difficult interaction is that there might be a tendency to plan your response while listening to the patient. It is important to listen without distraction and to concentrate on demonstrating to the patient that you are listening. It can be particularly difficult to actively listen to a patient when you feel the patient is wrong, because there is a tendency to immediately react and put the patient right.
Active listening allows us to move past assumptions and stereotypes to what is the reality for our patients. A patient who feels listened to is much more likely to engage.
The second of the key support skills is empathy. Empathy is the patient’s perception of being heard and understood and is inferred by the clinician’s good listening behaviour, body language, summarising of the story, and reflecting of their emotion. It is also based on working on the agenda that is important to the patient. Active listening is a critical component of conveying empathy.
It is possible to be empathic with a patient even if you disagree with what the patient is saying or find it difficult to be sympathetic to their plight. The beauty of empathy is that it can be applied to situations even where you are uncomfortable. Conveying empathy is a powerful way to increase the feelings of support of patient experiences.
Another key support skill is reframing. This is a technique used in psychology, where a therapist might ask a patient to consider a different explanation for their concern, knowing that doing so may well reduce their distress. To consider alternative explanations for a patient’s behaviour or attitude might allow us to approach that patient in a more objective or neutral manner. The interesting thing about reframing is that the alternative explanation does not have to be true, just as our immediate autonomic reaction to the patient may not be based on truth either. All we are trying to do in this situation is to open ourselves to the patient and in particular the patient’s needs.
An example of this is the patient who is quite hostile at your inability to find the source of pain, and where you label the patient simply as a ‘difficult and impatient’ person. The reality is that by reframing, that patient may be dealing with anxiety, but also a more serious disease that they have not been able to articulate to you.
When faced with a patient with whom you anticipate a difficult interaction, the above ‘theory’ can very quickly be forgotten, and we can default into ‘defence’ or ‘attack’ mode. A simple step to take towards de-escalating conflict is to first acknowledge how the patient is feeling. By doing so, you can demonstrate to the patient that you have actively listened to their concerns, and it allows you to check understanding. From here, it may be helpful to inform the patient of your position, clearly stating the reasons, and respectfully explaining any boundaries. Finally, if done effectively, you will be able to move with the patient to discussing a way forward. At this point, it can prove invaluable to empower the patient to propose possible options, albeit with some gentle encouragement. By taking this approach, patients are more likely to feel they are in control of the situation and are more accepting of the resolution they have jointly reached.
When preparing for a recent Dental Protection event, I was reminded that with only a few seemingly minor alterations to the course of an appointment, a situation can rapidly become disproportionately difficult and escalate beyond our control. While such a day is thankfully extremely rare in practice, we will all come across difficult interactions from time to time.
Every patient is different, just as every dental professional is different, and many will have found a process that works for them – often through trial and error – for dealing with a difficult interaction. Hopefully with a few tools, both to reflect on why a situation is apparently difficult and to provide some basic steps to follow when approaching a difficult interaction, dental professionals need not fear these interactions and can be empowered to resolve them amicably.