Dr Annalene Weston, Dentolegal Consultant at Dental Protection, looks at the communication skills required for those challenging conversations
It is a regrettable truth that difficult conversations can and will occur, and worth considering that we don’t just have difficult conversations with patients, but also with their partners, or parents and carers, and with our colleagues and staff too. The purpose of this article is to consider what makes a conversation difficult, and what steps we can take to prepare ourselves.
What does make a conversation difficult?
There are a number of factors that can influence the difficulty of a conversation. It is important to note that as with many things in life, what may be difficult for me, may not be difficult for you, and what may be difficult for me one day, may not be difficult for me on another.
One consideration to raise is that it will always be difficult to break bad news, even for the most skilled communicators; in the practice of dentistry, regretfully we have to break a lot of bad news to patients. That aside, it would be fair to say that the difficulty of the interaction is a direct result of the interplay between four factors.
It is manifestly unfair to label someone a ‘difficult patient’ or ‘difficult person’, and far better to simply acknowledge that this person is ‘difficult for me’. Naturally, however, there are patient factors at play in a difficult interaction. Communication can just be difficult, perhaps due to the patient’s overarching fear of you and the environment that they find themselves in, perhaps because you are not speaking the same first language. Consider how excessive technical talk can act to hinder good communication. There can be no doubt that some cultural barriers can also exist when it comes to having a conversation with a patient, and it is always important to take the time to understand any appropriate cultural context as best you can, particularly if the culture is one you have not been exposed to before.
Some of the communication issues related to the patient themselves can be due to their personality type, and we have all experienced a situation where the patient has unrealistic expectations or fixed and rigid views regarding the nature and type of treatment we can provide, and what their outcome is going to be. This can also be based on their prior experiences with colleagues, some of which may not have been favourable. Other patients can demonstrate this as they have such a strong internal locus of control that they cannot let you advise them, or conversely, such a strong external locus of control that they refuse to make decisions, attempting to pass all of that responsibility on to you, the clinician.
It is incredibly challenging to communicate well in an unruly or disruptive environment, whereby we are suffering with constant interruptions particularly in a ‘bad news breaking’ situation. Lack of privacy can impact on the quality of a conversation with a patient. Think about how hard it is to talk to someone when you are trying to reboot your system while maintaining a constant explanatory stream. Distraction, whether yours or on the part of the patient, will lead to ineffective communication – have you ever tried to talk to a patient who is glued to their phone? It is impossible.
Sadly, many practitioners have described to us circumstances where they are under the scrutiny of a third party such as their employer, who does not approve of trivialities such as talking with patients, and will clock watch and pester them if they are perceived as talking too much.
A great team around us can make our job smooth and be such an advantage when it comes to communicating well and offering good quality care. Conversely then, a poorly functioning toxic team will leach into every interaction you have, and impact on your communication style and ability.
We do not exist in a vacuum and try as we might to keep our private and work lives separate, the boundaries will, from time to time, lose distinction. Dealing with patients when you are dealing with personal stress is a challenge, and there can be no doubt that stressed out and burned out practitioners do not communicate as well as they do when they are on an even keel. This means that they receive more complaints, at a time in their lives when they least need it. It doesn’t even need to be a big influencing factor to negatively impact our communication style. Getting caught in traffic and arriving to work late and grumpy can be a recipe for a difficult day, peppered with terse patient interactions.
Essentially, there are two types of difficult interactions – ones you knew were going to happen and ones you did not. We would call these planned and unplanned difficult interactions.
Planned difficult interactions
Planned interactions are always preferable, as you know they are going to happen. You know that a patient is on their way in with an issue after your treatment, so you can prepare yourself and your environment for that. Another good example is having to tell a colleague that you have seen one of their patients and that there are problems with the care they provided. A challenging discussion to have, so one we would plan if we can.
It can be incredibly helpful to have some idea of the words you are going to use, or, in the case of a patient, the solutions you intend to offer them. We definitely can and should choose our words wisely. There are other elements that would not necessarily be obvious at first blush. For example, choosing your venue and your audience. Consider – do you want to have a heated discussion with a patient in the waiting room, in front of all the other patients who are scheduled that day? Our experience tells us it is far better to find a private space for the conversation, away from prying eyes, and one where the patient can feel comfortable. Remember, many patients are scared of the dental surgery environment – do you have an office space you can talk with them in instead? If you do, the interaction will likely go a lot better.
The audience can be a critical component. With a patient, it’s best to be chaperoned if possible, preferably by a calm and sensible staff member who is not going to be more of a distraction than a support to you. But what about a discussion with a colleague? Simply put, take this away from all staff if you can, maybe even away from the practice, as you do not want your colleague to feel that everyone has been talking about them, or poking fun at them behind their back. That would be an awful way to make someone feel and, respectfully, is not going to help you achieve your desired outcome of setting out your concerns for your colleague in a way that they listen to and respond to meaningfully.
You also need to choose to respond rather than react. Difficult conversations are stressful, and stress can limbically hijack us and cause us to lose higher function thinking. Loss of this occurs as the switch has been flipped on our sympathetic nervous system, and as adrenaline and cortisol start coursing through our systems, we are now in a full fight or flight reaction. While it is possible to have a meaningful conversation under these conditions, it is a lot harder than if we are cool, calm and collected. Choosing to respond, and squashing the fight or flight reaction, will invariably lead to a smoother outcome to the conversation.
Unplanned difficult interactions
If you are unaware that the interaction was about to occur, you have essentially lost control of some of the elements of this interaction. Consequently, it is critically important that you do not lose control of yourself. That limbic hijacking needs to be kept in check as far as is possible, so our fight or flight reaction can be managed. Do not underestimate the value of a few deep breaths here to help you stay calm and keep your head clear.
Bear in mind that your audience is judging you and your professionalism based on how you handle this interaction. Also bear in mind that in this day and age it is likely you are being illicitly filmed on someone’s phone. While this is a breach of the legislation across most of the States and Territories, it is hard to take the video back when you have become the latest YouTube sensation, and have been turned into a meme. Not what any of us would want or hope for.
Consequences of difficult interactions
The professional consequence of a difficult interaction can be a complaint, and while many of these complaints will be low level ones made at the practice, some will be escalated to the regulator. The code of conduct is the overarching guidance framework that sets out how we are expected to behave, and the regulator takes a dim view of those who do not communicate respectfully with their patients.
Also of concern are how difficult interactions can make us feel and, simply put, when things don’t go well, we feel bad. Bad about ourselves and sometimes bad about the situation or the patient. Needless to say, the consequences of these difficult interactions can be cumulative, and a snowball effect can occur, where we are so disenchanted it almost becomes impossible to have healthy interactions with patients and colleagues. This can seep into our personal life too.
In all, it is far better to try to pre-empt difficult conversations in difficult situations, and manage them, and ourselves, as best as we can.