Communication Skills for Dental Health Care Providers

Communication Skills for Dental Health Care Providers

Lance Brendan Young, PhD, MBA

Assistant Professor
Department of Communication
Western Illinois University-Quad Cities
Moline, Illinois

Cynthia Rozek O’Toole, MS, RDH

Assistant Clinical Professor
Department of Preventive and Community Dentistry
The University of Iowa College of Dentistry
Iowa City, Iowa

Bianca Wolf, PhD, MPH

Associate Professor
Department of Communication Studies
University of Puget Sound
Tacoma, Washington

Library of Congress Cataloging-in-Publication Data

Young, Lance Brendan, author.

  Communication skills for dental health care providers / Lance Brendan Young, Cynthia O’Toole, and Bianca Wolf.

      p. ; cm.

  Includes bibliographical references and index.

  ISBN 978-0-86715-690-4 (softcover)

  eISBN 978-0-86715-936-3

  I. O’Toole, Cynthia, author. II. Wolf, Bianca, author. III. Title.

  [DNLM: 1. Communication. 2. Dentist-Patient Relations. 3. Attitude of Health Personnel. 4. Clinical Competence. 5. Cultural Competency. WU 61]

  RK28.3

  617.6001’4--dc23

2015018425

© 2015 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc
4350 Chandler Drive
Hanover Park, IL 60133
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5 4 3 2 1

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Leah Huffman
Design: Ted Pereda
Production: Angelina Sanchez

Contents

Preface

Over the past 10 years, the three authors of this book have taught patient-provider communication skills to the dental students at the University of Iowa College of Dentistry. In addition to our academic training, each of us has different real-world experience, ranging from clinical dentistry (O’Toole) to health insurance (Wolf) to business marketing (Young). We therefore recognize the value of basing practical decisions on sound research. Recent years have seen tremendous growth in research on communication between dental professionals and their patients. Individually and collectively, however, we have been frustrated by the lack of a single resource presenting the most reliable and recent evidence to suggest how dental providers should interact with their patients.

In developing and refining our curricula at the university, we located four books published within the previous 30 years that address communication in the dental setting.^1–4 Although each text has its strengths, they all lack recent, evidence-based findings to support the communication practices they recommend. The communication patterns and expectations of patients have changed over time, so research conducted in the 1970s and 1980s may be less reliable than research conducted more recently. Further, demographic changes have resulted in patient diversity unknown to previous generations of oral health professionals. Diversity challenges current dental providers to develop flexible communication skills; scripted communication will not work.

The lack of a dental communication textbook left us scouring research journals for information we believed our students should know before they began practicing on patients. Having received positive feedback on the curricula we developed, we wrote this manual so that other dental professionals may benefit from our work.

Because we exclusively teach future dentists, our focus in writing has been patientdentist communication. We can think of few instances, however, in which the evidence-based communication skills described in this book do not also apply to dental auxiliaries, including dental hygienists, dental therapists, and dental assistants. We are familiar with one text addressing communication for dental auxiliaries,³ but it was published 30 years ago and is long out of print. Until another such book is published, we feel comfortable recommending our manual for dental auxiliaries who want to improve their skills in communicating with patients. Throughout this manual, we typically refer to dental or oral health providers and professionals, implying every member of the dental team but particularly the dentist.

The dental students we teach have completed an undergraduate degree, so most of them have taken at least one course in communication studies. Similarly, dental auxiliaries may have taken a communication course during or after high school. Therefore, this manual is written for readers with a basic understanding of communication theory and skills. We assume, for instance, that a reader advised to “make eye contact” does not need to be told how many seconds of eye contact are appropriate. We encourage readers who need more basic instruction in culturally appropriate communication to take an introductory course in communication.

Research into dental provider–patient communication is growing rapidly, yet it still lags behind research into physician-patient communication. The two contexts share many similarities, yet we are aware that they are not identical. In seeking research to support the skills we advocate for dental professionals, we attempted to locate recent articles using dentists or dental hygienists as participants. When such research has not been conducted, we relied on communication research using other medical professionals (eg, physicians or nurses). All such research is cited. In areas where research has not been conducted or is inconclusive, recommendations are based on clinical experience, observation, and feedback from dentists, professors, and students. Such recommendations are experience based and have no citation.

All three authors have completed extensive coursework in public health and highly value the behavioral change theories in which so much patient-provider communication research is grounded. We have introduced our students to the more popular theoretical models (eg, the transtheoretical model, the health belief model, and the parallel processing model). Results were mixed. Although students appreciate that these models provide a valid conceptual framework for encouraging patients toward healthy dental behaviors, they prefer that limited class time be devoted to specific recommendations for interacting with patients.

Given the considerable demands on the time of the dental students and professionals to whom this book is targeted, we have opted to write it as a practical manual instead of a comprehensive textbook. We therefore focus on specific communication skills and strategies rather than on the theory underlying them. The research cited throughout the book includes material that will appeal to those interested in exploring theories on health behavior.

Research suggests that much patient-provider communication training is not grounded in evidence.⁵ We wrote this book as a practical manual introducing dental students and professionals to evidence-based suggestions for effective patient communication. Readers vary in their communication skill level, and dental colleges vary in their instructional emphasis, so we have written each chapter to be comprehensible even if the other chapters are not read.

The manual consists of four parts. Part I presents fundamental communication skills for dental professionals. Part II presents those skills as they are applied in specific types of patient interactions. Part III presents chairside strategies to facilitate communication with patients during each stage of a regular appointment. Part IV presents situations that sometimes challenge dental professionals and offers communication strategies for managing such challenges.

This book reviews broad skills and presents specific strategies for optimal patient-provider communication. To enhance comprehension and retention of the material, each chapter includes activities such as exercises, discussion topics, and self-tests. In addition, because patient communication involves professional ethics, common ethical dilemmas are included throughout the text in a feature called “Question of ethics.” This feature fosters ethical behavior by enabling readers to consider how to respond to ethical dilemmas before they happen. Finally, checklists are now the state of the art in health care, so in lieu of chapter summaries we have included a checklist near the end of each chapter to provide a quick summary of the recommended communication strategies.^6,7

References

1. Geboy MJ. Communication and Behavior Management in Dentistry. Philadelphia: Decker, 1984.

2. Jameson C. Great Communication Equals Great Production, ed 2. Tulsa: PennWell, 2002.

3. Wiles CB, Ryan WJ. Communication for Dental Auxiliaries. Reston, VA: Reston, 1982.

4. Chambers DW, Abrams RG. Dental Communication. Sonoma, CA: Ohana Group, 1992.

5. Veldhuijzen W, Ram PM, Van Der Weijden T, Wassink MR, Van Der Vleuten C. Much variety and little evidence: A description of guidelines for doctor-patient communication. Med Educ 2007;41:138–145.

6. Gawande AA. The Checklist Manifesto: How to Get Things Right. New York: Holt, 2009.

7. Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: Designing the WHO Surgical Safety Checklist. Int J Qual Health Care 2010;22:365–370.

About the Authors

Lance Brendan Young, PhD, MBA

Dr Young is an assistant professor at Western Illinois University. He earned a master of business administration from Tulane University and worked in marketing for 14 years before enrolling at the University of Iowa, where he earned his doctorate in communication studies with an emphasis on health communication. He completed a 2-year postdoctoral fellowship with the Veterans Health Administration. He has also been a visiting assistant professor at the University of Iowa College of Dentistry, teaching patient-provider communication to dental students. His research has appeared in the Archives of Internal Medicine, Culture and Psychology, the Journal of Gerontological Nursing, and the Journal of Telemedicine and Telecare.

Cynthia Rozek O’Toole, MS, RDH

Ms O’Toole has worked at the University of Iowa College of Dentistry for 29 years. In addition to her clinical duties, for several years she has taught the communication curriculum to first-, second-, and third-year dental students. She contributed to the development of the communication curriculum for the first- and second-year students and single-handedly redesigned the standardized patient curriculum for the third-year students. She has secured several grants to implement innovative curricular enhancements through technology (eg, videotaping of patient interactions) and through diversity training (eg, Hispanic and deaf/hard-of-hearing patient awareness).

Bianca Wolf, PhD, MPH

Dr Wolf earned a master of arts in communication from Arizona State University and worked in the health insurance field for several years before entering the University of Iowa, where she earned a doctorate in communication studies and a master of public health degree, focusing on community and behavioral health. She taught patient-provider communication at the University of Iowa College of Dentistry. She is currently an associate professor of communication studies at the University of Puget Sound. She has presented her research on patient communication about cancer and other illnesses at regional, national, and international conferences. Her research has also appeared in Qualitative Health Research, the Journal of Social and Personal Relationships, and the Journal of Family Communication.

This first section introduces key concepts that are fundamental to effective chairside communication with patients. Individuals who develop communication skills without first understanding communication or their audience may express themselves in a way that sounds insincere or even aggressive. Effective communicators understand how communication functions and can anticipate how it might function with a specific patient in context. This section provides an overview of health communication and its importance to patient-centered care (chapter 1), describes patients’ perceptions of dentistry (chapter 2), and discusses cultural influences that shape patients’ communication patterns (chapter 3).

1

Understanding Communication

Why Communication Matters

This initial chapter provides a rationale for studying patient-provider communication. However, this manual is focused on skill acquisition, so we feel it is best to present the rationale as a competence to master instead of simply listing the reasons why you should read our book. The rationale-as-skill concept becomes clearer to us the longer we teach dental students. Let us explain.

When people ask what we do, we reply that we teach patient-provider communication skills to future dentists. Usually, the responses fall into one of two categories. Some people are completely baffled and ask to know what we mean. Others make a lame attempt at humor: “It should be pretty easy to communicate with dental patients because they can’t talk back!” We have heard many variations of this theme and try to smile every time.

In truth, the fact that dental patients are often restricted in their verbal expression makes instruction in communication more important, not less so. Communication is far more than rattling off the latest sports scores while manipulating dental instruments in a patient’s mouth. The quality of patient-provider communication determines a wide range of outcomes, including satisfaction, treatment adherence, information comprehension and recall, and ultimately oral health.¹ For this reason, we have developed a skill of explaining and illustrating the importance of effective communication with dental patients. Those who work in a dental office—as a dentist, hygienist, assistant, or receptionist—should master this skill so that all of the practice’s employees will better understand the value of effective patient communication.

The fundamental communication lesson professionals must learn is that they cannot assume that everyone understands a message in the same way. To apply this lesson to the task at hand, we will explain and explore four key concepts: (1) communication, (2) health communication, (3) patient-provider communication, and (4) patient-provider communication in dentistry. For each concept, we will define the key term and analyze its implications and associated goals.

What Communication Is

Definition of communication

People from varying disciplines have defined communication in vastly different ways, from the mechanical definition that relates communication to audiology and broadcast transmission, to the philosophic definition that ties it to ontology and epistemology.^2,3 Between mechanics and philosophy is a social science discipline, which acknowledges both the concrete realities of message transmission and the varied ways humans interpret the meaning of messages. A good working definition has been provided by Stoner et al⁴: “Communication can be defined as the process by which people share ideas, experiences, knowledge and feelings through the transmission of symbolic messages.” Four aspects of this definition are particularly important for dental professionals to keep in mind: (1) communication is a process, (2) communication is multifunctional, (3) communication is multichanneled, and (4) communication is not always intentional.

Communication is a process

Often, communication is understood as individual expression. However, when people view communication as a singular act of self-expression, they risk treating other individuals as mere witnesses or audience members, rather than people with whom they are building a relationship. The working definition on page 4 clarifies that communication occurs only when two or more people are mutually involved in a process of sharing. Dental professionals must remember that effective communicators cannot rely on a script to build relationships.

Communication is multifunctional

The messages shared when providers and patients communicate perform many functions, often simultaneously⁵ (Table 1-1). Because communication is a process, achieving those functions depends on both the way a message is sent and the way it is received. Dental professionals must remain aware of their communication goals and listen to patients for indications that the goals are being achieved.

Table 1-1 Functions of communication

Communication is multichanneled

Too often, people think that communication is synonymous with speech, but messages are transmitted through multiple channels, both verbal (speech and writing) and nonverbal (appearance, gesture, and facial expression, among others). Those channels usually operate simultaneously. Dental professionals must remember that some channels are better suited to certain messages than others and that messages sent through one channel should not contradict messages sent through another.

Communication is not always intentional

Another misconception is that communication is restricted to messages we intend to send. While it is true that intentional communication is valuable, any behavior can transmit a message, regardless of intent. Even complete passivity—the refusal to act—communicates, leading some to argue that humans cannot help but communicate. Further, the definition suggested by Stoner et al⁴ acknowledges that we communicate with others through symbols (such as words or gestures), and symbolic messages are effective only insofar as they hold similar meaning for both sender and receiver. This is perhaps the hardest lesson: Dental professionals are constantly communicating, and they have limited control over how messages are received. However, the chance that patients will receive the intended message can be improved if dentists enhance their skills of expression and patient monitoring.

Health Communication

Definition of health communication

The study of communication contains numerous subfields. Some of those subfields are differentiated based on message context or subject matter, such as family communication and environmental communication. Health communication is a subfield that has expanded tremendously in recent decades, as researchers and clinicians observed its impact on patient health. Definitions of health communication vary widely.⁶ The Centers for Disease Control and Prevention provides a useful definition: “Health communication is the crafting and delivery of messages and strategies, based on consumer research, to promote the health of individuals and communities.”⁷

Health communication can be further divided based on the number of people involved in the communication: mass communication, organizational communication, small group communication, and interpersonal communication. In this manual, we will address interpersonal communication in the patient-provider dyad (or pair).

Activity 1-1

Healthy People 2020

Healthy People is a government-sponsored initiative that uses scientific research to identify national health needs, establish benchmarks and 10-year goals, and monitor progress toward those goals.⁸ Healthy People 2020 has identified numerous measurable goals in 42 topic areas. The topic area of “health communication and health information technology” includes 13 goals (Box 1-1).

*Reprinted from the US Department of Health and Human Services.⁸

Patient-Provider Communication

Definition of patient-provider communication

Health communication contains numerous domains, including public health campaigns, social influences on health, and communication between medical professionals. The domain of patient-provider communication is communication between two people assuming the roles of patient and health care provider. Typically, it involves the face-to-face exchange of medical information. Recently, however, advances in communication technology have challenged providers to develop communication skills outside of the office through media such as email, text messages, and instant messages. As cultural emphasis shifts away from formality and privacy, providers must determine appropriate boundaries between professional and personal communication while adhering to the requirements of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).⁹

Activity 1-2

The patient-centered health care delivery model has focused on the importance of patient-provider communication.^10,11 Often promoted as evidence-based medicine, the traditional model is “diseased-centered” care, emphasizing diagnosis, symptoms, and treatment, rather than the patient.^12,13 Three characteristics distinguish patient-centered care from disease-centered care.¹⁴ First, in addition to biologic influences, patient-centered care acknowledges psychologic and social influences on health.¹⁵ Second, patient-centered care entails decision-making that involves both the patient and the provider.^16,17 Third, patient-centered care encourages an ongoing relationship between the patient and the provider.^18,19

Patients with a regular care provider rate provider relationships more positively than do those without consistent sources of care.²⁰ An ongoing relationship between a provider and a patient is associated with multiple advantages for the patient, including enhanced satisfaction, treatment plan adherence, and trust.^19,21 In turn, the health care provider benefits from long-term patient relationships because accurate diagnosis and treatment are easier to accomplish when a patient’s history and behavioral habits are well known. Further, loyal patients enhance a practice’s financial stability.

Question of ethics: Patient-centered health care acknowledges the patient’s right to determine treatment, but the treatment plan selected by the patient may not be the plan endorsed by an evidence-based health care approach. When such a conflict arises, what options are available to the health care provider? How does the provider proceed ethically?

American Dental Association guidelines

Patient-centered care and evidence-based care increasingly overlap in formal research studies of patient-provider communication. Innovative research designs—measuring interaction and its impact on patient health—have given rise to a large and growing evidence base of effective ways of engaging patients. Consequently, interest in this subfield is likely to increase.²² The communication style practiced by a health care provider is now recognized to have a significant influence on patients’ health outcomes. Therefore, simply assuming a lackluster “bedside (or chairside) manner” is no longer acceptable.

In 2009, the American Dental Association’s Council on Ethics, Bylaws and Judicial Affairs drafted the Dental Patient Rights and Responsibilities to guide dentist-patient relationships. The statement lists 9 patient responsibilities and 13 patient rights. The statement highlights the centrality of communication to the relationship between patients and dental professionals. Of the nine patient responsibilities, the first four address communication directly: providing accurate information, providing feedback, participating in decisions, and asking about treatment options. The list of patient rights includes even more communication-related elements, indicating the high expectations for a variety of communication skills among dental professionals (Box 1-2).²³

Box 1-2 American Dental Association Statement of Dental Patient Rights*

*Adapted from the Council on Ethics, Bylaws and Judicial Affairs, American Dental Association.²³

Patient-Provider Communication in Dentistry

Similarities to other medical contexts

Patient-provider communication in dentistry shares many similarities with patient-provider communication in other medical contexts. For instance, the primary relationship is between the dental or medical professional and the patient, although secondary relationships are sustained with others such as auxiliaries on the team, specialists, patient caregivers, and significant others. Also, the primary communication environment is the dental operatory or physician’s office, although advances in communication technology are expanding the options of both time and place at which providers can communicate with patients. Finally, the primary goal of the communication is the health of the patient.

In addition to the three similarities noted above, it is worth considering the ways in which disclosure in both dentistry and other medical contexts differs from typical dyadic (two-person) communication within social relationships. All medical professionals must become accustomed to three particular characteristics that are quite different from usual interpersonal communication. First, patient-provider communication is characterized by asymmetric disclosure. In social interactions, communicators expect to contribute equally to the conversation, but in medical encounters, patients disclose more than the provider. Second, high-level disclosure characterizes these interactions.^24,25 Doctors should be prepared for patients to reveal information to their doctors that their closest friends may not know. Third, rapid disclosure is a feature of patient-provider communication. Within minutes of meeting a provider, patients may quickly report details on their health and habits.

Question of ethics: Research indicates that provider communication influences patient satisfaction. Is it ethical for a provider to communicate poorly with challenging patients, patients with financial problems, or patients with difficult personalities in the hopes they will find another provider?

Differences from other medical contexts

Patient-provider communication in dentistry does differ from communication in other medical contexts in four important ways. First, patient encounters with dental professionals are more physically intrusive than typical medical encounters. The accepted normal amount of personal space for Americans and Europeans is about 20 inches.²⁶ During a routine examination, a physician may invade that space for a brief time, but a dental professional usually stands very close to—and above—a reclining patient for a substantial length of time. Second, dental examinations are routinely more invasive than most physical examinations. Physicians and medical specialists typically explore body cavities briefly, but dental professionals spend much of the appointment examining, cleaning, or repairing features of the oral cavity. Third, patients are more aggressive during dental visits than in other medical encounters in which their bodies are examined and manipulated. Inevitably, dental visits require patient activity (holding the mouth open, swishing water, spitting, etc). Often this activity can make patients feel uncomfortable and ultimately more difficult to manage. Finally, dental visits hold more potential for pain than other medical encounters. Dental professionals focus on the head and mouth, two of the most vulnerable and sensitive parts of the body. As a result, even a simple dental examination can cause pain in a way physical examinations rarely do. Taken together, these distinguishing features may explain why 1 in 10 people suffers from dental anxiety.²⁷

Criteria for training in communication skills

In 2008, the American Dental Education Association issued revised competencies for the new general dentist.²⁸ These 39 competencies fall into 6 domains: (1) critical thinking, (2) professionalism, (3) communication and interpersonal skills, (4) health promotion, (5) practice management and informatics, and (6) patient care. Fifteen of those competencies relate—either directly or indirectly—to communication with patients (Box 1-3). Training in communication skills is now required in all US colleges of dentistry. The Commission on Dental Accreditation²⁹ now includes two behavioral science standards entailing patient communication training:

Box 1-3 Communication-related competencies for the new general dentist*

*Adapted from the American Dental Education Association²⁸ with permission.

• 2-15 Graduates must be competent in the application of the fundamental principles of behavioral sciences as they pertain to patient-centered approaches for promoting, improving, and maintaining oral health.

• 2-16 Graduates must be competent in managing a diverse patient population and have the interpersonal and communications skills to function successfully in a multicultural work environment.

Benefits and Challenges of Enhanced Communication Skills

Value of communication skills

In dentistry, how important are interpersonal skills relative to clinical skills? Given the tremendous amount of work and resources dental professionals commit to their clinical training and the significant time and skill required at a dental practice, does proficiency in patient communication justify the extra effort required to learn and implement those skills? Patients indicate that it does. Perhaps surprisingly, practicing dentists agree. A 1998 study determined that dentists rated interpersonal skills, stress tolerance, and administrative skills as the most important determinants of professional success.³⁰ Moreover, although dental professionals might believe patients evaluate them solely on their clinical skills, patients tend to assume professionals are clinically competent and therefore base their evaluations on communication skills.^31,32

Measurable benefits of effective communication

Effective patient-provider communication supports patient-centered health care and is associated with specific, measurable benefits. Patient-provider communication is associated with greater patient satisfaction with care,^33–35 greater patient adherence to treatment plans,^34,36,37 and fewer medical errors and mistakes.^38,39 Skilled communication may even be associated with fewer malpractice claims.^40–44 Ultimately, effective patient-provider communication leads to better health outcomes for the patient.^45–47 Skilled communication yields a complementary benefit for the provider: Along with monetary reward and respect, positive patient relationships are a primary contributor to dentists’ job satisfaction.^48,49

Activity 1-3

*Adapted from Buhrmester et al⁵⁰ with permission.

Barriers to the use of evidence-based communication strategies

The many benefits of enhancing provider communication skills and using those skills when interacting with patients have already been discussed. In addition, a European study indicated that 87% of dentists and 84% of patients support the integration of communication study into dentistry coursework.⁴⁷ Yet a recent nationwide survey by the American Dental Association Survey Center found that dentists in private practice routinely engage in only 3.1 of the 7 basic communication techniques, a rate the authors of the study described as “low.”⁵¹

Question of ethics: Patient-provider communication can determine the level of a patient’s access to care. Should providers therefore strive to communicate the exact same information to every patient in the same way? Is it ethical for providers to tailor their message and its delivery to the needs of each patient? Who determines what those needs are?

Given the benefits of effective patient-provider communication and that communication training is now required in US colleges of dentistry, why would dental professionals exclude proven strategies for providing patient-centered care? Three reasons come to mind. First, training in communication skills generally involves a commitment of time and money. A 2007 study found that a single training session did not significantly improve the interpersonal skills of dental students and that a comprehensive communication curriculum was necessary to attain greater gains.⁵² Although training is included in colleges of dentistry, we have observed great variation in presentation, the amount of resources and time, and faculty attention devoted to teaching of communication skills.

Second, the practice of adapting communication style to each patient’s personality and needs requires a higher level of attention and effort than simply using the same approach with everyone. Patients with challenging clinical, behavioral, or personal characteristics can be particularly frustrating.^53,54 Research documents a decline in emotional empathy over the course of training in dental school, suggesting that the decline is associated with greater exposure to patients.^55,56 This negative association between patient exposure and empathy may carry into the practice. Similarly, “emotional labor” has been identified as a primary occupational stressor for dental hygienists.⁵⁷

Third, providers may perceive that the application of effective communication skills in every encounter takes too much time and interferes with scheduling.

Chapter Checklist 

For More Information

Patient-provider communication

• http://www.health.gov/communication/

• http://www.patientprovidercommunication.org/

• http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/P/PDF%20PatientProviderCommunicationTools.pdf

• http://healthcarecomm.org/

Healthy People 2020

• https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology

• https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health

American Dental Education Association competencies

• http://www.adea.org/about_adea/governance/Pages/Competencies-for-the-New-General-Dentist.aspx

• http://www.adea.org/about_adea/governance/Documents/ADEA-Competencies-for-Entry-into-Alied-Dental-Professions.pdf

Commission on Dental Accreditation standards

• http://www.ada.org/en/coda/current-accreditation-standards

Health communication associations

• http://www.aachonline.org/

• http://www.hesca.org/

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