Laura Harkin, DMD, MAGD 

Let’s delve deeper into the preclinical interview! 

It’s helpful to understand a patient’s perception of their overall health and oral health, as well as what type of restorative dentistry they’re hoping to have and why they feel the way they currently do.  

Sometimes, an integral family member has influenced the timing of care. For instance, you may hear, “My grandchildren are making fun of my teeth” or “My wife asked me to get my teeth fixed.” From this response, I know that I will need to be sure my patient personally desires treatment before rendering it. I’m also anxious to understand what type of restorative dentistry a patient is considering. For example, are they open to removable prosthetics, fixed crown and bridgework, or implantology? 

Recently a new patient came to my office with an emergency. Tooth #5 presented with the buccal wall broken to the gumline and a moderate-sized, retained, amalgam filling. He immediately said, “I do not want bridgework.” I listened quietly until he elaborated by saying, “When I had this front tooth replaced by my other dentist, I had to take it in and out, and I just found that so irritating.”  

I finally understood that he was referring to a flipper but calling it bridgework. So, it’s important to listen and ask questions when someone seems close-minded about having a certain modality of treatment. Delve deeper into the conversation because it may simply be confusion surrounding dental terminology. 

For the grandparents who ask for a better smile, I’d like to understand their thoughts on the scope of treatment and their expectations. Are they looking for a white, straight, Hollywood smile or a more natural appearance with a little bit of play in the lateral incisors? Are they mainly concerned about stains, gaps, or a missing tooth? Are there other problems they’re aware of such as tooth sensitivity, inflamed gums, or the need for a crown? This input is very important as we continue conversation with co-discovery throughout the clinical exam, diagnostic records, and treatment planning phase. 

Learn to count on your chairside for pertinent information. 

I’m fortunate to always have my assistant, Cindy, beside me for preclinical conversations, comprehensive examinations, and restorative procedures. Sometimes, Cindy interprets a patient’s statement or component of conversation differently than me. She may hear a message that I missed or read body language of which I wasn’t aware. Sometimes, auxiliary conversations between patient and assistant take place after I’ve left the room to complete a hygiene check.  

At the end of the day or in the morning huddle, we always take time to discuss interactions with our patients. Together as a team, we’re more efficient at acquiring accurate information so that we may approach the road to health most effectively for each individual. 

Determine if trust is present. 

As I’m getting to know a patient and before I choose to begin restorative treatment, I seek to understand if trust is present in our doctor/patient relationship. New patients often share past dental experiences, and, unfortunately, some have lost trust in dentistry itself. This may be warranted due to improper care, but it may also be due to a lack of understanding or unclarified expectations regarding a given procedure or material choice.  

It’s not unusual, particularly when a patient is considering a large scope of treatment, to serve as a second or third opinion. Building trust and waiting to be asked for our skills are key necessities before moving forward in irreversible therapy.  

The comprehensive examination, periodontal therapy, splint therapy, and gathering of records are all appointments during which opportunities exist to get to know our patients. True trust often takes time to establish, but the reward reaped is frequently one of empathy, friendship, and the ability to do our best work. 

The Pre-Clinical Interview – Part 1 

Laura Harkin, DMD, MAGD 

I am a third-generation, restorative dentist in New Holland, Pennsylvania, which may be best known for its blue, New Holland tractors. I own my grandfather’s and father’s dental practice where I am the sole provider for approximately 1,000 patients. My dental team consists of two hygienists, two assistants, and two front office administrators. 

I graduated from dental school in 2008 after short careers both in the actuarial sciences and as a stay-at-home mom. In 2010, I purchased my practice and signed up for my first course at The Pankey Institute. Note, my father also studied at the Institute when it first opened its doors in the early 70’s. One of my greatest challenges, early in my career, was learning how to diagnose oral conditions, develop and present treatment plans, and execute that treatment via phases. I found it quite overwhelming to simultaneously manage multiple, complex cases. Now, I love sharing my experience and the approach I’ve found works best for me. 

Above all, I’ve learned that in the midst of daily pressures in dentistry, we need to maintain our own health and strength to properly treat our patients and lead our teams. Surrounding ourselves with knowledgeable, positive, and compassionate colleagues helps! 

Knowing ourselves is as important as knowing our patient. 

Dr. L. D. Pankey’s Cross of Dentistry supports the belief that knowing oneself is of equal importance to knowing a patient whom we choose to treat. This challenge forever evolves because no person remains unchanged with time. I frequently evaluate my strengths and weaknesses as a provider, team leader, and mentor. At the same time, I ask myself what aspects of patient care and business management I excel at and most love to do. I can then choose my specialist team accordingly and empower my office team to best support me. 

Together we ultimately provide a better product and higher level of care. 

To prepare specifically for the treatment planning process, my team helps me gather key information and clinical records from a patient for a comprehensive evaluation. After a thorough analysis, I carefully craft written documentation which will help educate my patient, my team, and the specialist team I’ve chosen. An added benefit is its ability to serve as legal documentation.  

I always ask a team member to join me during treatment plan presentations. They bring another set of ears and eyes so that we may better understand a patient’s motivating factors as well as the challenges they may face in receiving treatment. We encourage open and honest conversations and understand that treatment plans evolve to fit the needs of individuals. 

How do we get to know our patients? 

In addition to gathering a thorough health history and dental history, we are seeking to learn more about our patient’s chief complaint, perception of their current state of oral health, desires for treatment, and barriers to care. 

We listen intently for clues to identify a patient’s communication style. I’ve always heard that we have two ears and one mouth for a reason. I practiced with my father for two years and once, after observing me, he said, “Laura, you do far too much talking. You need to really listen to what your patients are sharing.”  

I’ve had to develop the skill of active listening. To stay in the question and become comfortable with silence takes practice. Some observations that I try to make in order to effectively communicate and build a relationship with a patient are as follows: 

• Do they seem to enjoy conversing or are they responding with short answers in order to get through the interview quickly? 
• Do they readily ask questions and express thoughts, or are they quiet and need to be invited and prompted to share? 
• Are they amiable? 
• Are they distrustful or fearful due to past dental experiences? 

We need to intentionally verbalize our empathy when we’re in conversation with a patient to help them recognize that they’re being both heard and understood. 

It is beneficial to understand a patient’s background. For example, what have they done in life? What do they love to do? Who is important in their life? Sharing in these conversations will help build a rapport, lead to improved doctor/patient communication, and can help to begin a trusting relationship. 

Does the patient have limitations such as the ability to drive to appointments, afford dentistry, or find time for treatment? Do they need to discuss their oral health condition and treatment options with a trusted family member before making a decision? 

Understanding these answers helps us to not only provide respectful and resourceful solutions but also limit inaccurate assumptions. This knowledge is especially helpful in my third-generation practice, where I have many elderly patients who are dealing with health issues, multiple medical appointments, and scheduled drivers. Their desire is to simply make a careful decision for an oral rehabilitation which fits their objectives and abilities. 

Do we hear the desire for treatment? When speaking with an existing patient, I can often recognize signs of interest to move forward with previously recommended treatment. At that point in time, I often ask, “Why now?” The answer helps me clarify their chief concern(s) so that we can move forward fittingly. 

In Part 2 of this series, we will explore additional techniques to clarify our patient’s desire for oral health and long-term, oral stability. 

Getting Case Acceptance to 90% 

Paul A. Henny, DDS 

Studies show that the average comprehensive care treatment plan acceptance rate is in the 30% range. Why do you suppose that is? 

Humankind’s Innate Prediction Machine 

Our brain is a prediction machine that’s always turned on. To a large degree, it operates like the autocomplete function on our phone – it’s constantly trying to guess the next word when we listen to a book, read, or conduct a conversation. Contrary to speech recognition AI bots, our brains are constantly making predictions at different levels, from meaning and grammar to specific speech sounds. Our brain continuously compares sensory information with memories. The more negative the memories, the more negative the predictions. 

Additionally, there’s a central purpose behind our prediction machine: Survival, successful reproduction (propagation of our genome), and rewards that might take the form of rising up in the social hierarchy or gaining scarce resources. 

Regarding survival, our brain likes to stack the odds 4:1 in its favor, meaning, it tends to predict negative outcomes 4X more often than it will positive outcomes. This is nature’s way of staying safe so we’ll have the opportunity to live another day. 

Stacking odds in Its favor is very primal, yet the stacking influences many of our impressions and decisions. Complex situations requiring complex decisions must go through this 4:1 negative bias loop. 

A Steep Slope to Climb 

Now, apply this information to how you work with your patients. Unless you enter a relationship with a stellar reputation that has transferred a high level of trust, you are starting off with 4:1 odds against the advancement of your agenda. That’s a steep slope, yet we ignore that truth every day. 

The only way to overcome the 4:1 odds against us is to allow trust to organically develop in the relationship. And that must be achieved in small steps: Simple proposals, agreements, and experiences that meet unspoken expectations.  

Would you agree to hire a contractor to build your dream home after talking with them for only 15 minutes? Wouldn’t you want to see examples of their work and call one or more of their clients to learn how good they are at following through and sticking to their word? 

I thought so but for some reason, we all want to believe that when a person needs extensive oral restoration or rehabilitation, that they will be ready to make a multi-thousand dollar decision within minutes of seeing our amazing digital presentation. In fact, we’re so confident that it will work, that we’ll do our exams for free to create a “sales funnel.” 

The Common Approach Fails 

Most people don’t react well to this approach because it’s too much information-too fast, and it’s all coming from a virtual stranger. They’re not ready to have us build their dream home for obvious reasons. Why, then, do we ignore all of that and call them “tire kickers?” 

The Alternative Approach 

Dentists who deploy the co-discovery, co-diagnosis, and co-success treatment planning process outlined by Dr. Robert F. Barkley often get above 90% case acceptance. I bet you wouldn’t be surprised to know that Pankey Institute faculty are among them. Understanding how the mind works and structuring your new patient processes to beat the 4:1 odd is more than possible. I invite you to read my recently published book: Co-Discovery: Exploring the Legacy of Robert F. Barkley, DDS. The book is available at the Pankey Institute now with all proceeds benefiting the Institute.