A young dentist discusses her thoughts on how patient management should be managed in the transition from university to general practice.
You are expected by your patients to make the transition between a final year dental student to a general practitioner seamlessly and instantaneously. But, the learning curve is steep. Every new day of foundation training provides more information to fill your book of mental notes. Five years at dental school has prepared you to make clinical decisions on your own and to be able to diagnose and treat your patients effectively. However, patient management is sprinkled through the course intermittently, because ultimately you are not the leader of a team whilst you are studying. Yet in practice, your patients and staff look to you for guidance and you must make decisions that extend beyond the clinical realm.
While I am still developing these skills, below are some tips on patient management that I have learnt from my transition between university and general practice.
Discussion and the issue of valid consent
I have found there are two types of patients; Type A wants to spend ample time talking to you about their various treatment options, confirm and reconfirm the risks and the benefits of each procedure, and then go through the whole process again. Type B does not want a discussion, does not want you to go through their radiographs and explain to them the consequences of 80% vertical bone loss, they just want you to provide them with the appropriate treatment, and immediately, if possible.
If you were to try to please both of these extremes, you would spend all day talking to the former and simply hand the latter an estimated bill as they exit, without any preceding discussion.
The main issue here is obtaining valid consent from Type A (who may never really be sure of their decision) and from Type B (who may not understand the gravity of their decision). Equally, where Type A spends too long speaking to you, you may have taken time away from your patients in the waiting room, who may, incidentally, be more Type A's.
Identify Type A
Type A is often fairly nervous; they may shy away from the chair, take several breaths before you begin to examine them and roll their eyes to the ceiling as the chair lies flat. In this case, Type A is overly discursive because they feel too nervous to commit to any one treatment plan, and find it emotionally challenging to absorb all the information you are giving them. Thus, they seek comfort in discussion, delaying that final decision-making step. Conversely, the other Type A is overly confident, and in their own opinion, very knowledgeable. They may use some dental jargon to show you that they are no rookie. They are so sure of their dental experience that they are not seeking your advice and guidance, but more assessing your ability to carry out the required work.
Managing Type A
Run through treatment option as you usually would; slowly, with a pause between each one for any questions. The patient may then want you to run through things again. Allow a reasonable time for questions, so that you are not dismissive. At the end, write down the treatment options or provide the patient with a pre-printed list and ask them to consider their options and if they wish to, research online what each of them involves. This sense of empowerment relaxes the nervous Type A and assures those who are experienced that you are confident in your recommendations.
Write up a provisional plan based on your recommendations but reassure the patient this is subject to change. Bring the patient back for the simple stages of the treatment plan, usually there are small carious lesions to restore or simple scaling to be done. At the next appointment, ask the patient how they have decided to proceed. If they are still unsure, inform them that you will stabilise and they can reconsider their definitive treatment options in three months at their next reassessment. Or if that area is already stable (a non-carious retained root that is asymptomatic, for example) then simply revisit the decision making process in three months.
You can be sure that by being slow in your conversation and by providing the patient with the independence to research and consider the matter themselves, you have been supportive and eventually gained valid consent for the treatment, but Type A has not taken up much more of your appointment time.
Identify Type B
Type B patients usually behave in this way because they do not take the matter of their oral health seriously. After all, particularly where complex treatment planning is concerned, if their dental priorities were in line with yours, they would want to discuss treatment planning with you in some depth. Type B patients are often in a rush; they don't get too comfortable in the chair, speak abruptly and interrupt you as you try to delve further into their symptoms for your differential diagnosis. Some Type B's are young and find the entire decision-making process, as well as your diagnosis, fairly comical.
Managing Type B
Your aim here is to try to engage Type B in a productive discussion regarding their overall oral health as well as the required treatment. Given that Type B patients are usually misinformed, education is key to developing their understanding of the gravity of their oral health condition. This consequently sparks their interest in debating treatment planning with you. These patients are abrupt in their mannerisms, and so your opening sentence must be brief and directed, because it determines their continuing interest.
Sometimes, instantly providing the patient with a worst-case scenario can awaken them to the more severe consequences of deteriorating oral health. Where you have a young patient with gingivitis who does not take your oral health instruction seriously, immediately inform them of the link between gingivitis and destructive periodontal disease in the future, causing tooth loss. Although we are told to avoid dental terminology, I find this circumstance is a candidate for exception. Ultimately, using jargon carries with it the weight of the decision and ensures that the patient has a sense that there is a real health condition with real consequences to consider. Of course, you must explain each dental term you use, to be certain that the patient understands fully the information you are providing. You can then use visual aids and radiographs as you usually would.
Informed Consent- Do You Have it?
Appropriate, productive discussion is paramount to obtaining valid consent. Keeping time in these conversations is important in ensuring you can provide each patient with sufficient attention. The above examples are stereotypes and there is undoubtedly a spectrum of patient behaviour, each requiring different methods of management.
Danya Sbano