From Volume 44, Issue 8, September 2017 | Pages 774-780
The aim of this paper is to review the evidence about communication within the context of the dental setting. The need for good communication generally is considered, as is its role in managing anxious patients and in avoiding misunderstanding. Ways in which communication skills can be assessed and updated are also discussed.
’The single biggest problem in communication is the illusion that it has taken place’ (misattributed to George Bernard Shaw but probably originating from William H Whyte (Quote Investigator).1
One comment that the author has often received in feedback from dental students is ‘Why do we have to learn about communication – what does it have to do with dentistry?’ Attempts to convince students that communication is a clinical skill and one that is well worth developing, can fall on deaf ears; similarly, evidence that a considerable part of dental litigation is concerned with miscommunication and misunderstandings rather than clinical malpractice2,3 may be met with scepticism.
In order to answer criticisms such as these, one ought to consider communication theory and the literature on communication in healthcare, as well as, perhaps, personal experience. If we stop, for a moment, to think about whether communication events are always successful and whether the intended message is always received or that misunderstandings are ‘never’ events, then the need for modification or improvement of communication skills may become apparent.
With respect to the literature, scholars report that communication within a healthcare setting is both a clinical and complex skill:4,5 that is, ‘one that pertains to a clinic, direct patient care, or materials used in the direct care of patients',6 comprising ‘a set of constituent skills’.7 In dentistry, those constituent skills are likely to include (among other things) the ability to listen carefully, explain clearly using plain, easily understood language (ie not jargon or clinical terms), provide reassurance to anxious or upset patients, as well as delivering effective persuasive messages to promote positive changes in health behaviour. Without doubt, dental care can take place without these interpersonal skills, but life for both dentist and patient will surely be more satisfactory if they are part of the dentist's tool kit.
Communication can be verbal (spoken, sung, whispered) and modified by paralanguage (tone and pace of speech; er, um and ah, etc), written (letters, social media, advertisements, journal articles, clinical information leaflets, prescriptions) or non-verbal (drawings, models and body language) (Figure 1).
In order to communicate effectively, both a sender and receiver are necessary: someone needs to send a message and, just as importantly (but frequently forgotten), someone else needs to receive the same message. Communication comprises more than simply providing information – if a message isn't received as it was intended, then the communication process hasn't been completed (Figure 2).
As shown in Figure 2, the receiver may not decode the sent message in the way that it was intended; for that reason, a critical aspect of communication in the healthcare setting is to ensure that the message that has been sent (from patient to dentist or dentist to nurse and any other possible permutation) is the same message that has been received. This can be done by recapping to check that the receiver (patient) has heard correctly or by asking the receiver him/herself (the patient) to recap what you (the dentist) have discussed, to ensure that he/she has understood what has been said. In order to emphasize this point with her students, the author often uses the following example:
Message 1: ‘The lecturer said the student is a fool’
Message 2: ‘The lecturer’ said the student ‘is a fool’
Message 3: The lecturer said ‘the student is a fool’.
In each case, the physical content of the messages is the same – the stimuli are almost identical, give or take some speech marks. However, once punctuation and spaces have been added, each message has a completely different meaning, despite their similarity – it's no wonder that misunderstandings happen so often!
There is considerable evidence illustrating the importance of good communication skills in dentistry.8,9,10,11 Once a person has decided to seek healthcare, good and effective communication is associated with patient-centred care;12 patients are more likely to comply with treatment plans, their health outcomes will be better and they are more likely to report higher levels of satisfaction with the care that they receive.13,14,15 Similarly, dentists with effective communication skills are likely to be more accurate in their diagnosis and their practice will be more efficient.16 When treating children, an understanding of the benefits of supportive communication can facilitate effective behaviour management – one study has shown that a letter to a child reminding him/her of how ‘good’ his/her last dental visit was (ie a photo of him/her smiling after treatment) and a comment to the parents about how good the child has been, can have a positive impact on the subsequent dental visit. Blind assessment by others shows that the child's behaviour improves and self-reports from the children themselves indicate that the amount of perceived fear is reduced.17
Many patients will have an extensive ‘knowledge’ of dentists, even if they have never stepped over the threshold of a dental surgery: dentists are represented in fictitious media such as Marathon Man18 and the TV programme My Family,19 and they are sometimes represented with more or less accuracy in the national print or television media. Children receive communication about dentists and dental experiences from their parents, siblings and friends and adults communicate both positive and negative messages about their ‘dental careers’ to anyone who listens. All of these messages may contain perceived information about the dentists themselves or about dental procedures and they are subject to interpretation by others, eg Are dentists kind and understanding? Do they take the time to put their patients at ease?20 Are they professional? Are specific procedures painful, lengthy or expensive? Through communications such as these, dental patients will have sent and received messages about dentists long before they sit in a dental chair and will have their own perception about what dentists ‘are like’.
Patient-dentist communication often takes place around sensitive issues: it may be that individuals seeking dental care are anxious, fearful or even phobic that they have a chronic condition that they are concerned about disclosing.21 They may be embarrassed or ashamed, eg by the state of their teeth/because they haven't attended for a long time/because they are anxious and scared and worried about being perceived as troublesome – such perceptions can perpetuate an avoidance of dentists and treatment.22,23 (Figure 3).
The shame and guilt felt by a patient may promote anxiety about going to the dentist which, in turn, means that the individual is less likely to attend; consequently, his/her dental health is likely to deteriorate causing shame and embarrassment increases, taking him/her back to the beginning of the cycle.22,24Anxious patients may perceive that dentists are efficient and in a hurry, or that s/he won't listen to them or take them seriously;25 around 47% of patients also feel that they have no control over what happens to them once they are in the dental chair.26 These feelings are also likely to increase the individual's anxiety of dental situations and, as in Figure 3, result in dental avoidance.
Increasingly, there is evidence that patients want to be asked how they feel about being at the dentist: they want their dentist to know that they are anxious and worried.27 This can be done with simple and straightforward questions asking the patient whether s/he attends frequently and how s/he feels about coming to the dentist. If the patient admits to being anxious then care should be taken to find out why: is the anxiety due to hearsay, a difficult experience or shame or embarrassment?
Sensitive questions about tobacco, alcohol and recreational drug use, pregnancy and sexually transmitted infection are likely to be asked at some point during a dental consultation. Risks of treatment options may need to be communicated or bad news may need to be broken. In each of these specific contexts, different types of communication skills will be required: eg explanation, reiteration and recapping to check understanding; permission seeking either to ask sensitive questions during a social or medical history or to give details of bad news or planned treatments; reassurance that enables patients to ask questions and feel involved in decision-making about their treatment; negotiation about behaviour change and treatment options,28 and so on. While good communication in such sensitive situations is a priority for dental patients, it can also benefit the dentist: patients with HIV or diabetes have reported that they are more likely to disclose important details from their medical histories if they are comfortable with and trust their dentist,21 a relationship status that is achieved with good communication and the development of rapport. Such rapport relies on the dentist believing that he/she is justified in asking questions about sensitive topics and having the confidence to broach them: this means that s/he needs a clear understanding of why this sensitive information is relevant to patient-centred dental care in order to provide a clear explanation for the patient.
A search of the literature suggests that misunderstandings in communication can and do occur. A sizeable proportion of complaints and litigation occur not because there has been a technical or clinical error, but because patients did not understand, were not listened to, or were not treated with respect.2,3 These aspects of communication skill are often rated as ‘least good’ in surveys about patient satisfaction.29,30 The communication of risk is one area where there is room for improvement. The risks of treatment not going as expected, at best, or going wrong, at worst, are a sensitive topic. People undergoing dental treatment want their treatment to go well but, in order to provide informed consent, they need to understand both benefits and risks, as well as alternatives. The importance of communication of this type is considered in detail in a synthesis of the literature by Asimakopoulou and colleagues,31 who conclude that the communication of risk may be undermined because dentists may not communicate risk information clearly and consequently that patients may not, therefore, understand the risks to which they may be exposed. Similarly, there can be misunderstandings in the professional communication between dentists and dental and healthcare professionals (DCPs, HCPs): eg within referral letters and prescriptions that convey messages between general and specialty dental practitioners and between dentists and technicians.32,33 Such miscommunication can result in unsatisfactory outcomes, not only for patients, but also for dentists and DCPs.34,35 Misunderstandings are not the only adverse outcome, as far as written communication is concerned. A poorly written letter may prompt misunderstanding of the written content and, subsequently, inappropriate follow-up and investigations, at worst, or time-consuming re-investigation, at best. Patients expect to be sent a copy of any letters concerning them and letters therefore ought to be understandable to people with no dental knowledge. In the unfortunate event that something goes wrong or a complaint is made, lawyers and insurance companies may also ask for evidence of communication between dentist and patient or DCP and HCP. For this reason, communication and documentation (referral letters and clinical documentation) should be comprehensive, thorough and unambiguous.36
Gender also has an impact on communication. Overall, women and men communicate differently.37 Women are more likely to express more non-verbal warmth and emotions with higher levels of self-disclosure, whereas men are likely to be more direct.38 Differences in dentists' communication and interaction style as a function of their gender39 may impact on the working relationship between dentist and nurse: in the findings from several studies, dental nurses report that male dentists are more likely to have a business-like and gender-influenced communication style, whereas female dentists are more likely to practice a personal attention and friendly-relation communication style.40 Such differences can impact on job satisfaction and staff turnover, as well as levels of stress within the working environment, and so time spent on checking that everybody is receiving the same ‘messages’ is likely to be time well spent. Similarly, there are also reported interactions between the gender of the clinician and that of the patient: in one study of medics, female patient satisfaction was highest when female clinicians were rated as caring rather than non-caring, whereas male clinicians were rated more highly if they displayed moderate rather than lots of patient-centred communication. Ratings of satisfaction by male patients do not seem to be a function of communication style by either male or female clinicians.41
So far, this paper has comprised a summary of the communication literature in dentistry. Given the considerable evidence that there are issues with the effective and appropriate transfer of information from one person to another in a variety of dental contexts, what steps can be taken to refresh or improve one's communication skills?
The Calgary-Cambridge communication guide4 provides a structure for effective and appropriate communication with patients and family members. It breaks the consultation process into a series of stages:
It uses well-defined actions at each stage, many of which are generalizable to a variety of situations, eg posture, eye contact, expressions of sympathy/empathy/emotions, listening and negotiation skills.
Motivational interviewing42 is a method often practised by healthcare practitioners in different disciplines. It guides individuals in motivating themselves to change their behaviours and/or to adhere to treatment plans better. People exposed to motivational interviewing are more likely to begin, remain within and to complete treatment plans, eg flossing, changing diet, cutting down or stopping smoking and drinking alcohol.
Other tools relevant to more specific communication contexts include the SPIKES protocol (designed to help clinicians break bad news clearly, honestly and sensitively),43 and an academic discussion about the different ways in which risk can be communicated (eg is one's risk of caries possible or probable).44 Twelve tips for good written communication are provided by Keely et al (2002)36 with Davenport et al (2000)34 considering the importance of good communication between dentist and technician.
For those who would like to assess their own personal skills, a variety of measures exist (the Communication Assessment Tool (CAT) to acquire feedback from patients,45 the Communication and Working Styles Questionnaire (CWSQ) for feedback from dental nurses.40
Soft skills, including communication skills, are important in dental practice as they reflect dental care professionals' personal values and interpersonal skills and they also contribute to the successful provision of healthcare.46 For this reason, it is important that dentists and other dental care professionals consider the way in which they communicate with others – patients and colleagues – either wittingly or unwittingly, in spoken or written form. Communication is a clinical skill that needs to be learnt well, practised, reflected upon and updated on a regular basis if miscommunication and misinterpretation are to be avoided. This will entail taking the time to think about and improve one's communication skills: focusing on patients (and colleagues) as individuals, listening to them as they give their perspective of their teeth and their oral health (or professional issues and concerns), providing opportunities to ask and answer questions as they arise and, ultimately, making sure that any communication that takes place is ‘real’ and complete.9 Concerns that good or patient-centred communication takes time are unfounded: research suggests that the time taken for a patient-centred consultation is, at worst, the same as for a biomedical (disease focused) consultation and, at best, is reduced because the main point of the consultation is accessed more quickly.47
