As dental professionals, we are all too familiar with having to deal with difficult patient interactions. We are aware of and sympathetic to the fact that attending the dental surgery is not always a pleasurable experience for patients. Some may have heightened anxiety or be in extreme pain, which inevitably has a negative impact on the situation.
It won't come as a surprise that members' patient management skills have been under increased pressure during the last year. Members are trying to reach a balance between working within, and keeping up-to-date with, sometimes rapidly changing guidelines whilst meeting the needs and expectations of their patients.
This is often in addition to demands due to personal circumstances, and while this continues to be a challenging period for dental professionals, one of the positive outcomes may be an increased focus on communication and understanding. Managing patients' expectations is particularly important at this time, as the pandemic has affected the availability of dental care and resulted in frustration and stress for everyone.
As with any other human interaction, the factors that contribute to a difficult patient/dentist interaction can stem from concerns and frustrations on both sides. We must remember that the more factors coming into play, the harder it may be to manage the situation effectively.
It may be helpful to consider how the following contributory factors affect us and our patients, to try and keep these in perspective.
1: current climate
We are aware from working closely with members that the COVID-19 pandemic has added to the everyday stresses and strains, for staff and patients alike.
Practices have adapted incredibly well to the new way of working, but the capacity to see and treat patients has been unavoidably impacted, leading to waiting lists, limitations on available appointments and difficulties fulfilling contractual obligations.
There have also been huge frustrations arising from the early days of the pandemic, when practices closed and patients were caught mid-way through treatment, unable to get an appointment.
2: the individual patient
Generally speaking, the majority of patients are understanding and appreciative of the steps taken to ensure delivery of care is safe for all. However, a patient in pain and discomfort or unable to complete treatment in their own timeline can quickly become demanding and difficult to deal with.
3: the dental team
Dental professionals are dealing with new and restrictive protocols, uncomfortable working circumstances, time and financial pressures and more - all of which may negatively impact on our interaction with patients. We need to look after and look out for colleagues, especially signs of stress. The dental team is currently under an immense amount of pressure, and now more than ever, good supportive team working is so important.
A patient in pain and discomfort or unable to complete treatment in their own timeline can quickly become demanding and difficult to deal with.
Communication and information
It can be a difficult balance between providing clear and consistent information and an overload of information. During the pandemic patients are usually telephone triaged and provided with detailed information prior to their face-to-face visit which may be followed up by email.
This has provided an additional opportunity for a transfer of information. However it can be difficult to ensure full understanding in these circumstances and the restrictions have resulted in additional steps and procedures for patients which can be time-consuming and frustrating.
- Managing patient's expectations at all stages of their contact with the practice can help in reducing anxiety or misunderstanding.
- Regular team meetings can be beneficial in ensuring that colleagues are up-to-date with policies and procedures. This can be helpful in ensuring patients are provided with consistent and clear information from all members of the team which may avoid misunderstanding which can lead to a complaint.
- Good lines of communication with patients updating them on how to obtain dental treatment and what to expect when they attend is essential as communication during active treatment can be challenging.
- Make it clear what information is required and what patients can do to prepare for their attendance; for example bringing a mask and a pen. Let patients know what to expect in advance of the visit, and during their departure from their appointment.
- Planning ahead may avoid help in avoiding complaints. Be careful to update and amend standard operating procedures to reflect any developments in your setting. You may want to consider including appropriate arrangements for those unable to wear a mask to avoid confusion or conflicting information circulating amongst the team and in communications with patients.
- The additional layers of PPE can make communication more difficult and their use in combination with multiple changes in standard operating procedures can lead to frustrations both for the dental team and the anxious patient.
- Want to know more? Read our advice line dilemma on a difficult patient interaction.
The irregular patient
One example of a common issue is the irregular patient, who has unfortunately developed an apical abscess due to untreated caries progression over a number of years and now find themselves in the positon of being unable to readily access care.
When they are advised that in order to try and save the tooth an AGP appointment is required but there is a waiting list of some weeks and are presented with the alternative option of extraction, they become abusive and angry.
These situations are best managed with empathy, avoiding the patient feeling 'blamed' for the situation they are in due to their poor attendance history or being 'shamed' for failing to attend previous appointments.
Delays or breaks in treatment
Another difficulty colleagues have experienced are treatments halted due to the pandemic such as short term orthodontics, tooth whitening, crown and bridge work, where there was a high aesthetic demand from the patient at the outset. We should always try and see the situation from the patient's perspective.
Again, showing an understanding of their situation, the distress this may be causing them and setting out for the patient the steps you will take to try and expedite their care, can get the patient back on side, as they feel listened too and supported.
Managing challenging behaviour
Working with our patients on a solution can help manage their unrealistic expectations and help all involved find some common ground and diffuse the situation.
Try to focus on the following key points:
- Remain calm and professional at all times
- Be an active listener and avoid confrontational responses
- Put yourself in your patients' shoes and show empathy
- Work with them towards a solution and stress the positive outcomes that you can achieve together
- Be assertive without being aggressive - for example, responding with, "I can try and help you sort this out. In order to help you, I need you to provide me with a few more details so we so we can discuss the best options for you..."
It is important for everyone involved in communicating with patients to be prepared in advance on how to handle patients who may breach behaviour policies. If a patient is considered to have behaved in a rude or aggressive manner, it's clearly appropriate to remind them of the zero tolerance behaviour policy in place. Further action may need to be considered in line with this policy.
- A zero tolerance behaviour policy should readily available and patients made aware of it.
- It is essential to have robust policies and procedures to protect other patients, the dental team and visitors.
- Think about providing all members of the team with regular training and updates on how to manage aggressive or abusive behaviour which should also help to reassure them they will be well supported.
- Make sure everyone is aware of appropriate routes for escalation if circumstances require.
When all else fails
We all know from past experience how draining and time consuming a patient complaint can be. With many other stresses in our working day, avoiding conflict with a patient is key. This is in no way suggesting that you must give in to every difficult patient, and there will be occasions where a practice must take appropriate action in situations when someone has stepped over the line and the trust is irrevocably broken down.
It's important to be aware of ethical responsibilities, as set out in GDC Standards (1.7.8), not to decline a patient further care solely on the basis of a complaint.
If there is a breakdown in communication with a clinician on an individual basis, it may be appropriate for the treating clinician to make a decision as to whether continuation of care with them would be in the patient's best interests.
It is important to consider the patient's ongoing care and whilst an associate at the practice may make a decision to decline further care with them, it will be appropriate for the practice principal to decide whether the patient will be able to continue care with another clinician at the practice.
- In circumstances where an individual patient has clearly breached the workplace behaviour policy - for example, by aggressive or offensive behaviour with patient-facing members of the dental team - the principal or clinical lead needs to be involved in the decision about the patient receiving further care at the practice.
- It can be helpful to have a supportive team meeting after an incident involving a patient breaching behaviour policies and to take the opportunity to learn from the incident and implement any changes to policies and procedures that might be indicated.
- When a decision has been reached that there has been an irrevocable breakdown in the professional relation between an individual dental professional and a patient, the individual involved can decide if further care can be declined with them in the patient's best interests.
- However in these circumstances the final decision about the patient receiving care from another dental professional at the practice will rest with the principal or clinical lead.
It is important to realise that terminating a patient’s care not infrequently produces a patient complaint about the decision, but you may regard that as the lesser of two potential risks, the greater risk being to attempt treating the patient when the relationship has irrevocably broken down. When this happens we can assist with the wording of the correspondence you need to send to the patient.
Our team of dentists are here to help you through these difficult and testing times. Please do contact us for advice and guidance - sometimes just simply chatting through a situation can be of huge benefit.
DDU dento-legal adviser
DDU dento-legal adviser
Sue qualified from Guy's Hospital Dental School in 1986 and went into general dental practice in the UK. She spent two years in South Africa helping to set up dental practices in Johannesburg. After 20 years in general dental practice, she joined the Dental Law Partnership, advising on the clinical aspects of negligence claims. Sue joined the DDU in April 2011 and works as a full-time dento-legal adviser.
See more by Susan N'Jie
Dr Sarah Ide
Sarah Ide is one of the dento-legal advisers at the DDU. She qualified in 1992 from Guys and worked there as a house officer before entering general practice as a VT. Sarah worked in independent and private general practice for 25 years and completed an MSc in Aesthetic dentistry at King's. She's been working at the DDU for over six years, initially combining this work with general practice, and now working here full time.
See more by Dr Sarah Ide