Communication skills for successful relationships  Chapter 11: Safe enough to tell the truth

by Sandy Roth

Inez groaned, "Not another cancellation. Dr. Suarez will be furious if I can't fill it and I'm running out of people to call." The problem had been going on for months, and Inez was at a loss about what to do. Between Dr. Suarez and two hygienists, it wasn't unusual to have two or three cancellations each day. Almost without fail, Inez would arrive each morning to find a message, often left on the practice voice mail late at night. The excuses were always good: a terrible case of the flu, a sick child, an unexpected meeting at work, or an emergency trip out of town.

But the excuses didn't sit well with Dr. Suarez, who was understandably concerned about the loss of production. Inez confirmed each appointment — or at least left a message on the patient's voice mail the day before each appointment — but that didn't seem to help. Sometimes, the confirmation call seemed to trigger the cancellation. Some patients would pretend to have forgotten the appointment. "Omigosh! I'd completely forgotten about it, and I've scheduled a fill-in-the-blank." Others claimed to have left a message weeks before canceling the appointment. Frankly, she didn't believe them half the time, but she couldn't very well call them liars.

Often, she had a premonition that a patient would cancel. Sometimes, she felt it even as she was making the appointment — with the patient standing right in front of her! After the patient left. she would turn to a teammate. "Wanna bet she doesn't show up." At other times, she would make a self-wager about which patients would or wouldn't show. She was so good at anticipating these failures that she had to stifle her look of surprise on the rare occasions when her predicted no-show actually walked through the door.

Inez had become cynical about patients. They couldn't be trusted. They often lied. They hid behind voice mail and caller ID. They claimed not to remember. They lost their bills. They forgot to mail their check. She was getting angry with the patients and defensive with Dr. Suarez for holding her responsible for things that were beyond her control.

This series has embraced the types of skills necessary to create and maintain healthy and successful relationships. In each installment, I have invited you to first look at the part you play in creating great relationships — or those that are doomed to fail. We began last February by looking at how judgment crowds out curiosity — the most important communication mindset you can maintain. Curiosity prompts questions, which lead to understanding and respect, the foundations of healthy relationships. But once you begin judging others, you eliminate curiosity. Yet, as we discovered, what we don't know is significantly more important that what we do know.

We then explored the process of conveying expectations. Since relationships are nothing more than an array of expectations, the closer a person's behavior matches your expectations, the healthier the relationship will be. Thus, even a highly trained clinician must revert to learner status when it comes to patient expectations. When we clearly define expectations at the beginning of a relationship, we will be more successful at meeting them. When expectations are unclear, however, the practice will waste precious resources with the consequences — repairing broken relationships.

In the next three installments, we discussed situations that challenge almost any relationship: delivering bad news, discussing finances, and asking for forgiveness In each of these areas, I encouraged readers to come to a better understanding of how the other person feels. From there, we explored the importance of dialogue; I offered some guidelines for learning and developing this under-used tool. And in the last two installments, we had a serious look at feedback and damaged relationships.

Throughout this series, I have explained principles that, when mastered, will help doctors become stronger communicators and pave the way to healthier relationships with both patients and co-workers. I'd like to begin this final installment with a recap of those principles, which, when applied consistently, will create an environment safe enough for people to tell you the truth.

What you think is more important than what you say. If you think negatively about someone or something, nice words will not change your frame of mind. Nor are they likely to change what others actually hear. What you think and feel always speaks more loudly than what you say.

The most important communication tools are curiosity, sincerity, and listening skills. While most people think a great vocabulary or a quick wit are the most important skills, the best communicators are those who work hard to understand others. They stay curious; their questions are genuine attempts to get to the heart of matters. Because responses matter, they listen with the intent to learn and understand.

Examine your own role before looking elsewhere for blame or accountability. Relationships require two parties; each has a part in creating the outcome. Although you can't make others behave in a certain way, the choices you make about your own behavior can have a huge impact on how others respond. Not doing something often can be as problematic as taking action, so by omission or commission, the role you play will always be a significant factor in determining the health of your relationships.

If you have erred, say so. Sincere apologies are inexpensive and return huge dividends. Of course, mistakes happen, even with the most seriously vigilant service providers. Thoughtless comments can be harmful, but asking for forgiveness and taking responsibility can go a long way to regain lost ground. Defensiveness only escalates situations and makes resolution difficult. Once blame enters the picture, emotions intensify and issues become distorted, making it almost impossible to work through even normal issues.

To complete this series, this final installment will provide some guidance to help you look at how each of these principles contribute to the environment you create for your relationships. When the environment is safe, people are more likely to be honest and forthcoming. People rarely create an unsafe culture on purpose, yet there are many factors that unconsciously add up to trouble.

Let's begin by looking at how easily messages can come back to haunt you when you least expect it.

You have failed our testMost patients want your acceptance and will go to great lengths to avoid outright disapproval. If they have come to expect judgment from their health-care providers, this lack of safety causes them to protect themselves. Perhaps without realizing it, dentists and team members regularly ask questions that sound more like a test with right and wrong answers. "Do you want to keep your teeth for a lifetime?" regularly appears on patient registration forms. Yet, either answer has little meaning because it is clearly a trick question, skewed toward the clear bias of the practice. Any patient would anticipate that the answer "no" would surely meet with disapproval, while a "yes" opens a patient to a highly uncomfortable level of exposure. "If I mark 'yes,' does that mean I have to agree to everything you suggest?"

Patients regularly "get tested" about their home care as well. I recall hearing a new patient report that she avoided going to the dentist, and especially the hygienist, because, as she put it, "No matter how hard I work, I never measure up. Who wants to pay money to hear what you're doing wrong?" You probably know patients who engage in rigorous "flossing Olympics" two weeks before each hygiene appointment in order to get under their hygienist's radar. Thus, the patient either passes or fails the hygienist's test. The questions, "Have you been flossing?" or "How often do you floss?" can then be answered positively to elicit much-desired approval.

These questions suggest three erroneous principles:

That flossing itself is the goal.
That the hygienist's role is to dictate the patient's
homecare regimen.
That compliance with the hygienist's instructions is the mark of a good patient.

When a practice portrays these concepts as valid, they cause patients to avoid the inevitable disapproval. I'm not a hygienist, but my guess is that while flossing is one of many tools that accomplish a goal, it is not a goal itself. Moreover, the patient's willingness to engage in effective self-care is determined largely by motivations other than getting a "passing grade." Finally, although "compliance" is a word often used among professionals, it is patronizing and unlikely to motivate patient cooperation.

Another example comes when patients have not seen a dentist for some time. Although you may be curious about why and what has prompted them to seek care now, the question, "Why haven't you seen a dentist for ten years?" often makes patients defensive. Patients aren't stupid. They know that your business is dentistry and that you place great value on dental services in general. They understand that most practitioners think poorly of someone who seeks care only under dire circumstances. Because patients may have felt judged by other health care providers in the past, they may be predisposed to hearing your question in that light.

Our agenda is more important than yours I often hear team members and dentists making statements that amount to an indictment of their patient's values. A statement such as, "Why can't we get patients to see the importance of dental treatment?" suggests that their perception of what is important should prevail. If a practice isn't producing as much as desired, the financial pressure adds another dimension that can be very dangerous. This way of thinking can distort your approach to patients. Practitioners may be experts on clinical dentistry, but patients are the experts on themselves. When you get this distinction confused, you presume too much.

Every person has established a set of priorities about how to spend time, money, and energy. For anyone on the dental team to believe that dental care is more important than other things to a person — be they basic sustenance or even trips to Hawaii — is arrogant. Because you will never know enough about any patient to know what that trip to Hawaii might mean, suggesting that you know better than the patients about their lives almost always creates an unsafe environment.

The increasing rate of late cancellations and patients who are inconsistent about appointments is frustrating. Some rudely disregard your time, but I suspect many patients agree to appointments, only to later have second thoughts about the care, the costs, or the time. While everyone would prefer that patients be more thoughtful, I often suspect that patients feel pushed into agreeing to treatment before they have thought everything through. Once at home, life rears its head. The hot water heater needs to be replaced. Johnnie needs $50 for the soccer weekend. The kids need new shoes. The cost of eggs has risen.

Certainly, a full schedule is advantageous, but if your staff feels compelled to get patients to say "yes" and scheduled at all costs, they may be more coercive than facilitative. Patients will sometimes agree to things they have no intention of doing simply to get out of the office and away from the pressure. Little wonder why they call at 3 am with a cancellation message. When your gut tells you something is not right, pay attention to that message. It's the best opportunity to change the environment to one that makes patients feel safe.

Each of these examples explains why patients may put off appointments, make up stories to buffer rejection, and create excuses they believe will be more acceptable than the truth. If you make it unsafe for people to be truthful, patients will find it more palatable to lie. Thus, I'm suggesting that many of the problems you experience with patients have more to do with how you approach them than you realize.

What must happen for patients to feel safe enough to be truthful? Very simply, you must create an environment that honors understanding, respect, trust, and boundaries. If you operate on incomplete information, assumptions, or guesses, you will not understand your patients. If you judge their values and priorities, you will not respect them. If your drive to meet financial and other goals overpowers your ability to help patients deal with issues that are important to them, you will not earn their trust. When you presume that your values should be your patient's, you have overstepped a boundary and damaged the relationship. Each element must be honored and in place for patients to feel safe enough to tell you the truth, and for doctors to create successful relationships.

Note to readers: I have thoroughly enjoyed presenting this series in 2001, and I want to thank each of you who wrote, called, and sent emails or faxes asking for additional support and help. Next year, I will be offering a bi-monthly series beginning in February. The series will be called: Communications Workshop — Skills Every Dentist Needs. I hope you will look for it in 2002.

Guided personal exercise

This month, I want you take a safety inventory of your practice. Much like a fire drill or updating your CPR certification, a safety inventory is a good, regular review. This particular safety inventory, however, looks at the emotional environment you create for your patients. The fundamental question is whether it is safe enough for your patients to tell you the truth. Do this inventory as a team and discuss your findings together. Once you have completed the inventory, determine what should change.

How public are your discussions with patients? To complete this part of the inventory, one of you must be the patient, while another plays the team member so you can test whether their interaction can be overheard. Have the "patient" stand at your front desk, and engage in a discussion about an appointment, financial arrangements, or a specific treatment. The rest of the team should position themselves in various points within earshot. What can you hear? How does the "patient" feel? Under what circumstances might this be uncomfortable or unsafe for a normal patient?Complete the same test as above, but this time with someone playing the role of a patient on the phone. Actually place a call and speak with the receptionist about changing or canceling an appointment. Again, what can you hear and what are the implications?Monitor the routines you create and the discussions you have with your patients. Gather a set of every form or pre-printed document you have and evaluate them for trick questions. Place a tape recorder in the room to record what you say, perhaps without thinking. Do any of your questions sound like a test? Do you appear to disapprove? Look at how patients reply to questions on your forms. Listen to their responses. What are your instincts telling you?Role play! Re-create the discussions you heard above so you can get a better idea of how the patient might be thinking and feeling from their position. Review your procedures and approaches. How much of your effort, time, energy, and systems are designated for learning the patient's agenda vs. delivering your agenda? Is the balance out of kilter? Be sure to check into your mindset here as well. Listen to your instincts. Each day for a week, make a note of every situation when your instincts tell you the patient isn't being truthful; note the environment and circumstances that surround that situation. As a group, review these situations and ask yourselves two questions:

How did we contribute to creating an environment unsafe for this person to tell us the truth
Did we address our unsettled feelings, and if so, how?

Then practice with different ways to change the environment to make it safer as well as different ways to respond.

This is a mighty assignment, yet I believe it will yield huge dividends for those of you who choose to accept it. Best wishes to you all and please let me know how I can help you.

To learn more about how you and your team can develop stronger and more effective communication skills, call Sandy Roth at (800) 848-8326, or email her at [email protected] to request a catalogue of learning resources.