Written by Katherine Eitel Tuesday, 30 September 2008 19:00
Great hygienists are always looking for ways to help their patients understand, believe, and accept their recommended treatment plans. They spend the time required to develop a strong, trusting relationship with their patients. By the end of a hygiene appointment, they have received or retrieved an enormous amount of information that can help the doctor quickly assess, diagnose, and recommend appropriate treatment at the examination.
There are at least 2 compelling reasons to improve the hygiene handoff to the doctor during or at the conclusion of hygiene appointments. First, if the verbal handoff is really good, you will see a greater percentage of patients accepting more recommended periodontal, restorative, and cosmetic treatment. Second, you are likely to be on time more often, which is good for patients, the practice, and, of course, you.
Photograph by Brian Green
THE VERBAL HANDOFF
To think differently about the hygiene handoff, we must understand a few core communication principles. First, while you are talking, the patient as the listener has 2 conversations going on inside his or her head simultaneously. Patients are listening to what you are saying, and they are listening to their own internal conversation, which is analyzing what you have just said. For example, they may be listening to your explanation of their probing measurements and why this confirms the need to proceed with a periodontal therapy program, while at the very same time they are listening to their internal concerns about cost, time, and whether it makes sense to them. And to complicate matters further, the entire time they are probably looking straight at you with interested looks and nodding heads, implying understanding and acceptance. Often, that could not be further from the truth!
Nothing can be done about this very human condition, but we can understand it and anticipate, if not mitigate, the consequences. If you believe that patients toggle between these 2 conversations in their minds, then you will also know that for as long as they are listening to one conversation, they have completely missed part of the other—hence your frustration when you know you have told patients something and they say that they never heard it. (You’re sure to recognize this phenomenon happening often with children and spouses as well).
What does this have to do with the information handoff to your doctor? It solidifies the need to relay your information verbally in front of the patient to the doctor as often as possible. Your patient cannot hear it too many times—the more the better if you are striving for clear communication and greater compliance.
THE CONSTRUCT OF A GREAT HANDOFF
The second principle required is that you cannot relay information in a handoff that you never received in the first place. So to construct a great handoff, you have to work backward and start with the end in mind. For example, if you and your doctor decide that you would like to report on 5 areas at the hygiene exam—ie, changes in health or medications, current periodontal condition and treatment recommendations, oral cancer screening results, restorative concerns (the patient’s and your own), and aesthetic concerns—then you will have to structure your appointment protocol to allow for the assessment of all 5 areas. For instance, you may decide that in the initial patient interview at the beginning of the appointment, you will review the medical history, ask about restorative concerns, and always ask about any cosmetic concerns as well. Then you will perform an oral cancer screening and an appropriate periodontal assessment. You may also commit to an intraoral camera tour of the mouth to assess any restorative concerns so that pictures of any suspicious areas can be ready for the doctor’s exam. At the conclusion of such an appointment protocol, you would have all the information necessary to conduct your predetermined verbal handoff upon the doctor’s entry into the room.
This handoff can be very brief, but still complete. I recommend allowing the doctor a couple of minutes to connect personally with the patient. The information handoff works best when the doctor commits to giving a verbal cue to the hygienist that he or she is ready to hear it. Otherwise, if the hygienist has done his or her job in ascertaining the data and the doctor bypasses the handoff by jumping in to ask the patient questions, 3 things are virtually guaranteed to happen: the hygienist will not continue to ask questions the doctor will only ask again; patients will not be overly impressed with your communication, teamwork, and trust; and patients will not get the chance to clearly hear the information for a second time confirmed by the verbal handoff.
A great doctor cue could sound something like this: “I’m glad you’ve had a great summer, Jane. Now, Sara, I know the two of you have spent the last hour gathering some great information. Bring me up to speed on Jane’s current situation.” It can be any words that communicate the doctor is finished building personal rapport and now would like to hear the handoff preceding the examination. This cue is a small, but very critical piece.
The clinical handoff would then continue, perhaps sounding something like this: “Dr. Smith, Jane is doing very well overall. Her health is good, with no changes to her medications or health status (Health). The health of her gum tissue and bone levels has improved in some areas and worsened in others. The 4-mm pockets on the anteriors are now measuring at 3 mm with no bleeding, which is good news. However, I’m concerned about the lower molar area, where there are some fours along with bleeding on probing. These areas have proven difficult for Jane to floss, so I have recommended some additional homecare tools and also that we see Jane in 4 months instead of 6 months to keep a closer eye on the progression of the disease in those areas (Perio). As far as her jaw joint, she is experiencing some clicking occasionally in her left joint as well as frequent head and neck aches. I also noticed some advanced wear on some of her teeth, and we discussed the possibility of a nightguard to protect her bite and relieve some of her symptoms. Of course, we wanted to check with you to see if you concurred with that course of treatment, and if you do, she is very interested (TMJ). Jane’s current restorations appear healthy to me (Restorative), however she doesn’t care for the look of the composite fillings on her upper 2 front teeth. They have darkened, and she is interested in changing those. We discussed several options, including veneers, and she’s very interested and wanted to discuss that further with you at this time (Cosmetics).”
The point here is that whether your findings are positive or negative, there is always a report. It should include a report to the dentist of the findings in all the areas that you have decided upon in advance so that he or she hears they were checked and discussed. Remember to include all areas, every time, positive or negative. When it becomes the routine, patients love the thoroughness of this handoff and always feel well cared for.
HANDLING AESTHETIC ISSUES IN A HANDOFF
One note about the cosmetic or aesthetic piece of this handoff format: I find in observation of hygienists, they often do an outstanding job of relaying health and perio issues to the doctor. Many also do a great job with regard to restorative findings. However, aesthetic issues are often only articulated when the patient has initiated the conversation. I have queried many hygienists about this and found it very enlightening that, by and large, they worry it will be perceived as pushy or too “hard-sell” to ask patients about cosmetic concerns at every visit. I agree that if the opening conversation with a patient is more focused on selling something than really listening to the patient’s concerns, experiences, and desires, then you will always be perceived as a salesperson instead of a health-care provider. What we are after here is a comprehensive check-in at the checkup to ascertain (initially from the patient’s perspective and later in the appointment from yours) where things stand in all 5 areas. You would never stop asking about changes in patients’ health just because the last 4 times you saw them they were healthy. The same should be true for all other areas of the hand-off, including cosmetics.
Here’s a great example: I have been seeing my hygienist for many years. We have developed a deep trust relationship and friendship. In the last few years, I had received orthodontic treatment using Invisalign (Align Technology) and had noticed some darkening of my teeth over the course of my treatment. I had every intention on my next hygiene visit to ask if I could use my last Invisalign tray (currently serving as my retainer) as a whitening tray to whiten my teeth. As always, when I arrived, my hygienist and I got caught up on the life events that had transpired since my last visit as well as with a review of my health and an inquiry about any problems I might be experiencing. As usual, it was a great visit: no cavities, no failing restorations, no perio.
After my appointment, as I pulled out of the parking lot, I realized that I never asked about the whitening. Oh well. I’ll ask next time…in 6 months! What if my hygienist, as part of her initial interview, had simply added the last question to her usual ones? “Have there been any changes in your health or medications since we saw you last? Experiencing any problems with your teeth? How about cosmetically? Are you still as satisfied with the look of your teeth as you were the last time that I saw you?” No doubt my memory would have been jogged and I would have left with either some whitening gel or with impressions for new whitening trays. I would not have left thinking she was pushy. As a matter of fact, it would have been quite the opposite. I would have thought that she was being incredibly thorough. The power of this question rests in your true intentions and ease in asking it. Patients will follow your lead.
Additionally, I’m not a big believer in strict communication scripts because I find hygienists, and all team members for that matter, do better and are more consistent in the long run when they are part of an effort to create a communication structure rather than a word-for-word script. This allows for each of us to be genuinely and authentically ourselves in our interactions with patients, while still challenging us to become high-level communicators. I think it is much better to create a checklist of the points you always want covered in your handoff and ultimately to commit that list to memory.
I would like to finish with a synopsis of my recommendations for improving your clinical handoffs:
- Clinical Update
- CE Articles
- Dental Materials
- Dental Medicine
- Digital Impression Technology
- Forensic Dentistry
- Geriatric Dentistry
- Infection Control
- Interdisciplinary Dentistry
- New Directions
- Practice Management
- Oral Cancer Screening
- Oral Medicine
- Oral-Systemic connection
- Pediatric Dentistry
- Pain Management
- Post-and-Core Technique
- Sleep Disorders
- Sports Dentistry
- Technique of the Week
- Treatment Planning