Written by Irwin M. Becker, DDS, et al Tuesday, 30 September 2003 19:00
A middle-aged man peers into the mirror. His mouth looks and feels wrong. His appearance is declining and chewing is becoming difficult. He calls a local dentist to learn what can be done. How will the dental office respond to his call? What will he experience when he arrives? How will his dental health and sophistication be assessed? What options will be presented? What will be his role in decision-making? To what extent will he be asked to take responsibility for the process? How will the staff and dentist act toward him? The answer to each of these questions will have a profound impact on treatment acceptance and outcome.
As a dentist, assume you want to influence this man toward the best dental health he can achieve. Influencing people is not easy. You may need to influence him to change a number of behaviors, including the following:
•Adopt certain self-care habits such as brushing and flossing.
•Accept certain dental procedures that, in and of themselves, are not very appealing; only their results are appealing.
•Psychologically take responsibility for his dental health rather than passively depending upon the dentist, whereas the larger healthcare system in our country encourages dependency.
•Learn enough about his oral situation to make informed choices.
•Spend money on dental health that may have been targeted for other areas.
Psychologists report that people are most effectively influenced within the context of a meaningful relationship. Therefore, if this middle-aged man is your patient, you must build a relationship with him in order to do your best work. Such relationships go beyond rapport and good chairside manner. Good rapport ensures superficial cordiality and pleasant behavior as long as there is low stress. As every dentist knows, dental treatment often involves high stress. Creating relationships that go beyond good rapport is not easy, and the skills required to do so are not taught in dental school.
The skills needed to create influential relationships require dentists to have or develop psychological knowledge. The concept of emotional intelligence (known colloquially as EQ) has organized psychological knowledge so that non-psychologists can use it to develop the skills necessary to build powerful relationships. EQ has gained prominence because it has been proven to have substance and utility. It rests on a growing body of research of more than 20 years. Finally, EQ skills can be learned and developed. A low-EQ person today can become a stronger EQ person tomorrow.
EQ identifies specific skills that can be tested for relevance and value in specific work settings such as dentistry. For example, (1) high-EQ executives add 127% more to their company’s bottom line than average performers1, (2) high-EQ software experts add 320% more value than average performers2,3, and (3) high-EQ sales people sell more than their counterparts with lower EQ.1,4-6
It stands to reason that if EQ can contribute to the success of people in these roles, it is likely to contribute to success for dentists. (For a more complete account of the value of EQ in the workplace, refer to The EQ Edge by Steven Stein and Howard Book  and Working With Emotional Intelligence by Daniel Goleman .)
Definition of EQ
EQ can be defined as the set of skills people use to read, understand, and respond intelligently to the emotional signals sent to us by others and ourselves. It allows us to understand and adjust our reactions to events and people and enable us to influence others.
Research by psychologist Reuven Bar-On, PhD, has identified 15 distinct skills that comprise the overall concept of EQ. His list includes skills such as self-regard, assertiveness, empathy, stress tolerance, and optimism. Studies have found that different occupational roles require different combinations of these EQ skills for maximum success.7,8 For example, the skills needed by CEOs to achieve maximum success are different from those needed by people who are software experts or who have a career in sales.
THE PANKEY STUDY OF EQ
For over 30 years, The Pankey Institute has been a world leader in training dentists in advanced dental techniques. The core of the Pankey philosophy states “It is essential for the dentist to establish a deep, mutually rewarding relationship with the people whom she or he treats.” To test the utility of EQ skills for dentists, the institute conducted a study that proposed to answer 2 questions: (1) Do EQ skills contribute to a dentist’s success in implementing a relationship-based model of dental practice? And (2) if so, which EQ skills are most important for the dentist to master in order to implement the model?
The study was patterned after one done with US Air Force recruiters.8 In the mid-1990s, the Air Force was losing half of its recruiters every year, with a price tag of $30,000 for each replace-ment. It was a problem that had resisted solution for years. The Air Force knew that recruiters need certain technical skills but did not know which emotional skills were most critical for success. They undertook a study to learn which of the 15 EQ skills identified by Dr. Bar-On are most associated with recruiter success. Dr. Bar-On’s psychological measure of EQ, the Emotional Quotient Inventory (EQ-i), was administered to 1,171 recruiters. Test results were compared to job performance.
Recruiters strong in 5 skills (assertiveness, empathy, happiness, emotional self-awareness, and problem solving) were 270% more likely to achieve their recruiting quotas than recruiters weak in those skills. Furthermore, successful recruiters worked fewer hours than less successful recruiters. (EQ may have implications for overworked dentists.) The Air Force began to screen recruiter candidates with the EQ-i for strength in these 5 EQ skills. In addition, it trained incumbent recruiters in the same skills. Within 1 year, recruiter retention skyrocketed to 96%, saving $2.7 million per year.
A similar study was done with 76 CEOs of successful companies.9 It was found that these CEOs were, on average, superior to the general population in 5 EQ skills: independent thought, assertiveness, optimism, self-actualization, and self-regard.
To conduct our study, we needed to compare the EQ of dentists well-versed in the Pankey model with the success that they have had in implementing that model in their practice. To measure implementation, we created a 92-item self-report instrument, the Survey of Progress (SOP). (Note: Paul Henny, DDS, a Pankey-trained dentist practicing in Salem, Va, helped Dr. Ackley develop the initial version of this questionnaire.) It asks dentists to report the frequency with which they engage in Pankey-encouraged behaviors in the following 3 areas: (1) technical diagnostic skills taught at the institute; (2) behavioral steps of relationship building (such as initial patient interviews, codiscovery, and team development); and (3) business practices that benefit both patient and dentist.
Participants had to have completed at least 6 weeks of training at the institute to ensure they had deep exposure to the Pankey practice model. Two hundred twelve dentists responded to recruitment letters. Of those, 144 (130 men and 14 women) provided a complete set of responses. Their ages ranged from 33 to 63 years, with a mean age of 48.6 years. (Note: This article briefly summarizes a sophisticated study protocol. Complete study data are on file at The Pankey Institute,  428-5500.)
A positive, statistically significant correlation (+0.44) was found between the total EQ-i score and the SOP, meaning that as EQ scores go up, so do SOP scores. Similar correlations were found between 13 of the 15 EQ skills and total SOP score. Thus, EQ in general appears to be a key component in successful implementation of the Pankey practice model.
The second goal of the study was to identify which EQ factors are most important to that success. A regression analysis found that the 4 components of EQ that are most critical to success are emotional self-awareness, reality testing, assertiveness, and self-actualization.
Emotional self-awareness (ESA) is the ability to notice that you are having an emotional reaction and to recognize which emotion is being experienced (eg, anger or sadness). Such knowledge is significant information that we can use to decide how best to respond to a situation.
Highly skilled individuals in technical fields such as dentistry and engineering often have been trained to think of emotions as frivolous and unimportant. They strive to maintain objectivity. Objectivity, unfortunately, cannot be achieved by ignoring emotion. Denial does not make feelings go away. It does lead us to miss the information that emotions can provide. Only when we recognize our emotion can we then put that part of our response into its proper perspective and achieve objectivity when necessary.
Imagine a tired dentist with the last patient of the day. This patient presents with unexpected needs that exceed the scheduled time but cannot be ignored. If the dentist tries to ignore his or her own frustration, he or she is likely to express it in some unrecognized way (perhaps with curt answers to questions). Such responses will decrease the dentist’s long-range ability to influence dental health. Dentists who recognize and accept their frustration are in a position to control how it is expressed, perhaps by saying something like “We are going to have to be here a little longer this evening than either one of us would like, but we will make this right for you.”
How does emotion help you know how to respond to people to deepen the influence of your relationship? Imagine that you feel annoyed with a patient. Because you noticed the feeling, you can now ask yourself “I wonder what my irritation means?” The answer is apt to provide information that will help you identify a strategic response that fits this particular patient in this particular encounter. For example, suppose you take pride in empowering patients while this patient is behaving in a highly passive and dependent manner. Recognizing the source of annoyance gives you a conscious choice about how to respond. You might opt to accept that this patient is more passive than you would like. Alternatively, you might choose to take steps to help the patient learn how to increase active participation in her or his own oral health. Either way, you are less likely to express annoyance in a way that may harm the relationship.
Our emotions sometimes come from our own thoughts and memories rather than external events. For example, perhaps the patient with whom you are annoyed physically reminds you of someone you intensely dislike. Recognizing the reaction and its source can alert you that you have unconsciously confused these 2 people in your mind, a surprisingly common occurrence. This knowledge can lead you to step back, recognize the differences between the 2 people, and respond to the person who is actually in the chair.
Reality testing is the victory of judgment over raw emotion. Good reality testing occurs when we are able to keep our emotions from excessively influencing our interpretations of events. For example, if some people are reasonably optimistic, they have assessed a situation cognitively, seen possibilities (that pessimists miss), then have added the emotional seasoning of hope.
People often have trouble with reality testing in 2 ways. First, people sometimes wear rose-colored glasses because they want something to be true so much that they ignore data to the contrary. For example, imagine yourself in this situation: you have worked many hours on a major, comprehensive treatment plan. You are justifiably proud of your creative competence. Furthermore, your practice has been a little slow in recent months. While financial pressures have not compromised your clinical judgment, you can’t help but recognize that the fees from this case will ameliorate a “tight spot.” If you are wearing rose-colored glasses, you might jump to the conclusion that your patient is ready to agree to treatment and miss signs that the patient has reservations.
Conversely, some people misinterpret events from a negative perspective. A dentist may fear rejection and misinterpret a comment from a patient as disinterest in a treatment plan when that was not the patient’s intent. Such dentists commonly back away from presenting plans that might be well-received.
Strong reality testing contributes to sound judgment. The dentist whose reality-testing skills are well-developed can read situations for what they are without the excessive intrusion of hopes or fears. A common area of denial in dental practice is staff conflict. The dentist with strong reality testing is less likely to fall into the trap of pretending staff conflict could never happen “because everyone likes each other.” In reality, liking and conflict do coexist. This dentist will recognize staff conflict for what it is and is positioned to develop a strategic response.
Finally, strong reality testing can enhance hiring accuracy. Rather than hoping that a receptionist will work out, dentists with strong reality testing perform due diligence in screening potential employees. They learn to recognize the personality limitations that may make an otherwise qualified candidate a poor fit for their office.
Assertiveness is the ability to articulate one’s wants and needs in a constructive fashion. It is often confused with aggressiveness. We are aggressive when we try to force our ideas on someone else. Assertive communication occurs when we express what we want, think, and feel in a manner that creates the following subtext: “I’m not going to hurt you and I’m not going to let you hurt me. We are both safe here.”
Assertiveness helps establish trust, an essential part of the Pankey model. The assertive dentist is more capable of developing a nonthreatening doctor/patient relationship (which is not easy, given that many people feel threatened before they walk into the reception area). Assertiveness helps dentists create win/win outcomes wherein both doctor and patient leave the encounter feeling they got all they wanted and often more. For example, the patient receives dental treatment while feeling both safe and respected. The dentist is allowed to do her or his best work, gets paid, and earns the patient’s gratitude. Win/win experiences build long-term cooperative relationships that tolerate the stress that is often part of dental experiences.
Assertiveness also helps dentists in their role as office team leader. The successful dentist has established a vision, either formally or informally, that guides practice development and maintenance. An assertive dentist is better equipped to help staff understand the vision. When staff members understand what is expected of them, conflict is reduced. Assertively communicating clear expectations eliminates the power vacuum that occurs when people “fill the void” with their individual visions. Dentists who fill the void with their vision—in a nonshaming, nonthreatening way—will have happier, more cooperative staffs.
Self-actualization is the ability to engage our passions and talents. The more we see ourselves as developing and learning along lines that feel important to us, the higher our self-actualization score is likely to be.
Self-actualization has 2 elements: passion for our work, and interests outside our work life. People who score high on self-actualization are more likely to be involved with their families, communities, and other interests while enjoying their practice. A man recently captured the 2 parts of self-actualization beautifully when he said, “I’m a lucky guy. I’m looking forward to going home to be with my family and all we will do this weekend. Come Monday morning, I’ll be excited about getting back to the office.”
The life balance of self-actualization contributes to success because taking a break from the job creates refreshment and clearer thinking. While not measured by SOP, a long-standing principle taught at The Pankey Institute is “Dentists and patients benefit when dentists establish balance in their lives.”
We expected to find self-regard, empathy, and interpersonal relationships to be essential skills for success with this model. Indeed, their respective correlations with SOP scores were 0.44, 0.25, and 0.31, meaning that as dentists’ skills in these areas were shown to be stronger, their SOP scores were higher. While we continue to believe that these are important skills, they were not found to discriminate more successful Pankey dentists from less successful individuals. Whatever is measured by these components of the EQ is also measured–and measured more effectively–by the parts of the EQ related to emotional self-awareness, reality testing, assertiveness, and self-actualization.
The results of this study support the belief that emotional intelligence is a key component in the successful implementation of the Pankey relationship model of dental practice. Those participants who have higher emotional intelligence report better success in implementing the technical skills and business practices taught at Pankey. We believe this is because their higher EQ skills help them create relationships in which patients are engaged in positive health choices.
Specifically, the emotional intelligence skills that are most important to success appear to be emotional self-awareness, reality testing, assertiveness, and self-actualization. Thus, if a dentist is bogged down in the transition from a traditional practice model to a Pankey-style model, it may be that one or more of these skills have not been sufficiently developed. Since these EQ skills can be learned, this need not be a permanent barrier to success. The results of this study have implications for all dentists who seek to achieve success and fulfillment in practice and life.
1. Hunter JE, Schmidt FL, Judiesch MK. Individual differences in output variability as a function of job complexity. J Appl Psychol. 1990;75:28-42.
2. Jones C. Programming Productivity. New York, NY: McGraw-Hill; 1986.
3. Martin J. Rapid Application Development. New York, NY: Macmillan; 1991.
4. Spencer LMJ, McClelland DC, Kelner S. Competency Assessment Methods: History and State of the Art. Boston, Mass: Hay/McBer; 1997.
5. Hay/McBer Research and Innovation Group (1997). This research was provided to Daniel Goleman and is reported in his book, Working With Emotional Intelligence. New York, NY: Bantam; 1998.
6. Seligman MEP. Learned Optimism. New York, NY: Knopf; 1990.
7. Stein S, Book H. The EQ Edge: Emotional Intelligence and Your Success. Toronto, Canada: Stoddart; 2000.
8. Handley R. AFRS rates emotional intelligence. Air Force Recruiter News. April 1997.
9. Stein S, on behalf of Innovators Alliance. The EQ factor: does emotional intelligence make you a better CEO? November 2002. Available at: http://eqi.mhs.com/innovatorsalliance.htm. Accessed January 7, 2003.
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