We have all heard the expression: Patients don’t care how much we know until they know how much we care.
It’s happened to all of us at one time or another, often at a social gathering of friends or acquaintances. Someone mentions an upcoming appointment for root canal treatment and the jokes and stories start to emerge. The bottom line in all these nervous comments is typically anxiety, fear, sense of being out of control, and the unknown. Occasionally, however, some people may refer to the benefits they received from saving their tooth through endodontics and the positive experience they had. Or, they will attempt to describe the sophisticated technology used in the procedure, and their surprise at how relatively comfortable and easy the experience was. However, despite the significant advances in endodontic treatment and the benefits that endodontics provides to millions of patients every year, the old stories still live in the minds of most people, influencing their treatment decisions.
This Viewpoint article does not focus on that fear or its many manifestations but rather on how, one patient at a time, new “technologies” in relationships and communication can assist the endodontic profession in changing the stories and myths of endodontic treatment and ameliorate the anxiety that often accompanies endodontic treatment. The application of emerging research in neuroscience and neurophysiology is having a significant positive impact on communication and relationships with patients; particularly in those situations in which fear and anxiety may hinder the patient’s treatment decisions and recovery process.
ENGAGING PATIENTS TO CREATE SAFENESS
The word engage is derived from Old French meaning, “to attract the attention of.” Undoubtedly, attracting and maintaining the attention of patients is essential in discussing their diagnosis and treatment plan, and the experience of safeness is crucial to this process. One thing that is certain about endodontic treatment: there is a strong desire and motivation on the part of the endodontist and his or her team to help the patient feel safe and confident in the treatment. We invite you to think about the lengths to which you and your team go in order to create an environment and an experience in which patients feel safe and assured. There’s no question that all the things that the endodontic profession does to make this happen are important. What we want to present in this article is information to augment those efforts with skills based on Dr. Stephen Porges’ research in neurophysiology and described in his textbook The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation (available via the website stephenporges.com). Just as new technologies for endodontic treatment have profoundly advanced and enhanced the precision, effectiveness, and efficiency of endodontic treatment, so too Polyvagal Theory provides us with innovations in the way that our profession creates the experience of safeness for our patients.
The Social Engagement System
The essence of Polyvagal Theory revolves around what Dr. Porges calls the Social Engagement System and the role of the vagus nerve in modulating the fight-or-flight response. The essential point is that the human nervous system evolved to constantly evaluate risk and safety in the environment (outside of our conscious awareness), a process that he calls neuroception. His research illustrates how important the nonverbal cues of body posture, facial and eye contact, and facial expressions, as well as tone of voice, are in relationships; particularly professional relationships with patients. If a clinician is anxious or frustrated, the patient’s nervous system will pick up on subtle nonverbal cues and signal a “threat” to the patient’s nervous system, even if there is no real threat present. The vagus system will shut down, stimulating fight/flight responses and hamper hearing, thinking, and decision-making. In contrast, vagal stimulation calms the heart and dampens or turns off the stress response. The patient’s nervous system shifts to neutral or a nonthreatened state and his or her capacity to hear, listen, and think is facilitated. Thus, it becomes very important for the endodontic provider and his or her team members to develop skills for regulating their own social engagement system. It’s similar to the instructions we all receive just before an airline flight: In case of an emergency, put on your oxygen mask first before assisting others. Analogously, it’s important to regulate your own social engagement system, and thus, your own nonverbal signals first, before focusing on positively influencing a patient’s vagal responses. In this regard, focusing on being physically present and open to the patient is an invaluable asset and imperative for successful “case acceptance” with patient cooperation and full participation in their emotional and financial investment.
Go SOLER
A valuable skill to utilize goes by the acronym of SOLER. Developed for the counseling profession, SOLER describes 5 elements to bring awareness to how you physically show up in relationships, and these methods enable patients to experience the valuable qualities of being heard, being seen, and being important. SOLER involves facing patients squarely, being physically open, leaning forward slightly, making varied eye contact, and relaxing your body. This simple act, done with intention, communicates safeness to patients, increasing the probability that they are able to positively and responsibly think and act on clinical recommendations.
Trust and Responsibility
The patient has given trust to the general dentist. Trust, an ancient word from Old Norse and Middle English, refers to “placing reliance upon.” The general dentist must earn the patient’s “willingness to place reliance” upon the general dentist and accept the responsibility to uphold that trust. In the interdisciplinary referral, the conscientious general dentist accepts the responsibility of referring the patient to the specialist and recognizes the significance of that transfer of trust and placing reliance upon the specialist. Psychologists tell us that trust is transferable.1 Thus, the specialist must create the experience in which the patient grants the specialist a small amount of trust and then the specialist must build on that small amount of trust. The patient grants more trust and the specialist must continue to build on that increase in trust. In order to optimize a successful trust transfer, the process must continue until the patient feels safeness and is willing to surrender to that trust. The specialist, like the general dentist, is responsible for trust growing until the patient feels complete safeness in the specialist’s hands. Once this milestone is earned by the specialist, the clinical team can do their job for the benefit of the patient, the dentists, and dentistry.
As with the general dentist, the specialist, therefore, must recognize and accept the important responsibility for that transfer of patient trust. In order to have a successful relationship, the general dentist, the specialist, and the patient must ultimately trust each other. Throughout time, trust is built for the entire interdisciplinary network, including the referring dentist, the specialist, and the patient. The principle of trust needs to be both a thinking process and an action process involving the entire treatment team at all times. For example, the specialist is accountable for affirming the dentist’s treatment plan and trusting that the entire team can achieve the vision that the patients have for their oral appearance and function. Once patients have trust, they can think, become aware of their mouth’s condition, evaluate options, choose and, therefore, feel and actually be in control. Patients who understand the diagnosis will always act out of self-interest and choose the treatment plan that is best for them.2 While there is only one diagnosis, there may, of course, be several treatment plan possibilities, each of which has different pluses and minuses. The specialist who has earned the patient’s trust has the opportunity to lead the patient toward comprehensive aesthetic and restorative treatment.
AN INTERNAL TECHNOLOGY
Patients derive great benefit from the external technologies the endodontic profession has researched and developed. Now, the application of research from the fields of neuroscience and neurophysiology can also provide us with additional “internal technologies” that will help us in the quest to provide both clinical excellence and positive experiences for patients. We encourage exploring how operationalizing the research of Dr. Stephen Porges and Polyvagal Theory can enhance your life and your practice. Trust begins as an internal experience and being intentional about your physical presence can help generate the experience of trust.
Start with the simple, yet profoundly powerful, process of going SOLER and experience what happens in your practice as well as your life.
References
- de St Georges JM. The art of effective referrals. J Calif Dent Assoc. 1992;20:65-68.
- Wilde JA. Create a bond of trust in only two minutes. Dent Econ. 1995;85:54-57.
Dr. West is founder and director of the Center for Endodontics in Tacoma, Wash. He graduated from the University of Washington Dental School and received his MS degree and endodontic certificate at Boston University, where he was awarded the Alumni of the Year Award. He is an educator and clinician, and his focus is interdisciplinary endodontics. He has authored several textbook chapters and is an editorial board member for the Journal of Esthetic and Restorative Dentistry, Practical Procedures in Aesthetic Dentistry, and the Journal of Microscope Enhanced Dentistry. He can be reached toll-free at (800) 900-7668, via email at the address johnwest@centerforendodontics.com, or via the website centerforendodontics.com.
Disclosure: Dr. West reports no disclosures.
Dr. DesRoches is a Seattle-based psychotherapist, consultant, internationally known workshop facilitator, and published author. He has worked with dental professionals for more than 19 years providing consulting and coaching. He develops workshops for study clubs, dental groups, and associations around the country, which include such topics as Optimizing Your Influence in Patient Relationships; Engage, Influence, and Prosper; Practice Leadership; The Value of Clarity; and The Power of Choice. His innovative approach of integrating the latest research in neuroscience with practical skills provides a unique and powerful process for experiencing a high performing, profitable, and fulfilling practice. He is the author of Your Boss is Not Your Mother (William Morrow, April 1995; also published in 6 languages), Reclaiming Yourself (Dell Publishing, April 1990), and other books. He can be reached at (206) 323-6114 or via email at bdesroches@att.net.
Disclosure: Dr. DesRoches reports no disclosures.
