We have been coming to Australia regularly since October, 1996, and have seen the face of dentistry change for many of our clients as they incorporate behavioral principles into their practices. We recognize, however, that there are cultural challenges which are hard to change quickly, and our clients are tenacious in their efforts even when it feels like paddling upstream. It would be as unfair to characterize Australian dentistry in a single description as it would be to do so for dentistry in North America or the UK. There are, however, some significant impressions I’d like to share with you.
One would probably find a similar cross-section of patients almost anywhere. In any one area, there are many patients who are serious about their health and who pursue good preventive care by planning their dentistry in advance. At the other end of the spectrum are a group of people who rarely, if ever, include dentistry in their priorities and who seek care only when they experience the pain which motivates its elimination. Many of our Australian clients find that the number of daily urgencies* are extremely high and difficult to accommodate. We were in a practice earlier this week which averages 6-8 urgencies* a day! I believe the dental culture here is still heavily urgency*-oriented— even in cities.
Many practices see substantially more new patients as urgencies* than otherwise. So, the question is the degree to which those urgency* patients remain urgency*-oriented and how many are “converted” to patients who plan their dentistry and adopt a preventive orientation. (*I have used the term “urgency” specifically to make the distinction between traumatic in- jury [emergency] and discomfort [urgency]. I believe changing the language helps sort out how to deal with it. If you want to know more about this distinction, you can read about it in my first book, Reclaiming the Passion of Dentistry)
Our most effective client practices can almost measure their degree of overall success by their accomplishments in this area. The more behaviorally sophisticated the practice, the more likely they will respond well to people’s unexpected discomfort as well as encourage them to end the pattern.
Certainly, each dentist must decide if he or she is prepared to accept new patients originally as urgencies. For reasons valid to the dentist, some choose not to. Their own patient base, new patient flow and referral system are sound, and they are not willing to interrupt planned dentistry or reserve unscheduled urgency time to accommodate someone who is not an existing patient. If, however, the practice is looking to broaden the patient base from several sources, it makes sense to look at how urgency patients might best be supported in shifting from an urgency orientation.
In essence, an urgency arises when a person is experiencing discomfort, either physical or otherwise. Sometimes a tooth hurts because of an internal problem or has become sharp from a break. At other times it is unsightly. And at still other times it causes the person to worry that it is going to further break and cause a more serious problem. Something prompts the person to call your practice to seek relief. How you respond to this call may be the single most important determinant of whether the patient remains in urgency mode or shifts.
What are the goals? Initially, to relieve the physical discomfort, of course. But relieving the discomfort does not necessarily require you to provide definitive care for the problem. In fact, providing anything other than palliative treatment supports an ongoing urgency orientation. This is where the Comfort Appointment becomes a powerful tool that helps you do the right thing.
The phone rings and Lois learns that a new patient has a toothache. Now Lois had better be careful because her language and approach is very important here. If she simply says, “I’m sorry that you have a problem. We have some emergency time set aside at 2 pm. Can you come in then?” she will have missed a great opportunity to begin redefining the role of the dentist in this patient’s life.
Let me also pause here to make an important distinction. I often hear either on voice mail messages the following, “If you have a true emergency, please call the doctor at ....” Now what is a “true” emergency? I think this statement is one which expresses frustration on the part of the staff rather than something that a patient can understand. An urgency is an urgency as experienced by the person with the urgency. It is totally subjective. And it doesn’t matter if the tooth has been hurting for two hours, two days or two months. A person acts when he or she feels it is time to act. Be careful not to go to judgment; it will interfere with your ability to help.
Now back to Lois. How can she best respond when a patient with an urgent problem calls?
First, I’ll outline the steps and then I’ll review them with you.
1. Express concern about the patient’s problem.
2. Learn about the nature of the problem by asking questions.
3. Be clear in identifying how you are prepared to help by describing the Comfort Appointment.
4. Review the fees for the Comfort Appointment and identify how you expect the fees to be handled.
5. Ensure that the patient finds this approach agreeable before confirming the arrangements.
Now, let’s review how the conversation might go.
“Hello,” says Lois.
“This is Julie Smith calling. I’m a new patient and I have a terrible toothache. I need to see the doctor right away, please. It’s killing me.”
“Julie, I’m so sorry that you’re having a problem and I hope we can help you. I want to make sure we understand your problem, so bear with me while I ask some questions. Tell me everything you can about what is going on.”
Julie describes the problem and Lois takes good notes. The doctor has trained Lois to ask clarifying questions about the basics so that she can generally make a distinction between a broken tooth, an endodontic problem, a wisdom tooth and the other types of problems which may cause discomfort. Once Julie has a basic understanding, she proceeds.
“Julie, Dr. Wonderful tells me that those types of symptoms are often associated with (general concept). It will be important for her to determine if that is, indeed, the reason for your problem. If you would like us to see you today, our goal would be to get you comfortable. That means we won’t ask you to make any big decisions while you are in pain. We will make provisions to see you at 2 o’clock for a Comfort Appointment. Before that time, I’ll brief Dr. Wonderful thoroughly. When you come at 2, I’ll review your medical history. Then Sally, the doctor’s assistant will take a film of that tooth so we can see what is going on below the surface. Dr. Wonderful will then be able to examine that specific tooth, look at the x-ray and determine the best way to make you comfortable right away. Her goal will be to make you comfortable without eliminating any options. Does that sound like it will work for you?”
The patient either says, “yes” or “no.” If the patient says, “Yes,” Lois continues.
“Great. Now of course, since this is not something you had planned, I suspect you would like to know about the fees and how we will ask you to handle your account today. The fee for your Comfort Appointment is $XXX. That fee will cover the examination, radiograph and the basic treatment to make you comfortable. We will ask that you come prepared to take care of that fee in full today. I want to make sure that is agreeable for you before we confirm our appointment.”
Again, the patient either says, “yes” or “no.” If the patient says, “Yes,” Lois goes on. “I am so pleased that we will be able to help you today. Once you are comfortable, Julie, perhaps you and I can talk about the next step, which would be to learn why this problem happened and make a plan for solving it. We would do that by making arrangements for a proper examination of your entire mouth so that you and Dr. Wonderful will have all the information you need to do the job right. You and I can talk about that, however, once you are feeling better. So, shall we consider it confirmed that you will be here at 2 this afternoon?”
Now, if Julie and Lois have been clear and honest with one another, this may be the start of a beautiful relationship.
But what if.....?
What if Julie doesn’t agree to any of the points? She won’t tell Lois the symptoms. The time won’t work. The fee isn’t acceptable. Paying isn’t acceptable. Palliative treatment isn’t acceptable. A return for examination isn’t acceptable? Well, that you must decide. But I put it to you that if a patient won’t or can’t work within these basic, very reasonable guidelines, it is unlikely that there is a long term relationship in your future.
Now, I am not suggesting that you become rigid and unreasonable. It does make sense, however, for you to set aside planned time for Comfort Appointments during your day so that you don’t infringe upon the time set aside for planned dentistry. It also makes sense for you to prepare more fully so that the dentist is only minimally required for the Comfort Appointment. It is also reasonable to agree in advance what the fee for palliative treatment will be. This also ensures that the dentist will not go beyond those guidelines, for to do so would violate the promise made to the patient. (You cannot allow your schedule openings to sway you into providing definitive care for an urgency new patient. If you want to know more about why, send an e-mail to sandy@prosynergy.com or call (800-848-8326. I’m happy to speak with you about this important point.)
It is reasonable for you to be asked to be paid for your services. This is not a mean thing to do. It is proper and fair. And, it is reasonable for you to establish a standard of care based on proper examination, diagnosis, treatment planning and treatment selection when a patient can make rational decisions.
Want to get out of the “emergency” business? This is how to do it, I believe. I’ll be interested in hearing how you fare in this area.
