The Doctor-Patient Relationship

Question 1

Medical Evaluation in Dentistry

Answer 1

recognized as a priority in healthcare of 150 years
frequency of patient interaction requires quality care and a good relationship
-we see patients more than physicians
dentist serves as the role of primary care giver
primary objective is to improve patient well-being
in commitment to serve, we have responsibility to listen to patient with distraction or bias
-allows us to not overlook any symptoms or signs

Question 2

Importance of a Good Relationship

Answer 2

we may be the first to diagnose many chronic conditions
oral cavity can serve as an early manifestation of systemic disease
-hypertension, HBP, diabetes, neurologic problems…
long term relationships allow use to see changes physically and emotionally
signs of trauma to the face and neck may suggest a violent relationship or interaction
-actually very common

Question 3

Medical Responsibilities

Answer 3

recognizing underlying conditions
ensuring safety of dental treatment 
referral for evaluation and treatment 
admitting patients to hospitals 
maintaining medical knowledge and consistently reviewing these subjects

Question 4

Ulysses Syndrome

Answer 4

DOESN’T mean we should fish for a condition that does not exist
false positives and unnecessary tests have have significant impact on a patient
-places fear in patient
-any abnormality requires confirmation (additional tests)
ensure that referrals and tests placed are necessary and reasonably likely to lead to important new information

Question 5

Establishing the Relationship

Answer 5

start the second you meet the patient
doctor’s attitude and reactions to the patient’s complaints sets the tone
allow patient to guide the conversation (somewhat)
show care in responses to their descriptions
create a warm, welcoming, positive environment with privacy and comfort

Question 6

First Impressions

Answer 6

appearance 
dress 
actions 
attitudes (positive!) 
word choice (be welcoming) 
tone of voice (don't be fake, they can tell)

Question 7

Establishing a Rapport

Answer 7

exhibit care in responses
be respectable by not overly authoritarian
show patience and tact
allow small talk and positioning to make the patient comfortable
-sitting at their level can make a huge difference
-in urgent situations, sitting the chair can show patient that you understand the sense of urgency
speak to patients based on their understanding and level of education
remember personal details
-take notes

Question 8

Active Listening

Answer 8

empathy
-allow the patient’s anger without becoming angry
validation
reassurance (within reason)
respect
reflection (can be done by repeating patient)
-both in yourself and with the patient
-allows for identification of any habits or nervous tendencies
interpretation (rephrase to check understanding)
silence
-allowing for any processing or displays of emotions
summarization
motivation (oral hygiene or more complex areas)
communication
-sharing treatment philosophy and scope of practice
highlighting transitions
-continue the appropriate pace

Question 9

Experience of Illness

Answer 9

understand the patient’s perspectives on their complaint
-normal vs. life changing
discuss this experience in context of the objective data you have gathered
-patient’s experiences may cause them to have negative expectations (ex. friend had bad toothache)
disease - clinician’s scientific understanding of the process, diagnosis and treatment
illness - patient understanding and how the present fits with past experiences
understand expectations including about prognosis

Question 10

Psychologic Assessment

Answer 10

addressing the emotional aspect of the problem
allowing for open communication
bringing past diagnoses to play in both evaluation and treatment
how any other condition may affect their current complaints
-larger underlying condition (such as what they’re feeling) may effect what’s going on

Question 11

Assess

Answer 11

appearance (well dressed? over dressed?)
speech
motor activity (twitches? ticks?)
mood (low? high? alternating?)
thought (all over the place or organized?)
perception (do they perceive things the way you do? any paranoia?)
orientation and memory
attention and concentration
reasoning (linear? circular? does it seem to follow any appropriate path?)

Question 12

Anxiety as a Possible Concomitant Condition

Answer 12

high speed processing, loud and quick speech, physical movement, multiple questions
may become argumentative or compulsive
-if previous interactions have not been great

Question 13

Affective Disorders as Possible Concomitant Conditions

Answer 13

may not comply with instructions or hygiene regimens
may place an exaggerated weight on appearance
often associated with facial pain conditions as either a cause or sequela

Question 14

Somatic Disorders as Possible Concomitant Conditions

Answer 14

physical manifestations of a neurologic conditions
-ex) burning mouth syndrome
-ex) persistent idiopathic facial pain (phantom tooth pain)
should NOT be reinforced, but should be taken seriously

Question 15

Hypochondriasis as a Possible Concomitant Condition

Answer 15

lengthy history of many visits with different providers
may report previous substandard care
-may cause them to not be satisfied with any of your care

Question 16

Values

Answer 16

standards we use to measure our own and others’ beliefs and behaviors

Question 17

Biases

Answer 17

attitudes or feelings that we attach to perceived differences

 - avoid these with your patients! 
 - every person approaches an interaction based on their own pervious experiences

Question 18

Ways to Avoid Biases

Answer 18

reflect on your own thoughts (and any discomfort) around…
-finances
-sexuality and sexual practices
-alcohol and drug use
-gender
-socioeconomic groups
-racial or ethnic groups
educate yourself and discuss your background
practice discussing any subjects that you have previously considered taboo

Question 19

Avoid Assumptions

Answer 19

ask about any difficulty reading
-read aloud as needed
-do NOT assume that this is the same as stupidity
be sensitive to impaired hearing and sight
-make accommodations
do not allow stereotypes to shape your care
allow patients to teach you about their health, background, culture, and beliefs
be open to discussing all subjects, but do not force the issue

Question 20

Paralanguage

Answer 20

the non lexical component of communication by speech
match your responses to the patient
-tone
-pacing
-volume
***also try to match their emotions
use their language, but clarify its meaning
-beware of interpretation or language barrier
modulate your affect to show understanding
-use facial expressions

Question 21

“Do No Harm”

Answer 21

do not create barriers to communication
remove barriers and miscommunication as thoroughly as quickly as possible
do not provide inaccurate information
ensure patient understanding through rephrasing
use questions with high diagnostic values
-specificity: want to use general questions first and then get to more specific ones
-sensitivity

Question 22

Findings

Answer 22

ensure that your assessment is clearly and thoroughly communicated
check the patient’s grasp on the implications of your words
-this may include repetition
-remember that you are the expert
-what is obvious to you may not be to other
determine willingness to proceed, concerns, and questions
-make sure you understand all aspects that the patient is concerned about so that you can address them together

Question 23

Child Patients

Answer 23

attend to your relationship with both the patient and their caregiver

 - clarify who accompanies them (parent? family member?) 
 - understand their living and legal situations 
 - acknowledge the work of parenting/caregiving and that the person's role in the child's health 
 - the adult in their life is the most important health model and provider 
 - spend time to put child at ease 
 - with adolescents, allow for additional silence

Question 24

Forces Influencing Healthcare

Answer 24

explosion of technology 
social media influence 
changing market forces 
challenges in healthcare delivery 
prospect of (bio)terrorism 
globalization 
     -patients can now travel for treatment or get second opinions easily 
changing consumer attitudes

Question 25

Fundamental Principles of Medical Professionalism

Answer 25

principle of primacy of patient welfare
principle of patient autonomy
principle of social justice

Question 26

Principle of Primacy of Patient Welfare

Answer 26

based on dedication to serving the interest of patient
altruistic behavior contributes to the trust that is central to the dentist-patient relationship
-must be maintained at all times
market forces, societal pressures, and administrative needs must not compromise this principle
be able to balance your own interests with patient (and family) interests

Question 27

Maintain Balance Interests

Answer 27

treat in a calm and unhurried manner
ask about feelings instead of assuming
do not show disapproval of patients desires or actions
-can explain possible risks of delaying treatment instead
hide any embarrassment, impatience, boredom
do not condescend, criticize, or belittle
do not stereotype
never speak ill of patients to colleagues or to other patients
-goes the other way as well, don’t talk bad about colleagues in front of patients

Question 28

Principle of Patient Autonomy

Answer 28

physicians must be honest with their patients and empower them to make informed decisions about their treatment
-educate so they understand what’s going on
patient’s decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care
-it is within our rights to refuse patient care that we believe is not needed or we view as not beneficial to their long term health

Question 29

Principle of Social Justice

Answer 29

the medical profession must promote justice in the health care system, including the fair distribution of health care resources
physicians/dentists should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category

Question 30

Responsibilities of the Healthcare Professional

Answer 30

professional competence 
honesty with patients 
patient confidentiality 
maintaining appropriate relations with patients 
improving quality of care 
improving access to care 
just distribution of finite resources 
scientific knowledge 
maintaining trust by managing conflicts of interest 
professional responsibilities

Question 31

Commitment to Professional Competence

Answer 31

commitment to lifelong learning
responsible for maintaining the medical knowledge and clinical and team skills required for the provision of quality care
the profession as a whole must strive to see that all of its members are competent
must ensure that appropriate mechanisms are available for dentists to accomplish this goal

Question 32

Commitment to Honesty with Patients

Answer 32

ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred
-inform of alternatives and effects of each
patients must be empowered to decide on the course of therapy
if patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust

Question 33

Commitment to Patient Confidentiality

Answer 33

earning trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information
extends to discussions with persons acting on patient’s behalf when obtained the patient’s own consent is not feasible
-unconscious situation
increasingly difficult due to electronic information systems
make sure the patient understands that there are limits
-permission to share information
-any suggestions of harm to self or other creates an obligation to report
-includes well-being of a child

Question 34

Commitment to Maintaining Appropriate Relations with Patients

Answer 34

given the inherent vulnerability and dependency of patients, certain relationships between dentists and patients must be avoided
no exploitation of patients for:
-sexual advantage
-personal financial gain
-other private purpose
respectfully but firmly avoid any sexual advances from patients

Question 35

Commitment to Improving Quality of Care

Answer 35

maintaining clinical competence
work collaboratively to reduce medical error, increase patient safety, minimize overuse of health care resources (ex. excess testing), and optimize the outcomes of care
actively participate in development of better measures of quality of care and the application of quality measures
take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care

Question 36

Commitment to Improving Access to Care

Answer 36

strive to reduce and/or eliminate barriers to equitable health care

 - education 
 - laws 
 - finances 
 - geography 
 - social discrimination

Question 37

Commitment to a Just Distribution of Finite Resources

Answer 37

while meeting the needs of individual patients, doctors are required to provide healthcare that is based on the wise and cost-effective management of limited clinical resources

Question 38

Commitment to Scientific Knowledge

Answer 38

uphold scientific standards, promote research, and create new knowledge and sure its appropriate use
the profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience

Question 39

Commitment to Maintaining Trust by Managing Conflicts of Interest (COI)

Answer 39

many opportunities exist to compromise professional responsibilities by pursuing private gain or personal advantage
for-profit industries that if you are involved in, you will want to be open and honest with your involvement to the public
-medical equipment manufacturers
-insurance companies
-pharmaceutical firms
obligated to recognized, disclose to the general public, and deal with COI that arise in the course of professional duties and activities

Question 40

Commitment to Professional Responsibilities

Answer 40

work collaboratively to maximize patient care
be respectful of one another
participate in the processes of self-regulation
define and organize the educational and standard-setting process for current and future members

Question 41

ADA Principles of Ethics and Professional Code

Answer 41

patient autonomy (“self-governance”)
-duty to respect the patient’s rights to self-determination and confidentiality
nonmaleficence (“do no harm”)
-duty to refrain from harming the patient
beneficence (“do good”)
-duty to promote the patient’s welfare
justice (“fairness”)
-duty to treat people fairly
veracity (“truthfulness”)
-duty to communicate truthfully