Clear communication with the exceptionally difficult endodontic patient

Root canal treatment can be difficult at times, but predictable if you follow an endodontic prescription. On the other hand, patients can often be very unpredictable in their behavior and attitude toward you, your staff, and endodontic treatment.ADDITIONAL READING |3 patients who may not be candidates for complex dental care

I found that school did not prepare me for patient management, but life has. Dealing with difficult patients is no different than dealing with trying teachers, unyielding coaches, or demanding bosses. We are all prepared to deal with difficult and demanding patients because life is about dealing with these types of people. It’s the way we communicate with these patients that will make a difference in the resolution outcome of the perceived problem.

The following are two real-life cases of exceptionally difficult patients who recently came from my private practice.

Exceptionally DIFFICULT Patient No. 1: A 54-year-old female presents to my office in an emergency in “severe” pain. The patient has a continuous ache and is unable to chew on tooth No. 19. The patient is worked in between two appointed patients for a pulpectomy. I explain to the patient that today our goal is to help get her out of pain and that this is the first of two appointments. The pulpectomy is performed and calcium hydroxide is placed as an intracanal medicament. Postoperative instructions are given by my assistant, and the patient is brought to the front for payment and to appoint for a complete appointment. I am now 45 minutes behind schedule, and my appointed patient is waiting for treatment in another room.

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While trying to appoint for the RCT complete appointment, the patient becomes livid that she has to come back and demands to know why her root canal wasn’t finished. It became a “problem” enough that I had to come out of another room mid-treatment to calm the patient down. I informed the patient that we were trying to help her get out of pain and that I had explained the procedure would take two visits. The patient then said that I never mentioned a “two-visit” treatment and that if she would have known this, she would not have had the treatment done and would have just taken more Advil.

Exceptionally DIFFICULT Patient No. 2: This call came from a patient’s mother who no-showed an appointment two days earlier even though my office called and reminded her of her daughter’s appointment the day before.

Mother: “I need an appointment as soon as possible. My daughter is in great pain.”

Front office: “How about 4 p.m. today?”

Mother: “That’s not going to work. We are going to the hockey game tonight.”

Front office: “How about tomorrow at noon?”

Mother: “No, she has school.”

Front office: “How about next week?” (five days from now)

Mother: “Yes, that would be fine.”

One patient can “get into my head” and throw my entire office into turmoil. Over the last eight years of endodontic private practice, I have learned to better communicate with these exceptionally “difficult” patients. This article will discuss the pre-treatment, mid-treatment, and post-treatment patient communication that I use in my practice to communicate the root canal process with my “normal” and “difficult” patients.

Most patients are busy with work and family and just want the bottom line. Our goal is to minimize the unpredictable patient behavior by “difficult” patients by communicating effectively what the problem is, how it can be fixed, how much time it will take, and how much it will cost. This is the pre-treatment discussion. The mid-treatment discussion consists of: Asking how the patient is doing, explaining to the patient what you are doing (if they ask you to), and giving them a periodic end time estimate. The post-treatment discussion consists of: What does the patient do now?How long will the patient have discomfort?Does the patient need to come back for a second visit? and Does the patient have any questions?

Pre-treatment patient communication
We must be very clear to the patient that the root canal procedure will take one to one-and-a-half hours to complete and that it may take more than one visit. I also recommend that you have the patient sign a financial form outlining the cost of the root canal treatment, the insurance estimate and the patient’s estimate with the word ESTIMATE in bold prior to treatment. My front office verbally reviews this with the patient and then they sign the financial form. In my opinion, these three points are the most important part of patient communication, because it sets us up for success and resets patient expectations to a more realistic model. So many problems can be avoided if these three points are covered prior to root canal treatment.

This is an example of pre-treatment communication: “Mrs. Coulter, based on our testing and the pain you are having, you are going to need a root canal on that tooth. This process will take about an hour to an hour-and-a-half, and it may take more than one visit. Do you have any questions?”

I do not explain the root canal procedure unless the patient asks, because most patients just want to start treatment. The cost of the treatment was already reviewed prior to the patient coming back into the treatment room.

If patients need more information, I recommend a root canal model that visually explains to the patient the root canal process. Pictures or models tend to work much better than a verbal explanation of the treatment process. In my office, the pre-treatment patient education takes no more than a minute plus any patient questions.

Again, I must reiterate that the majority of the problems occur with demanding patients when they have unreal expectations on the time of the procedure (15 minutes) and that it will all be done in one visit. Clearly communicate the time and possibility of two visits prior to treatment and your patient problems will be cut drastically.

Mid-treatment patient communication
This is the easiest section of communication because the patient has a rubber dam over his or her mouth and is unable to clearly communicate. Show the patient that you care by periodically asking how he or she is doing and informing the patient if he or she needs a break or needs to use the restroom to just raise his or her hand. I tell the patient that he or she is still in control and can stop us anytime for a break. My assistant also will ask how the patient is doing and let her know if they need anything (neck pillow, different sized “resting” block, margarita, etc.) to just let her know.

Post-treatment communication
If you have set yourself up for success in the pre-treatment patient education, then this part will be easy. If a second visit is needed to complete the treatment, I explain that I have placed an anti-bacterial medicine (calcium hydroxide) that will help to continue to kill the infection inside the tooth. I intentionally use the words “antibacterial medicine,” because the patient hears antibiotic and equates this word with healing.

If I have completed the root canal treatment, then I give these postoperative instructions:
“Your root canal is completed. You will need to see your dentist for a final restoration within the next three weeks. We recommend making an appointment for about a week from now to start that process. Now, I just performed a small ‘surgery’ inside your tooth, so you will have some discomfort. I recommend chewing on the other side for the next three to five days and allowing this tooth to heal. If you are able and healthy, we recommend 600 mg Ibuprofen every six hours, three times a day for the next two to three days. If you need a stronger painkiller, we can write the prescription for you (only for certain cases). Do you have any questions?”

I also recommend calling every treatment patient the next day to check on how he or she is doing. I phrase it this way: “Hi, Mrs. June, this is Dr. Pullen. I was just calling to see how WELL you are doing after the treatment yesterday.” Very few physicians and dentists do this anymore, yet I believe the follow-up phone call on all treatment patients has been my biggest practice builder. The patients are very appreciative and often tell their dentist and friends.

In conclusion, I recommend discussing SIX key points with each patient prior to treatment and after treatment.

Point 1: Front office:“The cost of the root canal is $. The ESTIMATED portion that your dental insurance will pay is $, and your ESTIMATED portion is $ and is due today.” Avoid the patient statement: “I never knew it cost this much or I didn’t know I was out of network.”

Point 2: “You are going to need a root canal on this tooth for these reasons” … You want the patient to “own” the tooth and agree with you on the treatment recommendation. Avoid the patient questioning statement: “Did I really need this?”

Point 3:“The root canal will take an hour to an hour-and-a-half. Sometimes shorter; sometimes longer.” Avoid the patient statement: “I never knew it would take this long.”

Point 4:“The root canal may take more than one visit. It all depends on how difficult the tooth is to treat and how the bad the infection is inside.” Avoid the questioning statement: “I have to go through this again?”

Point 5:“I just performed a small surgery inside your tooth. It is going to be sore especially if you chew on it. I recommend avoiding chewing on this tooth for the next three to five days. Help yourself and take 600 mg Ibuprofen every six hours for the next two to three days. Try to stay ahead of any discomfort.” Avoid the statement: “I didn’t realize the tooth would still hurt. I thought you did a root canal.”

Point 6:“Call your dentist and make an appointment in the next two to three weeks for a permanent restoration.” Avoid the statement: “I didn’t know I had to go back to my dentist. You never told me that.”

Hopefully these tools will help you, the clinician, improve your communication with all of your patients and especially the exceptionally difficult ones.