Is it really about time? Overcoming the real barriers to complete oral cancer screening -- part 5
By Jonathan A. Bregman, DDS, FAGD
In the previous articles of this series, I discussed four barriers I see as stopping those in the dental profession from doing a complete oral cancer screening examination.
In Part 1, the barrier I discussed is the overall lack of confidence in doing a complete extra-/intraoral cancer screening exam. The rationale: “not doing the exam at all puts me at less risk than doing it and missing something.”
In Part 2, the barrier I discussed is being unclear about who to examine: the changing target population, especially the influence of the human papillomavirus (HPV 16/18).
In Part 3, the uncertainties of how the complete cancer screening examination should be done, plus communicating the reasons for doing it for patients.
In Part 4: Uncertainty about how to properly record the cancer screening examination
Barrier 5: Uncertainty about how to best and most effectively deliver the message of a positive finding
The more we look, the more we find.
The more we look, the closer we look, the more abnormalities we will detect with our cancer screening exam. This makes sense, of course. The same goes for the complete periodontal examination, the complete occlusal analysis, the complete updated radiographic evaluation, etc.
In each area — tissue abnormalities, periodontal abnormalities, occlusal abnormalities — we must address the needs of the patient in a way that sets the stage for understanding of the problem(s) and presenting possible options/solutions to correct the problems.
Build on what you already know
In every program I do on this important aspect of doctor/team and patient communication, I ask the same question, “What difficult message have you delivered in the past four to five days you have been in your office treating patients?”
The answers are varied.
- "You need a root canal. And afterwards, you need a build-up and a crown!!”
- “You will lose this tooth (or this front tooth).”
- “You will lose all of your teeth.”
- “You have a disease in your mouth called periodontal disease that, if left untreated, can cause heart damage and lead to a variety of maladies including pancreatic cancer.”
- “The crown (bridge) is failing and needs to be replaced.”
So, how do you consistently set the stage to effectively deliver these messages?
Creating the right environment is the first step
Think about what you do when having a difficult discussion with a patient.
What is your body position in relation to theirs?
- Behind?
- To the side?
- Across the room?
Most of you would say, “On eye level, right in front of the patient, and close enough to have this conversation, but not too close to invade personal space.”
And what would the overall environment be like?
- Noisy?
- People coming and going
- In a public space
Once again, the unanimous reaction is, “A quiet, private space that lends itself to this important communication.”
Establishing the demeanor of the ‘giver of the difficult message’ is the second step
How do you act when you meet with your patient to discuss a difficult problem?
- Preoccupied with what you have to get back to doing?
- Distracted?
- Judgmental of the patient’s reaction?
You are probably thinking, “Of course not! I am totally focused on the patient and react in a totally nonjudgmental manner.” Yes, that is indeed critically correct.
I have set the stage with the right environment and approach with the most effective demeanor. NOW WHAT?
The third step is effectively working through the four key aspects of delivering the message of a positive finding from an oral cancer screening examination.
One: Clearly and simply state the message in as few words as possible.
Example: “Ms. Jones, I have found an abnormality on the side of your tongue. It is a mixed red and white patch. I am referring you to an excellent doctor who will help to diagnose this abnormality.” (Or, “We will do a biopsy to determine exactly what this abnormality is.”)
Two: Just be quiet, listen, watch, and gauge the patient’s reaction.
One patient might very calmly say, “Well, I guess we need to find out what it is. What is the next step for me?” Another patient might become hysterical or totally melt down.
By saying nothing at this time, you will be able to determine the best way to help your patient proceed instead of assuming (and we all know what the word “assume” breaks down to be!) their needs and going into a long discussion or explanation that may or may not meet their needs.
Three: Use active listening when discussing the patient’s concerns and answering his or her questions.
Active listening is accomplished by using a feedback approach to a conversation to clarify questions being asked and concerns felt.
For example: “So I am hearing that you are very concerned about this area on your tongue since you sing in the church choir and are afraid that it would stop you from doing what you love to do. Is that right?”
Another example: “So that I am clear, are you asking me how long you can wait to make the appointment with the specialist or to have a biopsy done our office?”
Peter Barry, a premier speaker, trainer, and dental consultant, stated the following during one of his recent programs. “Our patients need for us to know that we not only hear them (one of the six senses) but actually are listening to them.” I could not agree more.
Active listening accomplishes these two key goals:
- Our patients know that we are really listening to them.
- There is no confusion as to what the patient is asking or feeling.
Four: Ensure that there are no further questions and clarify the next steps that the patient must take.
One of the first lessons in communications that I teach is how to find out if patients understood what was said to them and if they had any further questions.
If you say, ”So, do you understand?” Unspoken, the word “dummy,” will almost always get a “yes” because who wants to be dumb. BUT, if the phrasing of the question is changed to “Is there anything I have not made clear to you today?” and “Do you have any other questions or concerns I have not answered?” opens the door to any further clarification the patient may need.
So be clear that the patient’s questions and concerns have been answered, hand out your business card in case other questions come up after the patient leaves, and hand the patient off to the person who will help him or her take the necessary next steps of scheduling an appointment with the specialist.
One warning: don’t guess. Stick to your ‘mantra.’
Patients will always ask, “So what do you think this is” or “Should I really be concerned about this?” or “Do you think that this is cancer?’
DO NOT GUESS!! ONLY A BIOPSY WILL DIAGNOSE.
THE BEST SUGGESTION IS TO CREATE A MANTRA THAT YOU CONTINUE TO REPEAT WHEN THESE QUESTIONS ARE ASKED.
“We only know that this is an abnormality. We need to diagnose exactly what it is.” Or, “It is not good dentistry and not fair to you for me to guess at a diagnosis, which is why we are going to find out what this abnormality is or is not.”
Don’t let the need to deliver the difficult message of a positive finding from your cancer screening exam be a barrier for you and your practice.
1. You have done this before: use what you have learned about the effective delivery of other difficult messages and apply those same principles to the detection of an oral abnormality.
2. Create an environment that is “patient friendly” for delivery and receipt of this important message.
3. Remember the four key aspects for the delivery of the message:
- One: State the problem simply and clearly.
- Two: Stop, be quiet, listen, and observe.
- Three: Use active listening techniques to make certain that the patient knows that you are truly listening to him or her and to prevent misunderstandings.
- Four: Wrap up the question segment using the correct communication skills and turn the patient over for the next step, which is either a referral to a specialist or reappointing in your office for a biopsy.
