Estimated read time: 17.5 mins
difficult interactions with patients remain an unattractive occupational hazard
and one that can challenge even the most experienced of practitioners. Dental
Protection regularly receives calls from members seeking advice either on
preparing for an expected difficult interaction or dealing with the fallout
from one: it will come as no surprise that the way in which a difficult
interaction is handled can prove pivotal in how the patient responds.
well-managed interaction, even following a significant disagreement or
conflict, can strengthen the professional relationship. However, without
careful navigation, a difficult interaction can easily escalate and precipitate
a patient complaint while also increasing the risk to the dental professional
of aggression or violence from the patient.
is important to recognise that with all the will in the world, some
dentist-patient relationships may break down irrevocably and will require
careful management to ensure a transition of care that is in the patient’s best
and our own experiences tell us that generally, the source of any difficulty
lies in one or more of four interrelating domains – the patient, the dental
professional, the patient’s clinical condition and the systems in which we
normal day, we may be able to take difficulties arising in one or even two of
these domains within our stride. But the more domains that come into play, the
more difficult it is to manage the interaction effectively – partly because we
may have fewer positives we can draw on to provide a counterbalance. Consider,
for example, the ‘perfect storm’ of having a high-treatment need patient,
presenting with dental anxiety, 20 minutes late for a 30-minute new patient
examination on a day when you are short-staffed, the computers are
malfunctioning and you didn’t sleep well the previous night as your young child
was unwell! Taken in isolation many of us would be able to work unaffected by
any one of these factors. However, the cumulative effect of these when they all
come into play can create an entirely different context for the patient’s
Patient factors can include unrealistic expectations, differing interpretations of the same situation, extreme emotion (for example, dental phobia) or the patient’s inflexibility in relation to alternative treatment options. I recall from my own clinical practice a patient, presenting with multiple missing anterior teeth and severe periodontal disease, wishing to have their teeth replaced with a 7-unit bridge. Careful discussion with the patient yielded nothing in terms of their acceptance of the situation or what in my view were the available options (none of which were a lengthy bridge supported by two grade 3 mobile premolars!).
A patient’s clinical presentation and condition can also add a layer of unwelcome complexity, which might leave us feeling uncomfortable. Anecdotally at least, dentists report difficulty interacting with patients for whom they feel the patient’s pain is non-dental in origin or, for example, those patients with complex medical histories taking multiple medications.
System factors play a significant role in modern healthcare and are a source of frustration to many. Unfortunately, many of these factors sit outside our immediate sphere of influence and it is important to focus on those factors that can be controlled.
Research has shown in medicine that doctors are often less empathic with patients when there are system factors causing difficulties rather than other factors,1 and work on human factors in other industries such as aviation has also reached similar conclusions. For those not working in private practice, there are additional systems and process considerations that can further challenge even the most resilient practitioner. Members contacting Dental Protection for advice following a difficult interaction with a patient will often refer to systems and process factors as contributing to why an interaction evolved as it did. These might include factors such as time pressures, interruptions, availability of resources and equipment issues.
It is interesting to note that although all dentists recognise difficult patients, individual dentists are likely to vary as to which patients they would identify as such, or the degree to which they would rate them as difficult. So, identifying and rating the difficulty is not objective and, as dentists, we ourselves form part of the equation.
An interesting study conducted in Australia2 identified that, when asked, dentists believe that they are practising good patient-centred consultations “all the time”. Any failure or difficulty in the consultation is thus seen as an external or an ‘other’-related problem rather than it being directly dentist related.
Dentists had no difficulty in identifying barriers to patient-centred care that arise due to systems or processes. What was less obvious to them were the behavioural factors in themselves, the patients and/or the dental team that also could give rise to difficult interactions. Yet it is easier to influence the behavioural factors than it is to influence systems and processes. So it is worth focusing on the factors that are under our control and that can be improved to reduce the risk of complaint or claim.
Sometimes it can be just a personality clash, but often it’s something in the situation that triggers our ‘hot buttons’, which may activate our prejudices, stereotyping and assumptions. We may also have been profoundly affected in a negative way by our interactions with patients who have presented or behaved in a similar way to the patient before us, and this may significantly influence our attitude and ability to handle the interaction.
Examples include the patient who is always cancelling appointments, the patient who does not pay on time or the patient who only uses you in an emergency. Our degree of training in handling difficult interactions is also a major factor.
It is interesting that people in service industries receive a lot of training around handling difficult situations. Do we, as healthcare professionals, receive the same level of training?
Our own resilience can be affected by our own emotional baggage and a patient that might not otherwise have created a problem becomes a “difficult” patient. This might also explain why difficult patients to one person might be easy-to-manage patients to another. All of this is harder when we are Hungry, Angry, Late, Tired, Energy depleted, Distracted.
Dental research has shown us that the impact of difficult
interactions contributes to stress, and this creates long-term physiological
and psychological phenomena if not managed correctly.3 Difficult interactions tend to create a feeling of discomfort. The original
work of Corah and O’Shea on dentists’ perception of problem behaviours in
patients listed various behaviours that can be very annoying for dentists.
These included patients devaluing, being critical of or questioning a dentist’s
performance. Because such behaviours are likely to result in feelings of
personal assault on the dentist’s part, they are likely to have a deleterious
effect on the patient-dentist relationship.
It is helpful to be aware of your own warning signs – signs
that your emotions are starting to affect your behaviours. For example, what do
you do when you get angry? The consultation is a dynamic interactive process,
and patients and dentists will respond to each other’s behaviour in ways that
will either help or hinder the interaction.4
An interesting study by Thierer, Handleman and Black in 2001
assessed the relationship between dentist communication behaviour and their
perception of patient attributes such as likeability, manageability and
prognosis. The result suggested that dentists alter their communication
behaviour depending on their assessment of various patient qualities.
There are already branches of communication that look
specifically at these situations, for example neurolinguistic programming,
which recognises that people have different filters through which they see the
same situation, which predetermines their reaction. Is your reaction different
when you like or dislike a patient or with someone who fails to attend an
appointment? It is an innate human trait that if you don’t like someone, you
will often show it!
Making a careful and considered diagnosis of the difficulty
is a critical step in having an effective response. One of the most effective
strategies in managing a difficult interaction is to recognise our own
reaction. Our automatic reaction may be telling us things like “this person is
a nuisance” or “this person is uninterested in their oral health”. Such
reactions may be correct or incorrect; however, they are not helping us to
manage the situation. On the contrary they may be interfering with our self-control
and self-confidence, and our ability to demonstrate the necessary support
Various support skills can help to effectively manage a
difficult patient interaction. The first of these is active listening, which
involves two key components: open-ended questions to encourage the patient to
tell their story; and reflection of content back to the patient, including
short summaries and acknowledgement of emotions. We try to give a
considered response. This may take some time but trying to objectively define
the problem, name it and externalise it from the patient and the dental
professional can provide the backdrop to managing it effectively. It may be
useful for the dental professional to take time out by, for example, reviewing radiographs
or records while quietly going through this analysis of the difficulty.
One of the problems in a difficult interaction is that there
might be a tendency to plan your response while listening to the patient. It is
important to listen without distraction and to concentrate on demonstrating to
the patient that you are listening. It can be particularly difficult to
actively listen to a patient where you feel the patient is wrong, because there
is a tendency to immediately react and put the patient right.
Active listening allows us to move past assumptions and
stereotypes to what is the reality for our patients. The patient who feels
listened to is much more likely to engage.
The second of the key support skills is empathy. Empathy is
the patient’s perception of being heard and understood and is inferred by the
clinician’s good listening behaviour, body language, summarising of the story
and reflecting of their emotion. It is also based on working on the agenda that
is important to the patient. Active listening is a critical component of
It is possible to be empathic with a patient even if you
disagree with what the patient is saying or find it difficult to be sympathetic
to their plight. The beauty of empathy is that it can be applied to situations
even where you are uncomfortable. Conveying empathy is a powerful way to
increase the feelings of support of patient experiences.
Another key support skill is reframing. This is a technique
used in psychology where a therapist might ask a patient to consider a different
explanation for their concern, knowing that doing so may well reduce their
distress. To consider alternative explanations for a patient’s behaviour or
attitude might allow us to approach that patient in a more objective or neutral
manner. The interesting thing about reframing is that alternative explanation
does not have to be true, just as our immediate autonomic reaction to the
patient may not be based on truth either. All we are trying to do in this
situation is to open ourselves to the patient and in particular the patient’s
An example of this is the patient who is quite hostile at
your inability to find the source of pain, and where you label the patient
simply as a difficult and impatient person. The reality is that by reframing,
that patient may be dealing with an anxiety but also a more serious disease that
they have not been able to articulate to you.
When preparing for a recent Dental Protection event, I was
reminded how with only a few seemingly minor alterations to the course of an
appointment, a situation can rapidly become disproportionately difficult and
escalate beyond our control. While such a day is thankfully extremely rare in
practice, we will all come across difficult interactions from time to time.
Every patient is different, just as every dental professional
is different, and many will have found a process that works for them – often
through trial and error – for dealing with a difficult interaction. Hopefully
with a few tools, both to reflect on why a situation is apparently difficult
and to provide some basic steps to follow when approaching a difficult
interaction, dental professionals need not fear these interactions and can be
empowered to resolve them amicably.