“The most important time is the time we dedicate to patients.”
Giving bad news isn’t easy. Getting bad news is even harder. How can clinicians ease understanding and support patients when the risks of complication are high?
Dr. Rocchietta, patients love a miracle. What do you do when you know that the results patients expect cannot be achieved?
Dr. Rocchietta: I never promise perfection, even though I know the results could be close to perfect. Perfection and 100% success don’t exist in medicine, by definition. Instead, I try to under promise and over deliver. For example, when a case demands high esthetics, I’d rather say that we will strive to achieve “natural harmony” than “perfect results.” We need to evaluate the initial conditions, make sure that the diagnosis has been performed thoroughly, and subsequently inform the patient about all the risks and possibilities. A common mistake in clinics is that patients come in with a missing or fractured tooth, and we start the therapy by focusing only on that problem, without looking at the surrounding issues. Obviously, this is even more important when we treat a referred, failed case. We should always stay humble, understand all the risks of the procedure we perform, and explain to the patient why the situation could have a less favorable outcome. Patients get tired of all the treatment processes, and the financial stakes are high. Patients should get all of this information, including the risks, several days before surgery in a written consent form. This way they have time to consider and understand the procedure and tend to have more realistic expectations.
Does this mean you talk about technical complications? How do you help patients, who are not medical professionals, understand? Patients are different. Some have full trust and do not want to hear any explanation, and some search for cases online and watch YouTube videos before the visit. We need to adjust according to who the patients are and what they can understand. A lot of this comes with experience. In school nobody teaches us how to be psychologists. But there is one unchanging fact: when we take the time to educate patients, and they understand the procedures, they are much more compliant.
Have you ever found yourself worrying about complications more than your patients worry?
All the time. Clinicians know what could happen, which makes them worry more. Severe periodontal disease can cause bleeding on probing and other symptoms, but not necessarily pain. So, the patient is completely unaware of what is going on in their mouths. We need to be very strict when it comes to review and follow-up appointments. Before starting the treatment, I always make sure the patients are available for visits every week for the first month, every two weeks for the second month, and then once a month thereafter. And they need to comply with post-operative instructions. With all the digital tools we have nowadays, telemedicine is much easier. Sometimes we have a Zoom meeting to make sure that patients understand post-op instructions, or they send us a quick photo instead of planning a face-to-face visit.
Did your online visits begin with the pandemic?
Yes, and telemedicine is indeed a valuable and powerful tool. It became a crucial topic with the pandemic. During the lockdown, the only way we could talk to our patients, reassure them or give them advice and postoperative instructions, was through online visits.
What are the most powerful communication tools?
Technology helps. But the most important asset is the time we dedicate to patients. I use 3-D models that can be easily and cost-effectively built from CBCT scans. Also, photography is an enormous help. We have a large screen where we show all the collected diagnostic data so we can better and more fully discuss patient conditions and prognoses. So they can consider and digest the information after the first consultation. We also give patients written reports including PowerPoints of intraoral images and radiographs.
Communications failure: What’s the most common cause? I think it is time management – always being in rush or late so we do not have the time to spend for one-to-one exchange with the patient. Reserving and dedicating this time completely changes the outcome, especially when understanding possible post-operative outcomes and homecare are more critical. Once the trust is built, even if something doesn't go as planned, the patient understands, and it will be okay.
Do you remember the last time you dealt with a complication caused by miscommunication?
A few months ago, I had to perform a vertical augmentation GBR in a very large defect. The patient flew back to his home city and continued the therapy with the referral dentist who did not follow our post-op guidelines – maybe he had not read our email. The patient got a fixed resin retained restoration that was too tall and impacted the soft tissue, opening it up. He had to come back to our office. We reopened the case, removed the membrane, saved what could be saved and redid the GBR. Not so pleasant.
Can a communication protocol reduce the risks of complications? For sure. I think the most important measure to avoid complications is communication between the team members. All teams members should be on the same page, including what the patient has been told so stress levels stay under control.
How should communication be implemented in the real world?
By training, checklists, regular staff meetings, … and spending all the time necessary to talk to the team, to reassure and encourage them. Rather than the surgeons, for patients it's almost more important that the receptionists and nurses are kind and attentive. Patients accept that surgeons are less talkative and have less time, but they open up, chit-chat, cry and tell their stories to the nurses. If patients feel we are a safe and experienced team, they trust and listen more than if they find the team disorganized and stressed. And we don’t just see a patient half an hour before the operation. We see them when they go to the hygienist, for check-ups, assessments and reevaluations. We have a lot of opportunities to communicate with them at various stages, to build our relationship and bring them to where we hope they will arrive in their therapy. The team should know how important this relationship is.
Are patient-clinician relationships easier today?
Yes. A decade ago, there was almost no communication between patients and clinicians. The doctor was the key healthcare provider – the one who dictated the rules patients had to follow. The accessibility of medical information has made a massive difference. Anyone can find out about a procedure and better understand our therapies.