Imagine we’re on a Facebook forum, and you see that all-too-familiar question (with photo included, of course): “My patient has this tooth problem, and I’m wondering what I should do? Should I have fixed it or pulled it?” Most responses are clinical: “I would pull the tooth,” or, “I’d do an onlay.” However, my response is always, “What does the patient want?” While knowing the correct clinical approach to a dental problem is good, being a great dentist requires a deeper understanding of the people, not just the teeth we are treating. We have heard of Risk Factors regarding patient management; it’s time for us to explore Patient Risk Tolerance – the degree of variability that a patient is willing to withstand in his dental treatment plan decision-making, in regard to the patient’s perception of time, money and possible adverse outcomes such as pain, tooth loss and other forms of dental disease.
Understanding Risk Tolerance
I’ll admit something, I’m underinsured in some areas of my life. And I don’t care. I accept the unlikely possibility that a catastrophic event could happen, and I save the money now rather than pay for something I’m frankly not that worried about. And, even if I paid for the insurance and something happened, there always a clause that prevents me from getting the help I need. I’m someone who has a high-risk tolerance. I will take on a higher level of risk in certain areas of my life. Patients do the same thing. They weigh out whether the consequences are more severe than the financial burden of mitigating that risk through dental treatment. As their dentist, we need to ask our patients what amount of risk they will take on in each situation. We can advise and suggest, but they are responsible for their choices, and those choices come down to their risk tolerance.
What Does ‘Need’ Mean Anyway?
“You need a crown,” I say.
The patient responds, “I need a crown? Am I going to die if I don’t get it?”
Need is a complicated word. Do you need coffee in the morning? Do you need to wear your seatbelt? Does your child need that new video game? We use the word when we strongly desire something, feel like we cannot live without it, feel a lack of something or are being hyperbolic to make a point. But in dentistry, need boils down to the patient’s psychological position within the context of their life; and that isn’t something we can decide for them because we love healthy, natural teeth. Orthodontics is a great example. When patients ask, “Do I need it?” what they really want to know is (and sometimes subconsciously) will the negative outcomes from not getting orthodontic treatment (tooth wear, periodontal disease, occlusal trauma) outweigh the cost to getting the treatment? Will the positive outcomes (dental health) be worth the cost (financial, time, dental treatment discomfort) right now in my life? As the professional, our job is to outline all the options, risks and benefits. Then let the patient choose. Their answer is exactly what they need. I’ve learned to stop saying a patient needs something, and instead, I say, “How would your health be improved by doing this treatment, and is that worth it to you?”
Best is just another version of the complicated need. When we talk about the best treatment, we can’t know what is best without patient feedback.
Let me give an example from my office this week. I’m prepping tooth #18 for a crown, and I notice that the crack is deeper than the ideal prep, running mesiodistally through 2/3 of the tooth. I take a picture, sit the patient up, and show him the picture. I say, “Typically, I don’t bother showing patients intra-procedural photos, but once every couple months I stop, because there’s a risk worth discussing. I notice this crack is deep and there’s a chance it will be deeper than I can drill. So, I need to know if you’d like me to crown it today as planned, and hope the tooth will simmer down, and it might be years before we have to address it? Or would you rather me extract the tooth?
What Is the Best Option?
Or: The Best Treatment Option is the One the Patient Chooses
I get it. We all want the patient to choose what we would choose. We even recommend that! Historically, at times I would get cynical and jokingly say to my team … “If I give the patient five options, this particular patient is going to choose the worst one.” But what is the worst option? Is it simply my least favorite? Don’t get me wrong – if an option is not a viable option, then tell the patient that it’s not an option! And explain why. Or, if it’s ridiculous, don’t even mention it. I then walk them through what each choice may mean, while also understanding eventually the tooth may need extraction. For some patients, having the peace of mind the tooth is out and won’t cause pain at an inconvenient time is the best option. For others, they’d rather go with the crown because they might get more time out of their natural tooth. The point is, it’s their choice. Depending on their risk tolerance, financial situation or the value they place on the tooth, they need to determine what best means for them. Will it be the best choice for us as the dentist, knowing what we know? Maybe, maybe not. However, studies show patients that make choices about their own treatment experience better treatment satisfaction, treatment completion and clinical outcomes. What’s more, the onus is on the patient and not the dentist.
Managing Patient Expectations is Key
Dr. Bruce B. Baird is a great mentor of mine and taught me many things about managing patient expectations. One of the greatest lessons he taught me is the oral condition of the patient is solely the patient’s responsibility, not mine. I’m there as the dentist to help mitigate risk, either proactively or reactively, to understand the patient’s risk tolerance, ask them what they want, and then do a stellar job delivering the treatment they choose.
Regardless of what he or she chooses, the patient has chosen out of his own volition and understands the risks of treatment versus no treatment versus purposeful procrastination, perhaps. I can rest easy at night knowing that I didn’t dictate what they need or what is best for them. I will not offer an unreasonable option to the patient, but there are plenty of times that two or three options are viable, and the key to doing great dentistry is being able to gauge whether the patient will invest his time, money and potential discomfort for ownership of his choice.
So if you see me on an online forum, asking, “What was the patient’s risk tolerance?” or, “What does the patient want to do?” you understand why I want the patient’s feedback in the decision making. We need to make patient risk tolerance an hourly discussion within our practices. Ask the patient, “What’s your risk tolerance if what we’re proposing fails?” If you haven’t taken this approach before, try it. It’s been one of the most liberating choices I’ve made in my practice.