- Email: [email protected]
Communication by way of the consultation
Communication by way of the consultation Elliott M. Moskowitz Optimizing the consultation appointments with prospective patients or parents of young patients remain an important challenge in the overall management of orthodontic treatment. Without doubt, the orthodontic practitioner requires a profound understanding of the dentofacial characteristics of each patient who presents for an orthodontic evaluation for the need, timing, and extent of orthodontic treatment. In addition to understanding the various components of a specific malocclusion, the orthodontist needs to continue to hone his/her communication skills to ethically and successfully inform patients and parents of young patients as to the benefits, risks, cost benefit ratios, ideal and alternative treatment strategies associated with any contemplated orthodontic treatment. Intelligently analyzing the specific components of many malocclusions require a thorough and detailed study of the patient himself/herself as well as a meaningful scrutiny of orthodontic pre-treatment records. It is the author’s opinion that a more traditional approach to orthodontic consultations offer significant advantages over single visit consultations intended to expedite the entire consultation process with the obvious intent of immediately starting orthodontic treatment at the expense of more completely understanding the various underlying components of the malocclusion at hand and transmitting this information to patients and parents of young patients in a more cogent and thoughtful manner. (Semin Orthod ]]]]; ]:]]]–]]].) & 2016 Elsevier Inc. All rights reserved.
Introduction
O
ne of the most important orthodontic office visits is the actual consultation with patients or the parents of young patients. There is a distinct difference in the manner that such consultations are performed in private orthodontic offices in the United States and abroad. There are orthodontists who prefer to examine a patient, perhaps obtain a panoramic radiograph at that same visit, and with this information are prepared to discuss diagnostic, treatment, and retention considerations with the intention and expectation of placing separators (if necessary), and beginning orthodontic treatment at that very same visit. There is probably little argument that
Department of Orthodontics, New York University College of Dentistry, New York, NY. Address correspondence to Elliott M Moskowitz, DDS, MSd, Department of Orthodontics, New York University College of Dentistry, New York, NY. E-mail: [email protected] & 2016 Elsevier Inc. All rights reserved. 1073-8746/12/1801-$30.00/0 http://dx.doi.org/10.1053/j.sodo.2016.04.004
this protocol leads to more annual patient treatment “starts” in private practice and eliminates an “unnecessary” extra visit for the adult patient or parents of young patients. As an orthodontic colleague once posed the question (and answer) to me, “when is a person is more likely to buy a car?; when he (or she) is in the showroom.” It is hard to take issue with such practices or perception if patient starts remain as the top priority in an orthodontic practice. In fact, it appears that this “one stop shopping” type of mentality is becoming more rather than less popular in private orthodontic practice. It is the author’s belief that the more traditional approach to an initial examination of a new patient requires more than a mere cursory examination and “off to the races” with orthodontic treatment for individual patients. The author believes that a new patient examination in orthodontics should include a detailed clinical examination, initial discussion of the need for orthodontic treatment, careful attention to the attitudes and chief concerns of patients and parents of young patients, and obtaining all
Seminars in Orthodontics, Vol ], No ] (), ]]]]: pp ]]]–]]]
1
2
Moskowitz
pertinent orthodontic records for study before a more formal and thorough “consultation” visit is scheduled. Furthermore, that such a structured protocol (similar to what is taught and practiced in orthodontic residency programs) provides an extraordinary opportunity to profoundly benefit individual patients prior to beginning orthodontic treatment. A functional checklist of some of the more important elements of the initial patient examination and consultation appointment might include the following: (1) Review of medical and dental histories. (2) Note patient (or parental) chief concerns. (3) General assessment of maxillomandibular relationships in 3 planes. (4) Soft tissue examination. (5) Occlusal and functional exam. (6) Panoramic radiograph (mandatory, but especially important in the mixed dentition). (7) Discussion with patient or parents of young patient as to preliminary findings and general impressions. Does the patient require treatment? If so, is this the right time to begin treatment? Is the patient mature enough to undergo orthodontic treatment? Should the patient be placed on a recall list? (8) Discuss with the patients or parents of young patients the need to take complete orthodontic records to facilitate a detailed assessment, development of a problem list, and viable treatment options for the patient’s malocclusion. (9) Perform a comprehensive examination. (10) Obtain remaining diagnostic records as follows: (i) Cephalometric radiograph. (ii) Facial and intraoral photographs. (iii) Study casts (traditional or digital). (iv) Other diagnostic records, if necessary (A-P ceph?, CBCT if indicated, and mounted casts if necessary).
Reappoint for consultation visit The consultation visit (second visit) is quite a different experience from visit one and the goals and objectives of this visit differ markedly from the first initial visit, which entailed an
aforementioned clinical examination, medical and dental histories, appropriate record taking, etc. Without doubt, the evaluation of individual patients and consultation procedures involve a good deal of both science and art. In addition, communication skills and the ability to modify general communication protocols for individual patients and their parents are important aspects facilitating the parental or adult patient’s ability to understand the precise nature of the orthodontic problems at hand. The author prefers to perform the actual consultation visit (second visit) with the parents of young patients for obvious reasons. Young patients, perhaps requiring more invasive procedures (surgical exposures of impacted teeth and associated risks, etc.) will require a completely different “languaging” at some juncture than what might be initially discussed with the parents. This second visit or actual “consultation” would include but may not be limited to discussing. (1) Deviations in patient’s occlusion and dentofacial pattern from the ideal. (2) Are these deviations functional, esthetic, both, or neither? (3) The need or lack thereof for orthodontic treatment (timing of treatment). (4) Ideal goals and achievable optima for this patient. (5) Rationale for selecting particular strategy (nonextraction or extraction?). (6) Description of recommended orthodontic appliances or devices. (7) Viable alternative treatment plans that might be appropriate. (8) Informed consent (risk/benefit ratio of recommended treatment plans). (9) Estimated length of treatment and dependent variables. (10) Patient compliance requirements. (11) Contingency planning (need for extractions/orthognathic surgery, adjunctive periodontal procedures). (12) Retention considerations—removable or fixed appliances (problematic areas: rotations, decreased alveolar bone support). (13) Fees associated with treatment and retention. (14) Obtaining patient or parental consent to begin treatment. (15) Planning to begin orthodontic treatment.
Communication by consultation
Patient or parental expectations Structured and unrushed discussions with parents of young patients or adult patients can often establish reasonable expectations of all parties, which naturally include the orthodontist. Establishing realistic expectations cannot be overstated. It is wise to ascertain how patients might feel about contingency plans and changes of strategies or devices during orthodontic treatment prior to beginning orthodontic treatment if possible. Borderline extraction cases that might require mid-treatment recommendations for extractions when patient response or cooperation is unfavorable or recommendations for orthognathic surgery as a result of adverse growth vectors during treatment might be met with parental or patient resistance and emotional bias. It is wise to learn about how parents of young patients and adult patients feel about such contingency planning prior to beginning orthodontic treatment even if it means that they will seek another opinion from another practitioner who will tell them what they want to hear rather than what they need to hear. Orthodontists will be judged only on the care that they deliver to patients they treat; not the patients they choose not to treat or those who go elsewhere for treatment. Well structured, unrushed, and thorough discussions with prospective patients or their parents during consultation appointments serve as another screening process to identify patients or parents of young patients who might not be satisfied with even the best treatment effort or outcome.
3
In retrospect, the prime sources of parent or patient dissatisfaction can be traced to what was said or not said during the consultation process. Lastly, much of the consultation discussions should be memorialized with individually crafted letters to patients or parents of young patients in as plain language as possible. Often, critical points of a consultation may be forgotten and these communications serve as an important reminder of what was actually discussed with respect to expectations, patient requirements, and risk/benefit factors. The value of these communications cannot be overstated.
Conclusions We are experiencing a time when orthodontic services are in great demand. The introduction of new technology offering minimal or no visibility of orthodontic appliances has certainly played a significant role in increasing that demand. As such, this new era demands more efforts in patient education than in salesmanship. Carefully structured consultation appointments and a honing of practitioner communication skills will best serve that goal. Further Reading 1. Ceib Phillips, Elizabeth Bennett, Hillary Broder. Dentofacial disharmony: psychological status of patients seeking treatment. Angle Orthod. 1998;68(6):547–556. 2. Eleanor Thickett, Newton J. Using written material to support recall of orthodontic information: a comparison of three methods. Angle Orthod. 2006;76(2):243–249. 3. Moskowitz Elliott. Consultations in the real world. Am J Orthod Dentofacial Orthop. 2005;127:358–359.
Introduction
O
ne of the most important orthodontic office visits is the actual consultation with patients or the parents of young patients. There is a distinct difference in the manner that such consultations are performed in private orthodontic offices in the United States and abroad. There are orthodontists who prefer to examine a patient, perhaps obtain a panoramic radiograph at that same visit, and with this information are prepared to discuss diagnostic, treatment, and retention considerations with the intention and expectation of placing separators (if necessary), and beginning orthodontic treatment at that very same visit. There is probably little argument that
Department of Orthodontics, New York University College of Dentistry, New York, NY. Address correspondence to Elliott M Moskowitz, DDS, MSd, Department of Orthodontics, New York University College of Dentistry, New York, NY. E-mail: [email protected] & 2016 Elsevier Inc. All rights reserved. 1073-8746/12/1801-$30.00/0 http://dx.doi.org/10.1053/j.sodo.2016.04.004
this protocol leads to more annual patient treatment “starts” in private practice and eliminates an “unnecessary” extra visit for the adult patient or parents of young patients. As an orthodontic colleague once posed the question (and answer) to me, “when is a person is more likely to buy a car?; when he (or she) is in the showroom.” It is hard to take issue with such practices or perception if patient starts remain as the top priority in an orthodontic practice. In fact, it appears that this “one stop shopping” type of mentality is becoming more rather than less popular in private orthodontic practice. It is the author’s belief that the more traditional approach to an initial examination of a new patient requires more than a mere cursory examination and “off to the races” with orthodontic treatment for individual patients. The author believes that a new patient examination in orthodontics should include a detailed clinical examination, initial discussion of the need for orthodontic treatment, careful attention to the attitudes and chief concerns of patients and parents of young patients, and obtaining all
Seminars in Orthodontics, Vol ], No ] (), ]]]]: pp ]]]–]]]
1
2
Moskowitz
pertinent orthodontic records for study before a more formal and thorough “consultation” visit is scheduled. Furthermore, that such a structured protocol (similar to what is taught and practiced in orthodontic residency programs) provides an extraordinary opportunity to profoundly benefit individual patients prior to beginning orthodontic treatment. A functional checklist of some of the more important elements of the initial patient examination and consultation appointment might include the following: (1) Review of medical and dental histories. (2) Note patient (or parental) chief concerns. (3) General assessment of maxillomandibular relationships in 3 planes. (4) Soft tissue examination. (5) Occlusal and functional exam. (6) Panoramic radiograph (mandatory, but especially important in the mixed dentition). (7) Discussion with patient or parents of young patient as to preliminary findings and general impressions. Does the patient require treatment? If so, is this the right time to begin treatment? Is the patient mature enough to undergo orthodontic treatment? Should the patient be placed on a recall list? (8) Discuss with the patients or parents of young patients the need to take complete orthodontic records to facilitate a detailed assessment, development of a problem list, and viable treatment options for the patient’s malocclusion. (9) Perform a comprehensive examination. (10) Obtain remaining diagnostic records as follows: (i) Cephalometric radiograph. (ii) Facial and intraoral photographs. (iii) Study casts (traditional or digital). (iv) Other diagnostic records, if necessary (A-P ceph?, CBCT if indicated, and mounted casts if necessary).
Reappoint for consultation visit The consultation visit (second visit) is quite a different experience from visit one and the goals and objectives of this visit differ markedly from the first initial visit, which entailed an
aforementioned clinical examination, medical and dental histories, appropriate record taking, etc. Without doubt, the evaluation of individual patients and consultation procedures involve a good deal of both science and art. In addition, communication skills and the ability to modify general communication protocols for individual patients and their parents are important aspects facilitating the parental or adult patient’s ability to understand the precise nature of the orthodontic problems at hand. The author prefers to perform the actual consultation visit (second visit) with the parents of young patients for obvious reasons. Young patients, perhaps requiring more invasive procedures (surgical exposures of impacted teeth and associated risks, etc.) will require a completely different “languaging” at some juncture than what might be initially discussed with the parents. This second visit or actual “consultation” would include but may not be limited to discussing. (1) Deviations in patient’s occlusion and dentofacial pattern from the ideal. (2) Are these deviations functional, esthetic, both, or neither? (3) The need or lack thereof for orthodontic treatment (timing of treatment). (4) Ideal goals and achievable optima for this patient. (5) Rationale for selecting particular strategy (nonextraction or extraction?). (6) Description of recommended orthodontic appliances or devices. (7) Viable alternative treatment plans that might be appropriate. (8) Informed consent (risk/benefit ratio of recommended treatment plans). (9) Estimated length of treatment and dependent variables. (10) Patient compliance requirements. (11) Contingency planning (need for extractions/orthognathic surgery, adjunctive periodontal procedures). (12) Retention considerations—removable or fixed appliances (problematic areas: rotations, decreased alveolar bone support). (13) Fees associated with treatment and retention. (14) Obtaining patient or parental consent to begin treatment. (15) Planning to begin orthodontic treatment.
Communication by consultation
Patient or parental expectations Structured and unrushed discussions with parents of young patients or adult patients can often establish reasonable expectations of all parties, which naturally include the orthodontist. Establishing realistic expectations cannot be overstated. It is wise to ascertain how patients might feel about contingency plans and changes of strategies or devices during orthodontic treatment prior to beginning orthodontic treatment if possible. Borderline extraction cases that might require mid-treatment recommendations for extractions when patient response or cooperation is unfavorable or recommendations for orthognathic surgery as a result of adverse growth vectors during treatment might be met with parental or patient resistance and emotional bias. It is wise to learn about how parents of young patients and adult patients feel about such contingency planning prior to beginning orthodontic treatment even if it means that they will seek another opinion from another practitioner who will tell them what they want to hear rather than what they need to hear. Orthodontists will be judged only on the care that they deliver to patients they treat; not the patients they choose not to treat or those who go elsewhere for treatment. Well structured, unrushed, and thorough discussions with prospective patients or their parents during consultation appointments serve as another screening process to identify patients or parents of young patients who might not be satisfied with even the best treatment effort or outcome.
3
In retrospect, the prime sources of parent or patient dissatisfaction can be traced to what was said or not said during the consultation process. Lastly, much of the consultation discussions should be memorialized with individually crafted letters to patients or parents of young patients in as plain language as possible. Often, critical points of a consultation may be forgotten and these communications serve as an important reminder of what was actually discussed with respect to expectations, patient requirements, and risk/benefit factors. The value of these communications cannot be overstated.
Conclusions We are experiencing a time when orthodontic services are in great demand. The introduction of new technology offering minimal or no visibility of orthodontic appliances has certainly played a significant role in increasing that demand. As such, this new era demands more efforts in patient education than in salesmanship. Carefully structured consultation appointments and a honing of practitioner communication skills will best serve that goal. Further Reading 1. Ceib Phillips, Elizabeth Bennett, Hillary Broder. Dentofacial disharmony: psychological status of patients seeking treatment. Angle Orthod. 1998;68(6):547–556. 2. Eleanor Thickett, Newton J. Using written material to support recall of orthodontic information: a comparison of three methods. Angle Orthod. 2006;76(2):243–249. 3. Moskowitz Elliott. Consultations in the real world. Am J Orthod Dentofacial Orthop. 2005;127:358–359.