- Email: [email protected]
Dentists’ Perceptions of the ‘Good’ Adult Patient: An Exploratory Study
T
ARTICLES
Dental consumers are concerned about having a good dentist, but how concerned are dentists about having good patients?
Dentists’ perceptions of the ‘good’ adult patient: an exploratory study Robert M. O’Shea, PhD Norman L. Corah, PhD W illiam A. Ayer, DDS, PhD
A . his paper presents the results of an exploratory and descriptive study of den tists’ positive expectations of those they treat. Reports of what the patient should and does expect of the dentist have been prom inent in both the popular con sumerism literature and in the scientific literature on dentistry’s “image,” patient satisfaction, and similar topics. In con trast, the dentist’s perceptions of what the patient ought to be and do have been less often studied,1 although a profession as large and old as dentistry does have a large anecdotal, journalistic, and essay literature regarding the patient’s obliga tions. Examination of the dentist-patient rela tionship from the dentist’s perspective deserves a more formal investigation than it has received. If relationships are consti tuted largely by the expectations each person has of the other, positive relation ships are more likely in areas in which re ciprocal rights and obligations are first understood and then accepted by the per sons who are interacting. Further, den tistry is widely perceived as stressful for both patient and doctor, with one source of that stress often located in the dentistpatient relationship itself.2,3 It is indeed curious that studies have been largely re stricted to only the patient’s side of the re lationship. In an earlier paper,4we listed some par ticular problem behaviors and tried to es tim ate how m uch those behaviors bothered practitioners. To some extent, such negatively evaluated behaviors are reverse images of how dentists want pa tients to act. General practitioners were asked to rate lists of general and chairside problem behaviors in terms of how often they occurred and how m uch they bothered the dentist when they did occur. Problems of relatively high frequency and bothersomeness included patients with poor oral hygiene, missing or late for ap pointments, not paying bills, and, in the chair, jerking the head away from the den tist. In our review of the research, we were unable to find studies specifically aimed at describing dentists’ preferences for pa tients’ behavior. However, one essay is worth quoting because it represents the candor of “clinical wisdom” that some dental writers have brought to the subject. A good patient is one who has a little money, is clean, does not smell very bad, is articulate, understands the lingo . . ., does not argue very much, is not hostile, comes back when he is told, does what he is told, takes his medicine regularly, and always thanks you.s
This short and colorful summary iden tifies several expectations that dentists may have of their patients: that they be compliant, personally responsive, comJADA, Vol. 106, June 1983 ■ 813
A R T IC L E S
municate well, share the dentist’s own definition of the importance and meaning of oral health and dental care, be able to pay for the dentist’s services, and be per sonally unobjectionable. Although their focus was not on iden tifying the behavior and attitudes dentists want from their patients, two scientific studies can be cited. W einstein and others6 hypothesized that “the dentist may respond to perceived differences be tween patients (in response to treatment, priority given oral health, appreciation of the dentist’s skill) by providing a dif ferent level of skill in the services he pro vides. Although their data did not seem to give strong confirmation to the hypothe sis that quality of care received was af fected by a dentist’s perception of pa tients, there seemed to be enough of a re lationship to keep the hypothesis alive. Frazier and others7 surveyed lowincome families and practicing dentists in a Midwestern city and observed a dis crepancy between the high priority placed on dental care by low-income pa tients and the low priority that the com m unity’s dentists believed such patients place on dental care. In interpreting their findings, the authors suggested that the lesser use of dental services by the poor might be partly a result of bias and nega tive reception by dentists rather than a lower-class cultural devaluation of oral health. In summary, what dentists want from patients and how they expect them to act has an apparent importance that belies the lack of attention paid to these issues. A recent national American Dental Asso ciation meeting provided an opportunity to begin exploring some of these current conceptions. We decided to test some concepts of our own and also to elicit what dentists replied to a free-answer question on their definition of the “good patient.”
Table 1 ■ Patient’s attributes considered relevant to pre dieting a “ good patient.” Percent of 628 dentists saying: Very im portant
Somewhat im portant
Concern about oral health Respect for dentist’s opinion On time for appointment
79 76 76
19 24 23
2 1 1
How referred: friends Accepts treatment plan Initial oral condition How referred: other dentist Can pay for needed treatment
53 48 46 44 35
38 48 43 43 57
9 4 11 13 8
How referred: self Not symptomatic How patient speaks Has private insurance How patient dresses
25 20 12 7 5
56 56 59 47 58
19 24 29 46 37
Characteristic
scribe a “good patient” in their own words.
Materials and methods Dentists participating in the health screening program at the 1981 Annual Session of the American Dental Associa tion were asked to complete a one-page questionnaire concerning characteristics of the “good dental patient.” Respon dents were asked to rate the importance of each of 13 items in the context of advising a new practitioner how to determine if a new patient would be a good patient. The categories of importance were: not at all, somewhat, very. The particular items were derived from our experience and from others who have studied dentist-patient relations. Dentists were also asked to estimate their own success in choosing the good patient. Finally, they were asked to de
814 ■ JADA, Vol. 106, June 1983
Characteristics of the respondents A total of 906 dentists participated in the health screening program. Men ac counted for 94% of the group and women accounted for 6%. In age, sex, years in practice, and proportion in general prac tice, this group compares favorably with characteristics of the national sample of dentists reported in the 1979 Survey of Dental Practice.8 Participants in the health screening program came from all regions of the country; however, the Midwest around Kansas City, where the convention was held, was noticeably overrepresented in comparison with the 1979 survey. Questionnaires from specialists and foreign dentists (n = 278) were excluded
Not at a ll im portant
from the sample because we were con cerned with the typical general practice alone. Usable questionnaires were ob tained from 628 general practitioners who participated in the health screening program. Men accounted for 97% of this sample. The median number of years in practice was 20 and the median number of patients seen per week was 50. A l though it is difficult to specify the extent to which this sample is scientifically rep resentative of the national population of dentists in general practice, we believe that the attitudes expressed are rea sonably representative of the national population.
Findings Table 1 shows the answers to the question aimed at identifying the relevance of 13 patient characteristics for predicting
A R T IC L E S
whether a new patient would be a good patient. Although every item in Table 1 is seen as relevant (as somewhat or very impor tant) by at least half the sample, the 13 characteristics can be categorized in three levels of importance. At the top, endorsed as very or somewhat important by virtu ally all the dentists surveyed, are concern about oral health, respect for dentist’s opinion, and on time for appointment. Each of these items appears as a value to be easily linked to the requirements for an orderly and successful practice. For the next five characteristics, the proportion of “very important” ranges from a half to a third of the dentists. It is not hard to speculate why these items are signs of good patients. Most private gen eral practices are fed by lay referrals from existing patients, and those referred are likely not only to show characteristics of existing patients in the practice but also to know how the practice is run and how the dentist does business. That the patient accepts the treatment plan is an obvious cue to further desirable behavior as it in dicates an acceptance of professional au thority. The surprise is that this item is not seen by more dentists as very impor tant. Initial oral condition may denote the value placed on oral health, the dental care previously received, and the pa tient’s level of home care. Again, the sur prise is that more respondents did not rate this characteristic more highly. Being re ferred by another dentist is important be cause it may suggest that the patient is motivated enough first to ask for, and then to follow up on, professional advice. Only a third of the dentists said that being able to pay for needed treatment was a very important predictor. This finding also invites explanation. Perhaps most dentists believe income may be a neces sary but not a sufficient guarantee of good performance as a patient. In other words,
Table 2 ■ H ow dentists describe a good patient. Percent of 559 dentists
Characteristic Dental sophistication Interpersonal responsiveness Compliance All other replies/not classifiable Total
A ny mention
35 10 44 11 100
51 18 62 17 148*
' Multiple answers possible.
surprising because we thought that this item suggested a patient who is interested in preventive, regular care. Perhaps most new patients are symptomatic and the ones who are not are too few to matter. The two characteristics meant to tap so cioeconomic status (speech, dress) may be inadequate, indirect measures of status; socioeconomic status itself may be
The conception of the good patient involves several underlying factors, particularly compliance, dental sophistication, and responsiveness. being able to pay is not the same as being willing to pay. The five other characteristics seem the least salient of the 13 listed. Self-referral may be comparatively less important be cause it does not tell much about the pa tient. Indeed, it conveys the idea that the new patient does not know much about the dentist’s reputation, and comes to the office out of convenience or chance. Why our respondents did not value being not symptomatic more highly as a predictor is
M entioned first
perceived as comparatively less related to patient performance. Having private den tal insurance may be a fringe benefit that does not necessarily predict an individu al’s orientation to dental health.9 Insur ance itself may be a mixed blessing that combines sure payment with regulations and paperwork. After identification of a good patient, the next question was: “What is your track record in picking out the good pa tient?” Most of the dentists’ replies
suggested a considerable but not com plete confidence in their own judgment; the average (median) response was for 80% “of my patients.” The number of years that a dentist had practiced was re lated to the number of different charac teristics of patients from the list of 13 thought to be very important— the longer the dentist had practiced, the more characteristics he or she deemed impor tant. However, time in practice was unre lated to the dentist’s perceived track rec ord for picking good patients. One important omission from the list of characteristics was the dentist’s expecta tion that patients be positively respon sive. H ow ever, th is ch aracte ristic emerged in the responses to the final question. The final question, “ How would you describe a good patient?,” seemed to have responses mainly in one of three general categories. Table 2 lists these as follows: — Dental sophistication: the patient shares or agrees with the dentist’s values. This category includes having positive, appropriate, and “correct” attitudes, be liefs, and values regarding oral health; pa tient subscribes to appropriate self-care; maintains oral health.
O ’Shea-Corah-Ayer : PERCEPTIONS OF GOOD ADULT PATIENT » 815
ARTICLES
The dentist and the staff are similar to other people and to other service providers in that much of their job gratification and reward comes from the appreciation and warmth shown by the persons they are trying to help.
— Interpersonal responsiveness or “warmth”: the patient shows positive af fective response; respect, mutual trust; is pleasant; can communicate; attentive; thankful, courteous, fun to work with. — Compliance: the patient is on time for appointments; pays bills; comes in at re call; accepts treatment plan; follows ad vice; cooperates; accepts suggestions; is willing to pay. A residual “other answer” category was included for responses that did not fit any of the first three. To accomplish this classification, two independent raters were trained to categorize the responses. Inter-rater agreement was determined for a subsample of 100 questionnaires, with 97% agreement on categorization for the first characteristic mentioned and 90% for overall characteristics of the “good pa tient” mentioned by the respondents. “Mentioned first” in Table 2 means that the respondent wrote only this charac teristic or put it before others named. “Any mention” disregards the order in which the characteristic was mentioned. The absolute sizes of percentages are probably less meaningful than their rela tive magnitude; it appears that the most important characteristic for these dentists is compliance, followed by dental sophis tication, and then responsiveness.
Discussion We think the findings from this explora tory study support the notion that den tists in general have certain key expecta tions of how their patients ought to act. The conception of the good patient is a complex one. Several underlying factors are probably involved, particularly com pliance, dental sophistication, and re sponsiveness. These expectations are heavily slanted toward the same things that W ills10 identified in an extensive re view of studies on the perceptions of clients held by professional helpers— manageability, treatability, and likability. These three dimensions seem germane to any helping relationship because they provide answers to the basic questions: W ill the client (patient) pose a manage ment problem? How much will the pa
816 ■ JADA, Vol. 106, June 1983
tient improve? How much w ill I like the patient? There seems to be an equivalence be tween our category of compliance and W ills’ manageability. As W ills found with mental health workers, this dimen sion seems to be the most important. The health care provider evidently believes that it is important for a patient to respect the professionals’ authority and to follow their rules of behavior. Here, it is useful to think about what typically transpires be tween the dental surgeon and his or her patient. The dental patient is “operated on”; the patient is passive and anes thetized; and there is ljttle verbal com munication during procedures. Further, private, fee-for-service practice as a small business itself requires considerable con formity in punctuality and timeliness in paying bills. Finally, compliance is also likely to reflect a natural preference for personalities that particularly value or derliness and predictability. W ills ’ treatability (m otivation for treatment) overlaps our category of dental sophistication, although there seem to be particular connotations for dentistry in the latter term as attested to by the wide currency of the notion of “Dental IQ” in dental vocabulary. Much of what the den tist wants to accomplish depends on the patient’s voluntary agreement to expend time, effort, and expense to accomplish the same goals. The patient is unlikely to make the necessary sacrifice unless he or she views oral health and good dental care as high priorities. Positive interpersonal responsiveness and likability seem to be related notions, with responsiveness as a typical basis for likability. The dentist and thè staff are similar to other people and to other ser vice providers. Much of their job gratifi cation and reward comes from the appre ciation and warmth shown by the persons they are trying to help.
Summary This exploratory, descriptive study claims to have identified at least some of the bases for the perceptions that dentists have of their patients. Our findings are
hardly definitive but do invite further in vestigation. The criteria against which dentists measure their patients’ behavior and attitudes are important. Preferences are a component of the meanings and pat terned behavior that dentists mutually build with patients. When understood, they also give insights into the value and meaning of the dentist-patient relation ship and set the possibilities for satisfac tion or conflict.
___________________________ J » Q A This investigation was supported, in part, by the American Fund for Dental Health, Warner-Lambert Foundation, the S. S. White Co, and Research Grant DE 04494 from the National Institute of Dental Re search. The authors thank P. Jankowiak, B. Nowak, and A. Volk for their assistance in the conduct of this re search. Dr. O ’Shea is associate professor, social and pre ventive medicine, School of Medicine, and Dr. Corah is professor of behavioral science in the School of Dentistry, State University of New Y ork at Buffalo. Dr. Ayer is assistant director for behavioral research, American Dental Association. Address requests for reprints to Dr. Corah, Department of Behavioral Sci ence, State University of New York at Buffalo, School of Dentistry, Farber Hall, Buffalo, NY 14214. 1. Linn, E.L. The dentist patient relationship. In Richards, N.D., and Cohen, L.K„ eds. Social sciences and dentistry: a critical bibliography. Federation Dentaire Internationale. The Hague, A. Sijthoff, 1971, pp 195-208. 2. Dunlap, J.E. Surviving in dentistry, the sources of stress. Tulsa, Petroleum Publishing Co, 1977. 3. Forrest, W.R. Stresses and self-destructive be haviors of dentists. Dent Clin North A m 22:3éi-371, 1978. 4. Corah, N.L.; O ’Shea, R.M.; and Skeels, D.K. Den tists’ perceptions of problem behaviors in patients. JADA 104(6):829-833,1982. 5. Cronkhite, L.W., Jr. The delivery of medical care: a look into the future. Harv Dent A lum Bull 28:42-45, 1968. 6. Weinstein, P., and others. Dentists’ perceptions of their patients: relation to quality of care. J Public Health Dent 38:10-21,1978. 7. Frazier, P.J., and others. Provider expectations and consumer perceptions of the importance and value of dental care. Am J Public Health 67:37-43, 1977. 8. Bureau of Economic and Behavioral Research, 1979 survey of dental practice. Chicago, American Dental Associatibnn, 1982. 9. Avnet, H.H., and Nikias, M.K. Insured dental care: a research project report. New York, Dental In surance, Inc, 1967. 10. Wills, T.A. Perceptions of clients by profes sional helpers. Psych Bujl 85:968-1000,1978.
ARTICLES
Dental consumers are concerned about having a good dentist, but how concerned are dentists about having good patients?
Dentists’ perceptions of the ‘good’ adult patient: an exploratory study Robert M. O’Shea, PhD Norman L. Corah, PhD W illiam A. Ayer, DDS, PhD
A . his paper presents the results of an exploratory and descriptive study of den tists’ positive expectations of those they treat. Reports of what the patient should and does expect of the dentist have been prom inent in both the popular con sumerism literature and in the scientific literature on dentistry’s “image,” patient satisfaction, and similar topics. In con trast, the dentist’s perceptions of what the patient ought to be and do have been less often studied,1 although a profession as large and old as dentistry does have a large anecdotal, journalistic, and essay literature regarding the patient’s obliga tions. Examination of the dentist-patient rela tionship from the dentist’s perspective deserves a more formal investigation than it has received. If relationships are consti tuted largely by the expectations each person has of the other, positive relation ships are more likely in areas in which re ciprocal rights and obligations are first understood and then accepted by the per sons who are interacting. Further, den tistry is widely perceived as stressful for both patient and doctor, with one source of that stress often located in the dentistpatient relationship itself.2,3 It is indeed curious that studies have been largely re stricted to only the patient’s side of the re lationship. In an earlier paper,4we listed some par ticular problem behaviors and tried to es tim ate how m uch those behaviors bothered practitioners. To some extent, such negatively evaluated behaviors are reverse images of how dentists want pa tients to act. General practitioners were asked to rate lists of general and chairside problem behaviors in terms of how often they occurred and how m uch they bothered the dentist when they did occur. Problems of relatively high frequency and bothersomeness included patients with poor oral hygiene, missing or late for ap pointments, not paying bills, and, in the chair, jerking the head away from the den tist. In our review of the research, we were unable to find studies specifically aimed at describing dentists’ preferences for pa tients’ behavior. However, one essay is worth quoting because it represents the candor of “clinical wisdom” that some dental writers have brought to the subject. A good patient is one who has a little money, is clean, does not smell very bad, is articulate, understands the lingo . . ., does not argue very much, is not hostile, comes back when he is told, does what he is told, takes his medicine regularly, and always thanks you.s
This short and colorful summary iden tifies several expectations that dentists may have of their patients: that they be compliant, personally responsive, comJADA, Vol. 106, June 1983 ■ 813
A R T IC L E S
municate well, share the dentist’s own definition of the importance and meaning of oral health and dental care, be able to pay for the dentist’s services, and be per sonally unobjectionable. Although their focus was not on iden tifying the behavior and attitudes dentists want from their patients, two scientific studies can be cited. W einstein and others6 hypothesized that “the dentist may respond to perceived differences be tween patients (in response to treatment, priority given oral health, appreciation of the dentist’s skill) by providing a dif ferent level of skill in the services he pro vides. Although their data did not seem to give strong confirmation to the hypothe sis that quality of care received was af fected by a dentist’s perception of pa tients, there seemed to be enough of a re lationship to keep the hypothesis alive. Frazier and others7 surveyed lowincome families and practicing dentists in a Midwestern city and observed a dis crepancy between the high priority placed on dental care by low-income pa tients and the low priority that the com m unity’s dentists believed such patients place on dental care. In interpreting their findings, the authors suggested that the lesser use of dental services by the poor might be partly a result of bias and nega tive reception by dentists rather than a lower-class cultural devaluation of oral health. In summary, what dentists want from patients and how they expect them to act has an apparent importance that belies the lack of attention paid to these issues. A recent national American Dental Asso ciation meeting provided an opportunity to begin exploring some of these current conceptions. We decided to test some concepts of our own and also to elicit what dentists replied to a free-answer question on their definition of the “good patient.”
Table 1 ■ Patient’s attributes considered relevant to pre dieting a “ good patient.” Percent of 628 dentists saying: Very im portant
Somewhat im portant
Concern about oral health Respect for dentist’s opinion On time for appointment
79 76 76
19 24 23
2 1 1
How referred: friends Accepts treatment plan Initial oral condition How referred: other dentist Can pay for needed treatment
53 48 46 44 35
38 48 43 43 57
9 4 11 13 8
How referred: self Not symptomatic How patient speaks Has private insurance How patient dresses
25 20 12 7 5
56 56 59 47 58
19 24 29 46 37
Characteristic
scribe a “good patient” in their own words.
Materials and methods Dentists participating in the health screening program at the 1981 Annual Session of the American Dental Associa tion were asked to complete a one-page questionnaire concerning characteristics of the “good dental patient.” Respon dents were asked to rate the importance of each of 13 items in the context of advising a new practitioner how to determine if a new patient would be a good patient. The categories of importance were: not at all, somewhat, very. The particular items were derived from our experience and from others who have studied dentist-patient relations. Dentists were also asked to estimate their own success in choosing the good patient. Finally, they were asked to de
814 ■ JADA, Vol. 106, June 1983
Characteristics of the respondents A total of 906 dentists participated in the health screening program. Men ac counted for 94% of the group and women accounted for 6%. In age, sex, years in practice, and proportion in general prac tice, this group compares favorably with characteristics of the national sample of dentists reported in the 1979 Survey of Dental Practice.8 Participants in the health screening program came from all regions of the country; however, the Midwest around Kansas City, where the convention was held, was noticeably overrepresented in comparison with the 1979 survey. Questionnaires from specialists and foreign dentists (n = 278) were excluded
Not at a ll im portant
from the sample because we were con cerned with the typical general practice alone. Usable questionnaires were ob tained from 628 general practitioners who participated in the health screening program. Men accounted for 97% of this sample. The median number of years in practice was 20 and the median number of patients seen per week was 50. A l though it is difficult to specify the extent to which this sample is scientifically rep resentative of the national population of dentists in general practice, we believe that the attitudes expressed are rea sonably representative of the national population.
Findings Table 1 shows the answers to the question aimed at identifying the relevance of 13 patient characteristics for predicting
A R T IC L E S
whether a new patient would be a good patient. Although every item in Table 1 is seen as relevant (as somewhat or very impor tant) by at least half the sample, the 13 characteristics can be categorized in three levels of importance. At the top, endorsed as very or somewhat important by virtu ally all the dentists surveyed, are concern about oral health, respect for dentist’s opinion, and on time for appointment. Each of these items appears as a value to be easily linked to the requirements for an orderly and successful practice. For the next five characteristics, the proportion of “very important” ranges from a half to a third of the dentists. It is not hard to speculate why these items are signs of good patients. Most private gen eral practices are fed by lay referrals from existing patients, and those referred are likely not only to show characteristics of existing patients in the practice but also to know how the practice is run and how the dentist does business. That the patient accepts the treatment plan is an obvious cue to further desirable behavior as it in dicates an acceptance of professional au thority. The surprise is that this item is not seen by more dentists as very impor tant. Initial oral condition may denote the value placed on oral health, the dental care previously received, and the pa tient’s level of home care. Again, the sur prise is that more respondents did not rate this characteristic more highly. Being re ferred by another dentist is important be cause it may suggest that the patient is motivated enough first to ask for, and then to follow up on, professional advice. Only a third of the dentists said that being able to pay for needed treatment was a very important predictor. This finding also invites explanation. Perhaps most dentists believe income may be a neces sary but not a sufficient guarantee of good performance as a patient. In other words,
Table 2 ■ H ow dentists describe a good patient. Percent of 559 dentists
Characteristic Dental sophistication Interpersonal responsiveness Compliance All other replies/not classifiable Total
A ny mention
35 10 44 11 100
51 18 62 17 148*
' Multiple answers possible.
surprising because we thought that this item suggested a patient who is interested in preventive, regular care. Perhaps most new patients are symptomatic and the ones who are not are too few to matter. The two characteristics meant to tap so cioeconomic status (speech, dress) may be inadequate, indirect measures of status; socioeconomic status itself may be
The conception of the good patient involves several underlying factors, particularly compliance, dental sophistication, and responsiveness. being able to pay is not the same as being willing to pay. The five other characteristics seem the least salient of the 13 listed. Self-referral may be comparatively less important be cause it does not tell much about the pa tient. Indeed, it conveys the idea that the new patient does not know much about the dentist’s reputation, and comes to the office out of convenience or chance. Why our respondents did not value being not symptomatic more highly as a predictor is
M entioned first
perceived as comparatively less related to patient performance. Having private den tal insurance may be a fringe benefit that does not necessarily predict an individu al’s orientation to dental health.9 Insur ance itself may be a mixed blessing that combines sure payment with regulations and paperwork. After identification of a good patient, the next question was: “What is your track record in picking out the good pa tient?” Most of the dentists’ replies
suggested a considerable but not com plete confidence in their own judgment; the average (median) response was for 80% “of my patients.” The number of years that a dentist had practiced was re lated to the number of different charac teristics of patients from the list of 13 thought to be very important— the longer the dentist had practiced, the more characteristics he or she deemed impor tant. However, time in practice was unre lated to the dentist’s perceived track rec ord for picking good patients. One important omission from the list of characteristics was the dentist’s expecta tion that patients be positively respon sive. H ow ever, th is ch aracte ristic emerged in the responses to the final question. The final question, “ How would you describe a good patient?,” seemed to have responses mainly in one of three general categories. Table 2 lists these as follows: — Dental sophistication: the patient shares or agrees with the dentist’s values. This category includes having positive, appropriate, and “correct” attitudes, be liefs, and values regarding oral health; pa tient subscribes to appropriate self-care; maintains oral health.
O ’Shea-Corah-Ayer : PERCEPTIONS OF GOOD ADULT PATIENT » 815
ARTICLES
The dentist and the staff are similar to other people and to other service providers in that much of their job gratification and reward comes from the appreciation and warmth shown by the persons they are trying to help.
— Interpersonal responsiveness or “warmth”: the patient shows positive af fective response; respect, mutual trust; is pleasant; can communicate; attentive; thankful, courteous, fun to work with. — Compliance: the patient is on time for appointments; pays bills; comes in at re call; accepts treatment plan; follows ad vice; cooperates; accepts suggestions; is willing to pay. A residual “other answer” category was included for responses that did not fit any of the first three. To accomplish this classification, two independent raters were trained to categorize the responses. Inter-rater agreement was determined for a subsample of 100 questionnaires, with 97% agreement on categorization for the first characteristic mentioned and 90% for overall characteristics of the “good pa tient” mentioned by the respondents. “Mentioned first” in Table 2 means that the respondent wrote only this charac teristic or put it before others named. “Any mention” disregards the order in which the characteristic was mentioned. The absolute sizes of percentages are probably less meaningful than their rela tive magnitude; it appears that the most important characteristic for these dentists is compliance, followed by dental sophis tication, and then responsiveness.
Discussion We think the findings from this explora tory study support the notion that den tists in general have certain key expecta tions of how their patients ought to act. The conception of the good patient is a complex one. Several underlying factors are probably involved, particularly com pliance, dental sophistication, and re sponsiveness. These expectations are heavily slanted toward the same things that W ills10 identified in an extensive re view of studies on the perceptions of clients held by professional helpers— manageability, treatability, and likability. These three dimensions seem germane to any helping relationship because they provide answers to the basic questions: W ill the client (patient) pose a manage ment problem? How much will the pa
816 ■ JADA, Vol. 106, June 1983
tient improve? How much w ill I like the patient? There seems to be an equivalence be tween our category of compliance and W ills’ manageability. As W ills found with mental health workers, this dimen sion seems to be the most important. The health care provider evidently believes that it is important for a patient to respect the professionals’ authority and to follow their rules of behavior. Here, it is useful to think about what typically transpires be tween the dental surgeon and his or her patient. The dental patient is “operated on”; the patient is passive and anes thetized; and there is ljttle verbal com munication during procedures. Further, private, fee-for-service practice as a small business itself requires considerable con formity in punctuality and timeliness in paying bills. Finally, compliance is also likely to reflect a natural preference for personalities that particularly value or derliness and predictability. W ills ’ treatability (m otivation for treatment) overlaps our category of dental sophistication, although there seem to be particular connotations for dentistry in the latter term as attested to by the wide currency of the notion of “Dental IQ” in dental vocabulary. Much of what the den tist wants to accomplish depends on the patient’s voluntary agreement to expend time, effort, and expense to accomplish the same goals. The patient is unlikely to make the necessary sacrifice unless he or she views oral health and good dental care as high priorities. Positive interpersonal responsiveness and likability seem to be related notions, with responsiveness as a typical basis for likability. The dentist and thè staff are similar to other people and to other ser vice providers. Much of their job gratifi cation and reward comes from the appre ciation and warmth shown by the persons they are trying to help.
Summary This exploratory, descriptive study claims to have identified at least some of the bases for the perceptions that dentists have of their patients. Our findings are
hardly definitive but do invite further in vestigation. The criteria against which dentists measure their patients’ behavior and attitudes are important. Preferences are a component of the meanings and pat terned behavior that dentists mutually build with patients. When understood, they also give insights into the value and meaning of the dentist-patient relation ship and set the possibilities for satisfac tion or conflict.
___________________________ J » Q A This investigation was supported, in part, by the American Fund for Dental Health, Warner-Lambert Foundation, the S. S. White Co, and Research Grant DE 04494 from the National Institute of Dental Re search. The authors thank P. Jankowiak, B. Nowak, and A. Volk for their assistance in the conduct of this re search. Dr. O ’Shea is associate professor, social and pre ventive medicine, School of Medicine, and Dr. Corah is professor of behavioral science in the School of Dentistry, State University of New Y ork at Buffalo. Dr. Ayer is assistant director for behavioral research, American Dental Association. Address requests for reprints to Dr. Corah, Department of Behavioral Sci ence, State University of New York at Buffalo, School of Dentistry, Farber Hall, Buffalo, NY 14214. 1. Linn, E.L. The dentist patient relationship. In Richards, N.D., and Cohen, L.K„ eds. Social sciences and dentistry: a critical bibliography. Federation Dentaire Internationale. The Hague, A. Sijthoff, 1971, pp 195-208. 2. Dunlap, J.E. Surviving in dentistry, the sources of stress. Tulsa, Petroleum Publishing Co, 1977. 3. Forrest, W.R. Stresses and self-destructive be haviors of dentists. Dent Clin North A m 22:3éi-371, 1978. 4. Corah, N.L.; O ’Shea, R.M.; and Skeels, D.K. Den tists’ perceptions of problem behaviors in patients. JADA 104(6):829-833,1982. 5. Cronkhite, L.W., Jr. The delivery of medical care: a look into the future. Harv Dent A lum Bull 28:42-45, 1968. 6. Weinstein, P., and others. Dentists’ perceptions of their patients: relation to quality of care. J Public Health Dent 38:10-21,1978. 7. Frazier, P.J., and others. Provider expectations and consumer perceptions of the importance and value of dental care. Am J Public Health 67:37-43, 1977. 8. Bureau of Economic and Behavioral Research, 1979 survey of dental practice. Chicago, American Dental Associatibnn, 1982. 9. Avnet, H.H., and Nikias, M.K. Insured dental care: a research project report. New York, Dental In surance, Inc, 1967. 10. Wills, T.A. Perceptions of clients by profes sional helpers. Psych Bujl 85:968-1000,1978.