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Perceived orthodontist behaviors that predict patient satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment
Perceived orthodontist behaviors that predict patient satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment Pramod K. Sinha, BDS, DDS, MS," Ram S. Nanda, DDS, MS, PhD, b and Daniel W. McNeil, PhD °
Oklahoma Ci~ Okla. Orthodontist-patient relationships have significant effects on the success of orthodontic treatment. The purpose of this study was to evaluate the effects of patient-perceived orthodontist behaviors on (a) patient perceived orthodontist-patient relationship, (b) patient satisfaction, and (c) orthodontist-evaluated patient adherence or compliance in orthodontic treatment. The sample consisted of 199 orthodontic patients, 94 boys and 105 girls, ages 8 to 17 years, who were recruited at the beginning of orthodontic treatment by a member of the research team who was not involved in treating the patients. The patients were asked to complete standardized questionnaires in a room away from the orthodontic clinic, 8 to 12 months into treatment. At the same time, the orthodontic resident treating each patient completed a standard instrument that evaluated patient compliance. Orthodontist behavior items such as politeness, friendliness, communicativeness, and empathy were evaluated by the patients. Stepwise multiple regression analyses ( p < 0.05) showed that eight behaviors predicted perception of the orthodontist-patient relationship (final model R2 = 0.7930 and 0.7333) as well as patient satisfaction (final model R2 = 0.7952) and two behaviors predicted patient compliance (final model R= = 0.0986). Of the 24 orthodontist behaviors, 22 were significantly correlated ( p < 0.0001) with favorable orthodontist-patient relationship and patient satisfaction. Of the 24 behaviors, 10 were significantly correlated (five at p < 0.01 and five at p < 0.05) with patient compliance. Patient-perceived orthodontist behaviors are related to and predict (1) patient perceived orthodontist-patient relationship, (2) patient satisfaction, and (3) orthodontist-evaluated patient adherence or compliance. (Am J Orthod Dentofac Orthop 1996;110:370-7.)
D o c t o r - p a t i e n t relationships have a significant impact on successful treatment in dentistry) Hence, it is important to improve this relationship for superior treatment outcomes, patient satisfaction, and doctor satisfaction.1-6 In a busy practice, it is often difficult to establish a close rapport with the patient. Communicating with the patient may or may not expedite treatment procedures, but there are many more pragmatic reasons for establishing a healthy doctor-patient relationship. With better communication, the patient can relate more information with greater accuracy, thus improving the quality of care. Patient management may be ~Assistant Professor, Department of Orthodontics, University of Oklahoma. bProfessor and Chairman, Department of Orthodontics, University of Oklahoma. CAssociate Professor, Department of Psychology, West Virginia University, Morgantown, W.Va.; formerly at Department of Psychology, Oklahoma State University. Reprints requests to: Dr. Pramod K Sinha, Department of Orthodontics, University of Oklahoma College of Dentistry, PO Box 26901, 1001 SL Young Blvd., Oklahoma City, OK 73190. Copyright © 1996 by the American Association of Orthodontists. 0889-5406/96/$5.00 + 0 8/1/65927
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greatly enhanced when the patients understand the nature of their conditions and the proposed treatment plan or procedure to be performed that will be used to improve their condition.5'6 Patient anxiety, fear, and stress can be allayed by effective communication with the doctor. 6 Poor communication also increases the chances of malpractice suits that probably reflect the patient's feeling that there is a lack of interest and concern on the part of the doctor than of dissatisfaction with actual treatment results. 5-7 The successful practice of orthodontics is significantly dependent on the interaction between the orthodontist and the patient. Doctor-patient relationships in orthodontics can positively influence treatment outcomes by encouraging the patient to cooperate in following prescribed instructions related to appliance wear and maintenance of oral hygiene.2 Successful orthodontic treatment requires active cooperation from the patient throughout the necessary lengthy orthodontic procedures: '9 Adherence by the patient makes it possible to achieve the treatment objectives in a minimum treatment time. Improved cooperation by the pa-
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tient can also result in a reduction of expenses involved in o r t h o d o n t i c treatment. T h e efficiency of care and i m p r o v e d oral hygiene can minimize d a m a g e to the p e r i o d o n t a l tissues, limit the deleterious effects of decalcification, 1°-14 and even frank caries. 1° W i t h a n o n c o m p l i a n t patient, it is necessary to c o m p r o m i s e t r e a t m e n t m e t h o d s and t r e a t m e n t objectives. 8 T h e r e f o r e standards o f orthodontic care can be immensely improved with greater patient adherence. I n the long run, the time invested to establish r a p p o r t with patients will be less t h a n that required to correct the potential difficulties resulting f r o m p o o r adherence. T h e r e is a n e e d for research evaluating the doctor-patient relationship, patient satisfaction, and a d h e r e n c e in o r t h o d o n t i c t r e a t m e n t based on specific orthodontist behaviors as perceived by the patient. This study was designed to evaluate the effects of patient-perceived orthodontist behaviors on (a) the orthodontist-patient relationship as perceived by the patient, (b) patient satisfaction, and (c) orthodontist-evaluated patient a d h e r e n c e in o r t h o d o n t i c treatment. MATERIALS AND METHODS The sample consisted of 199 orthodontic patients from the graduate orthodontic clinic at the University of Oklahoma Health Sciences Center. There were 94 boys and 105 girls, ages 8 to 17 years, who were recruited at the beginning of orthodontic treatment by a member of the research team who was not involved in treating the patients. The mean age of the sample was 14.4 years (SD - 2.4 years). These patients were being treated by eight different orthodontists. The patients were asked to complete standardized questionnaires 8 to 12 months into treatment. Procedure The patients who were enrolled in the research project were asked to complete paper-pencil questionnaires in a room away from the orthodontic clinic. They were assisted by a research assistant who was not an orthodontist and was not involved in the treatment of the patients. The patients were informed that the information collected was kept confidential and was not made available to anyone other than the investigators. These questionnaires pertained to patient-perceived orthodontist behaviors, patient satisfaction, and perceived orthodontist-patient relationships in orthodontic treatment. At the same time, the orthodontist treating each patient completed a standard instrument to evaluate patient adherence. Materials 1. Orthodontist behavior questionnaire. This instrument was used to evaluate verbal communication relating to information given to the patient about procedures, comforting the patient, and reassurances provided by the
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orthodontist treating the patient. It also evaluated a range of nonverbal behaviors of the orthodontist as perceived by the patient. It consisted of 24 items relating to the orthodontist's behaviors as perceived by the patient. These items were identical to those from an instrument designed to assess dentist behaviors used in previous research, 3with the exception that items were presented as gender neutral and that one nonapplicable item ("made me numb") was dropped. Further, all items were written with reference to the orthodontist and orthodontic treatment. This questionnaire was completed 8 to 12 months into orthodontic treatment. All items were scored on a 5-point Likert-type scale with categories ranging from strongly disagree to strongly agree. Higher scores on items indicated a more positive evaluation. 2. Orthodontic visit satisfaction scale. The instrument to assess patient satisfaction was an adaptation of a questionnaire designed to measure satisfaction of patients undergoing general dental treatment. 15 The only change was the substitution of the word orthodontist for dentist. This 10-item instrument for evaluating orthodontic patient satisfaction was also completed 8 to 12 months into orthodontic treatment. This instrument measures patient satisfaction in areas of information-comprehension, understanding-acceptance, and technical competence. All items were scored on a 5-point Likert-type scale with categories ranging from strongly disagree to strongly agree. A total satisfaction score was obtained by summing the individual item scores, with reverse scoring for one negative item. 3. Orthodontist-patient relationship (Table I). These two items were used in a previous investigation z for assessing the orthodontist-patient relationship as perceived by the patient. Responses to these items were obtained 8 to 12 months into orthodontic treatment. These items were also scored on a 5-point Likert-type scale with categories ranging from strongly disagree to strongly agree. Higher scores indicating a positive relationship. 4. Orthodontic patient cooperation s c a l e . 16 The orthodontists treating the patients completed this instrument to assess the level of patient adherence. Slakter et al. 16 found this instrument to have strong internal consistency. This 10-item instrument measures patient cooperation as it relates to keeping appointments, wearing and maintaining appliances, patient attitude toward treatment, oral hygiene maintenance, and parental interest in treatment. It was completed by the orthodontists after completion of 8 to 12 months treatment for each patient. All items were scored on a 5-point Likert-type scale with categories ranging from Always to Never. This instrument consists of five positive and five negative items. Negative items were reverse scored, hence, a higher score is indicative of increased patient adherence. Statistical Analysis The instruments were scored in the following manner. 1. Satisfaction score. This is an aggregate score of the 10 items in the questionnaire.
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Table I. Orthodontist-patient relationship items Item 1 Item 2
T h e orthodontist w h o is treating m e likes m e as a person. T h e orthodontist is concerned about m e and wants to do w h a t is best for m e in the long run.
2. Patient cooperation score. This is an aggregate
score of the 10 items in the questionnaire. 3. The doctor-patient relationship items one and two. These items were scored individually. 4. Orthodontist behavior questionnaire. The individual items from this instrument were used as independent variables and, hence, scored individually for a portion of the analyses. The mean score for the orthodontist behavior questionnaire was also obtained by adding the scores for each of the 24 items for each patient and averaging this score for the entire group. For the mean orthodontist behavior questionnaire score, item 3 (criticized my teeth or how I have been taking care of them) was reverse scored. The scores obtained on each questionnaire were entered in a SAS data set (SAS Institute, Cary, N.C.) and analyzed by using this statistical program. Correlation and stepwise multiple regression analyses were used to evaluate the data. Regression analyses were performed with the individual orthodontist behavior items, as well as the mean orthodontist behavior score as independent variables, and four dependent variables. The dependent variables were (1) the satisfaction score, (2) the patient cooperation score, and (3) the doctor-patient relationship items one and two. RESULTS Correlations
Correlations between the perceived orthodontist behaviors and the dependent variables are presented in Table II. Of the 24 orthodontist behaviors, 23 were significantly correlated with favorable patient satisfaction and both orthodontist-patient relationship items at p < 0.0001. Nine of the 24 orthodontist behaviors were significantly correlated (four behavior items at p < 0.01 and five of the behavior items at p < 0.05) with favorable patient cooperation. Item 3 of the orthodontist behavior questionnaire negatively correlated with all four independent variables: (a) patient satisfaction score ( p < 0.05), (b) the orthodontist-patient relationship item 1 ( p < 0.05), (c) the orthodontist-patient relationship item 2 ( p < 0.01) and (d) the patient cooperation score ( p < 0.01).
American Journal of Orthodontics and Dentofacial Orthopedics October 1996
Significant correlations shown in Table III were found between the composite mean score of the orthodontist behavior questionnaire and the patient satisfaction score ( p < 0.0001), both orthodontistpatient relationship items ( p < 0.0001), and the patient cooperation score (p < 0.05). Table III also shows significant correlations (p < 0.05) between a favorable patient cooperation score, the patient satisfaction score, and the orthodontist-patient relationship item 1. Stepwise multiple regression analyses
Separate stepwise multiple regression analyses were conducted to predict various dependent variables with the individual orthodontist behavior items as predictors. Eight behaviors were found to significantly predict patient satisfaction a t p < 0.05, as shown in Table IV, accounting for almost 80% of the variance in the total satisfaction score. Politeness alone accounted for almost 61% of the variance. Stepwise multiple regression analyses were also conducted for each relationship item. Eight orthodontist behaviors were found to significantly predict the orthodontist-patient relationship item 1 at p < 0.05, as shown in Table V, accounting for almost 79% of the variance in the total item score. The patients perception that the orthodontist paid attention to what the patient had to say, accounted for 63% of the variance. Ten behaviors were found to significantly predict orthodontist-patient relationship item 2 at p < 0.05, as shown in Table VI, accounting for approximately 73% of the variance in the total item score. Of these, making the patient feel welcome, accounted for almost 57% of the variance. Stepwise multiple regression analysis was conducted for the total patient compliance score. Two behaviors, i.e., was polite to me during my visit and criticized my teeth or how I have been taking care of them, were found to significantly predict patient adherence at p < 0.05. These items accounted for approximately 10% of the variability in the total patient compliance score. Evaluation of different age groups
To evaluate differences in response by age, the sample was divided into three subgroups, i.e., those below the age of 11 years, 11 through 14 years, and more than 14 years. All independent and dependent variables were subjected to analysis of variance procedures to evaluate whether differences existed between the means of the different age
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Table II. Correlations between orthodontists' behavior and patient satisfaction, orthodontist-patient relationship and
patient cooperation in orthodontic treatment
t Behavior
Sat~faction
1. Warned me when he/she felt the procedure might hurt. 2. Told me to be calm or to relax. 3. Criticized my teeth or how I have been taking care of them. 4. Showed that he/she knew what 1 was feeling. 5. Worked quickly but didn't rush. 6. Was friendly to me. 7. Encouraged me to ask questions about my treatment. 8. Made me feel welcome. 9. Was polite to me during my visit. 10. Used words that were understandable about my treatment. 11. Told me what he/she was going to do before starting to work. 12. Showed me that he/she paid attention to what I said. 13. Reassured me during the procedure. 14. Asked during the procedure if I were having any discomfort. 15. Had a calm manner. 16. Asked during the visits if I were concerned or nervous. 17. A step-by-step explanation of what he/she was doing. 18. Showed that he/she took seriously what I had to say. 19. Was patient with me. 20. Carried on casual conversation and small talk. 21. Told me that if it started to hurt he/she would relieve the pain. 22. Gave me moral support during the procedure. 23. He/she would do everything he/she could do to prevent pain. 24. Smiled.
0.60:~ 0.545/ -0.16" 0.605/ 0.74:~ 0.69:~ 0.675/ 0.78~: 0.78:~ 0.615/ 0.625/ 0.74:~ 0.685/ 0.725/ 0.635/ 0.585/ 0.635/ 0.765/ 0.705/ 0.70:~ 0.645/ 0.745/ 0.74~ 0.575/
Relationshipitems
'
2
Cooperation
0.535/ 0.475/ - 0.16" 0.60:~ 0.695/ 0.56:~ 0.565/ 0.755/ 0.705/ 0.515/ 0.51:~ 0.745/ 0.555/ 0.695/ 0.555/ 0.53:~ 0.61~ 0.675/ 0.66~: 0.645/ 0.59:[: 0.71~: 0.725/ 0.52:~
0.21"* 0.12 - 0.24** 0.04 0.17" 0.22"* 0.12 0.20* 0.26** 0.06 0.16 O.17" 0.15 0.17" 0.20* 0.03 0.03 0.13 0.12 0.21"* 0.10 0.13 0.14 0.15
I
0.635/ 0.565/ - 0.18" 0.58¢ 0.685/ 0.645/ 0.65:~ 0.765/ 0.695/ 0.595/ 0.585/ 0.765/ 0.625/ 0.705/ 0.63~ 0.605/ 0.62~ 0.76:~ 0.725/ 0.725/ 0.615/ 0.765/ 0.775/ 0.665/
*p < 0.05; **p < 0.01; ~p < 0.0001.
Table III. C o r r e l a t i o n s b e t w e e n t o t a l o r t h o d o n t i s t s ' orthodontist-patient
relationship
behavior score (OBS), total patient satisfaction score,
items, and patient cooperation
I Total OBS Total patient satisfaction score Orthodontist-patient relationship item 1 Orthodontist-patient relationship item 2 Total PCS
(PCS) in orthodontic
TotalPCS 0.18" 0.16" 0.19" 0.15 -
treatment
[
TotalOBS -0.845/ 0.82:~ 0.765/ 0.18"
*p < 0.05; 5/p < 0.0001.
groups. No significant differences were found for any of the variables among the different age groups. DISCUSSION
There is a paucity of studies evaluating the relationship between the orthodontist and the patient and its effects on patients undergoing orthodontic treatment. The nature of today's busy orthodontic practices often results in minimal communication between the doctor and the patient. 5'17'1s Although the treatment provided may be adequate, the patient's feelings toward the practice may become strained because of a lack of effort by the orthodontist to make the patient feel that he/she is being treated like a person. This can
result in a dissatisfied patient, who may not like the orthodontist, has feelings of indifference toward the office and the orthodontist, and consequently, does not adhere to prescribed instructions. This lack of doctor-patient rapport can also lead to malpractice law suits that may prove to be very expensive and inconvenient. 5-7 Patient Satisfaction
Patients generally think that the doctor-patient interaction should be comfortable and warm with a doctor who is technically competent and provides adequate information about the problem and procedures he/she will perform. 1"17-21 Several reports in the literature have suggested that when these expectations are not met, the patients feel disappointed,
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Table IV, Summary of stepwise procedure for dependent variable patient satisfaction score*
rioble
['a olR21Mo,'e' l' q"rob F
Was polite to me during my visit. Showed that he/she took seriously what I had to say. Let me know that he/she would do everything he/she could do to prevent pain. Worked quickly but didn't rush. Reassured me during the procedure. Asked during the visits if I were concerned or nervous. Carried on casual conversation and small talk. Gave me a step-by-step explanation of what he/she was doing as he/she did it.
0.6086 0.1151 0.0279 0.0145 0.0060 0.0095 0.0082 0.0053
0.6086 0.7237 0.7516 0.7661 0.7721 0.7816 0.7899 0.7952
0.0001 0.0001 0.0001 0.0024 0.0463 0.0109 0.0162 0.0500
Model R 2
['rob > F
0.6330 0.7121 0.7479 0.7678 0.7789 0.7851 0.7887 0.7930
0.0001 0.0001 0.0001 0.0004 0.0060 0.0374 0.0456 0.0225
*No other variable met the 0.0500 significance level for entry into the model.
Table V, Summary of stepwise procedure for the orthodontist-patient relationship item 1 Partial R e Showed me that he/she paid attention to what I said. Let me know that he/she would do everything he/she could do to prevent pain. Showed that he/she took seriously what I had to say. Smiled. Made me feel welcome. Carried on casual conversation and small talk. Reassured me during the procedure. Asked during the visits if I were concerned or nervous.
[
0.633 0.0791 0.0358 0.0198 0.0112 0.0062 0.0056 0.0072
*No other variable met the 0.0500 significance level for entry into the model.
Table VI. Summary of stepwise procedures for the orthodontist-patient relationship item 2 Partial R 2 Made me feel welcome. Showed that he/she took seriously what I had to say. Worked quickly but didn't rush. Let me know that he/she would do everything he/she could do to prevent pain. Showed me that he/she paid attention to what I said. Asked during the visits if I were concerned or nervous. Gave me a step-by-step explanation of what he/she was doing as he/she did it. Asked during the procedure if I were having any discomfort. Warned me when he/she felt the procedure might hurt. Told me what he/she was going to do before starting to work.
0.5680 0.0693 0.0229 0.0146 0.0095 0.0083 0.0134 0.0112 0.0119 0.0069
[
Model R 2
}
0.5680 0.6373 0.6601 0.6747 0.6842 0.6925 0.7059 0.7172 0.7264 0.7333
Prob > F 0.0001 0.0001 0.0014 0.0090 0.0327 0.0426 0.0091 0.0151 0.0110 0.0498
*No other variable met the 0.0500 significance level for entry into the model.
less satisfied, fail to keep appointments, and do not comply with prescribed instructions. 1'5'6"22-25The psychological impact of a dissatisfied patient may be increased anxiety, reduced patient compliance, and eventually a poor orthodontic result. The results of this study showed strong correlations between perceived orthodontist behaviors and patient satisfaction, thus indicating that orthodontist-patient interactions have strong influences in predicting patient satisfaction. Although all items in the orthodontist behavior questionnaire were significantly correlated with patient satisfaction, eight behaviors were found to be more influential in affecting satisfaction. The most important item was found to be the doctor's polite behavior toward the patient. Other verbal communication behaviors like information, reassur-
ance, and concern were also important. The doctor's calm and confident attitude and an unhurried approach to treatment appeared to increase patient satisfaction. Further, correlations performed between patient satisfaction and a total score for the orthodontist behavior instrument showed that these two scores were strongly correlated. This suggests that orthodontist behaviors, in general, have a strong influence on patient satisfaction. Also, correlations between patient satisfaction and patient adherence showed that patient satisfaction is important for ensuring patient adherence in orthodontic treatment. The Orthodontist-Patient Relationship
In the practice of orthodontics today, time should be invested in creating and maintaining the
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important "patient-doctor bond"? Patients must be treated as people who have malocclusions, not realocclusions attached to people. Orthodontist behaviors such as listening, empathy, and explanation are important in achieving that goal? All orthodontist behavior items as perceived by the patient in this study were significantly correlated with both of the orthodontist-patient relationship items. However, 8 of the 24 behavior items were found to be most influential in predicting the patients' perception of whether the orthodontist liked the patient as a person. The most important of these was the patient's perception that the orthodontist paid attention to what the patient said. Other significant patient behaviors were the orthodontist's reassurance that he/she would do everything to prevent pain, as wel! as friendliness. Smiling and making the patient feel welcome were also important. Finally, the patient's perception of the orthodontist's concern toward the patient was significant in predicting a positive orthodontist-patient relationship. Ten of the 24 orthodontist behaviors were significant in predicting the patient's perception that the orthodontist was concerned about the patient and wanted to do the best for the patient in the long run. The most important of these was the fact that the orthodontist made the patient feel welcome. The second most important of these behaviors was found to be the patient's perception that the orthodontist took seriously what the patient had to say. A concerned orthodontist who listened to the patient and expressed concern while he/she worked efficiently were found to be significant factors. A survey conducted recently evaluated professional qualities rated by patients as being extremely important in their general dentists. This study showed that dentist qualities such as professional competence, reassurance, friendly and patient behavior, and informing patients about the procedures were highly valued by the patients. 1 Interpersonal caring (gentleness, patience, and friendliness) was found to be the most popular dentist behavior among the patients surveyed? Studies have also shown that patients would like to see professional traits like gentleness, friendliness, and professional competence in an ideal dentist. 2~'27 Similar orthodontist behaviors in this study were found to significantly predict satisfaction, the doctor-patient relationship and patient adherence. Patient Adherence in Orthodontic Treatment
This study focuses on the importance of interpersonal relationships between the orthodontist and
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his patient, based on orthodontist behaviors that may have a significant impact on patient adherence in orthodontic treatment. Previous studies in this field have attempted to help clinicians identify potentially noncompliant patients. 9'28-38 Some have reported that in addition to certain personality traits, interpersonal relationships are exceedingly important. 2"28'3°'39-4a Other studies note that once noncompliant patients have been identified, cooperation can be improved through better comnmnication and feedback from the orthodontistY 2-44 Nanda and Kierl 2 have shown that orthodontist-patient relationships have significant effects on patient adherence. They showed that a positive orthodontist-patient relationship resulted in an increase in the level of compliance by the patient. Our study has analyzed correlations between 24 orthodontist behaviors and how they interacted with patient cooperation, individually and collectively, i.e., mean orthodontist behavior score. When the behaviors were individually considered, it was shown that nine specific orthodontist behaviors were significantly correlated with patient adherence. The most important behavior was politeness toward the patient. The orthodontist's criticism of the patient's teeth or how he/she looked after them had a negativ e influence on patient adherence. The doctor's expression of concern about the well being of the patient was also found to be significant in predicting patient adherence. Verbal communication, a calm and confident manner, and reassurance, were also found to increase patient compliance. Patient cooperation in orthodontic treatment has been reported to be influenced by a variety of patient factors. The results of this study, however, emphasize that the orthodontist can influence patient cooperation by trying to establish a good rapport with the patient. Important Orthodontist Behaviors
Some orthodontist behaviors appeared to influence more than one dependent variable like satisfaction, the orthodontist-patient relationship, and patient cooperation in orthodontic treatment. The behaviors that were important in influencing patient satisfaction and orthodontist-patient relationships were related to communication between the orthodontist and the patient and the fact that the orthodontist was perceived to be concerned about the patient. Patient satisfaction and patient cooperation were found to be influenced by politeness and verbal communication showing that the ortho-
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dontist was interested in the patient's concern and alleviating anxiety.
Communication Cooperation Klages et al? 5 found that the orthodontist's verbal behaviors strongly correlated with patient's verbal behaviors. Further, behaviors where the orthodontist encouraged the patient were strongly correlated to patient participation in this dialogue. This finding may be extended to assume that the orthodontist's initiation of verbal communication stimulated an increase in the patient's verbal communication. Communication between the orthodontist and the patient, and reassurance by the orthodontist, was found to be significant in predicting patient satisfaction and the orthodontistpatient relationship in this study. Elliot ~6 found that interpersonal communication was strongly related to reassuring and understanding behaviors. In this study, reassuring and understanding orthodontist behaviors predicted patient satisfaction, the orthodontist-patient relationship, and patient cooperation in following the prescribed instructions. Evaluation of Different Age Groups The sample in our study included an age group with an average age of 14.4 years and a standard deviation of 2.4 years, hence results of this study may apply to this age population alone. Comparing responses based on age groups revealed no significant differences. This indicates that all the patients responded similarly to positive and negative items in this study. Further, age was not found to be a factor in the patients' perception of the doctors behavior. In some instances, young patients perceive their orthodontists as role models 47 and many have been influenced to choose orthodontics as their profession. Therefore orthodontists can influence people's lives in many ways. Yet another pragmatic reason for building a good doctor-patient rapport is the prevention of litigation issues, s-7 Orthodontist behaviors influence patient satisfaction, the orthodontist-patient relationship, and patient cooperation in orthodontic treatment. It is therefore important to establish good rapport with the patient. Time invested to establish rapport with patients will be less than that required to correct the potential difficulties resulting from failure to do so. In other words "An ounce of prevention is worth a pound of cure. ''7
American Journal of Orthodontics and Dentofacial Orthopedics October 1996 REFERENCES 1. Gerbert B, Bleecker T, Saub E. Dentists and the patients who love them: professional and patient views of dentistry. J Am Dent Assoc 1994;125:264-72. 2. Nanda RS, Kierl MJ. Prediction of cooperation in orthodontic treatment. Am J Orthod Dentofac Orthop 1992;102:15-21. 3. Corah NL, O'Shea RM, Bissell GD. The dentist-patient relationship: perceptions by patients of dentist behavior in relation to satisfaction and anxiety. J Am Dent Assoc 1985;111:443-6. 4. Corah NL, O'Shea RM, Bissell GD. The dentist-patient relationship: perceived dentist behaviors that reduce patient anxiety and increase satisfaction. J Am Dent Assoc 1988;116:73-6. 5. Dougherty HL. Qno vadis (guest editorial). Am J Orth0d 1985;87:345-6. 6. Laskin D. The doctor-patient relationship: a potential communication gap. J Oral Surg 1979;37:786. 7. Barbat LD. Orthodontic TMJ litigation in the 1990s: an ounce of prevention is worth a pound of cure. Am 3 Orthod Dentofac Orthop 1992;101:97-8. 8. Jarabak JR. Management of orthodontic practice. St Louis: CV Mosby, 1965:15081. 9. Story RI. Psychological issues in orthodontic practices. Am J Orthod 1966;52: 584-98. 10. Zachrisson BU. Cause and prevention of injuries to teeth and supporting structures during orthodontic treatment. Am J Orthod 1976;69:285-300. 11. Gorelick L, Gieger AM, Gwinett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod 1982;81:93-8. 12. Mirhazi E. Enamel demineralization following orthodontic treatment. Am J Orthod 1982;82:62-7. 13. Glatz EGM, Featherstone JDB. Demineralization related to orthodontic bands and brackets. Am J Orthod Dentofac Orthop I987;87:87 (Abstract). 14. O'Rielly MM, Featherstone JDB. Demineralization and remineralization around orthodontic appliances: An in vivo study. Am J Orthod Dentofac Orthop 1987; 92:33-40. 15. Corah NL, O'Shea RM, Pace LF, Seyrek SK. Development of a patient measure of satisfaction with the dentist: the dental visit satisfaction scale. J Behav Med 1984;7:367-73. 16. Slakter M, Albino JE, Fox RN, Lewis EA. Reliability and stability of the orthodontic patient cooperation scale. Am J Orthod 1980;78:559-63. I7. Mayerson M. Patient appreciation: the cornerstone of internal marketing. J Clin Orthod 1990;24:747-51. 18. Moawad K. The patient is always right. J Clin Orthod 1988;22:46-7. 19. Deisher RW, Engel WC, Spielholz R, Standfast SJ. Mother's opinions of their pediatric care. Pediatrics 1965;35:82-90. 20. Fisher AW. Patients evaluation of outpatient medical care. J Med Educ 1971;46: 238-44. 21, Koos EL. "Metropolis" what city people think of their medical services. Am J Pub Health I955;45:I551-7. 22. Becker MH, Maiman LA. Sociobehavioral determinants of compliance with health and medical care recommendations. Med Care 1975;13:10-24. 23. Davis MS. Variation in patient's compliance with doctor's orders, medical practice, and doctor-patient interaction. Psychiat Med 1971;2:31-54. 24. Francis V, Korsch BN, Morris MJ. Gaps in doctor-patient communication, II: patients response to medical advice. New Engl J Med 1969;280:535-40. 25. Stimson GV. Obeying doctors' orders: a view from the other side. Soc Sci Med 1974;8:97-104. 26, Van Groenestun MA, Maas-de Waal CA, Mileman PA, Swallow JN, The ideal dentist, Soc Sci Med 1980:14A:533-5. 27. McKeithen E. The patients image of the dentist. J Am Cull Dent 1966;33:87-107. 28. Kreit Lid, Burstone C, Delman L. Patient cooperation in orthodontic treatment. J Am (2oll Dent 1968;35:327-32. 29. Starnbach HK, Kaplan A. Profile of an excellent orthodontic patient. Angle Orthod 1974;45:141-5. 30. Weiss ,1, Eiser HM. Psychological timing of orthodontic treatment. Am J Orthod 1977;72:198-204. 31. Clemmer EJ, Hayes EW. Patient cooperation in wearing orthodontic headgear. Am J Orthod Dentofae Orthop 1979;75:517-23. 32. Miller ES, Larson LL. A theory of psychoorthodontics with practical applications to office techniques. Angle Orthod 1979;49:85-91. 33. Albino J, Cunat J, Fox R, Lewis E, Slaker M, Tedesco L. Variables discriminating individuals who seek orthodontic treatment. J Dent Res 1981;60:1661-7. 34. Gross AM, Samson O, Dierkes M. Patient cooperation in treatment with removable appliances: a model of patient noncompliance with treatment implications. Am J Orthod I985;87:392-7. 35. Jamison RN, Lewis S, Burish TG. Cooperation with treatment in adolescent cancer patients. J Adolesc Health Care 1986;7:162-7. 36. Cucalon C, Smith R3. Relationship between compliance by adolescent orthodontic patients and performance on psychological tests. Angle Orthod 1989;60:10713.
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American Journal of Orthodontics and Dentofacial Orthopedics Volume 110, No. 4 37. Albino J, Lawrence S, Lopes C, Nash L, Tedesco L. Cooperation of adolescents in orthodontic treatment. J Behav Med 1991;14:53-70. 38. Sergl H, Klages U, Pempera J. On the prediction of dentist-evaluated patient compliance in orthodontics. Eur J Orthod 1992;14:463-8. 39. Allan TK, Hodgson EW. The use of personality measurements as a determinant of patient cooperation in an orthodontic practice. Am J Orthod 1968;54:433-40. 40. E1-Mangoury N. Orthodontic cooperation. Am J Orthod 1981;80:604-22. 41. Southard KA, Tolley EA, Arheart KL, Hackett-Renner CA. Application of the million adolescent personality inventory in evaluating orthodontic compliance. Am J Orthod Dentofac Orthop 1991;100:553-61. 42. Clark JR. Oral hygiene in orthodontic practice: motivation, responsibilities, and concepts. A.M .10RTHOD 1976;69:72-82.
43. Forte G, Richardson A. Patient compliance and medical audit in orthodontics. Br Dent J 1990;8:374-5. 44. Rinchuse D J, Rinchuse D J, Zullo TG. Oral hygiene compliance: a clinical investigation. J Clin Orthod 1992;26:33-8. 45. Klages U, Sergl HG, Burucker I. Relations between verbal behavior of the orthodontist and communicative cooperation of the patient in regular orthodontic visits. Am J Orthod Dentofac Orthop 1992;102:265-369. 46. Elliot R. Helpful and non-helpful events in brief counseling interviews: an empirical taxanomy. J Consult Psychol 1985:307-22. 47. Tayer BH, Burnes H. Patient empowerment: the young patient. Am J Orthod Dentofac Orthop 1993;103:365-7.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS
Bound volumes of the American Journal of Orthodontics and Dentofacial Orthioedics are available to subscribers (only) for the 1996 issues from the Publisher, at a cost of $76.00 ($93.09 Canada and $87.00 international) for Vol. 109 (January-June) and Vol. 110 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; telephone (314)453-4351 or (800)325-4177. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
Oklahoma Ci~ Okla. Orthodontist-patient relationships have significant effects on the success of orthodontic treatment. The purpose of this study was to evaluate the effects of patient-perceived orthodontist behaviors on (a) patient perceived orthodontist-patient relationship, (b) patient satisfaction, and (c) orthodontist-evaluated patient adherence or compliance in orthodontic treatment. The sample consisted of 199 orthodontic patients, 94 boys and 105 girls, ages 8 to 17 years, who were recruited at the beginning of orthodontic treatment by a member of the research team who was not involved in treating the patients. The patients were asked to complete standardized questionnaires in a room away from the orthodontic clinic, 8 to 12 months into treatment. At the same time, the orthodontic resident treating each patient completed a standard instrument that evaluated patient compliance. Orthodontist behavior items such as politeness, friendliness, communicativeness, and empathy were evaluated by the patients. Stepwise multiple regression analyses ( p < 0.05) showed that eight behaviors predicted perception of the orthodontist-patient relationship (final model R2 = 0.7930 and 0.7333) as well as patient satisfaction (final model R2 = 0.7952) and two behaviors predicted patient compliance (final model R= = 0.0986). Of the 24 orthodontist behaviors, 22 were significantly correlated ( p < 0.0001) with favorable orthodontist-patient relationship and patient satisfaction. Of the 24 behaviors, 10 were significantly correlated (five at p < 0.01 and five at p < 0.05) with patient compliance. Patient-perceived orthodontist behaviors are related to and predict (1) patient perceived orthodontist-patient relationship, (2) patient satisfaction, and (3) orthodontist-evaluated patient adherence or compliance. (Am J Orthod Dentofac Orthop 1996;110:370-7.)
D o c t o r - p a t i e n t relationships have a significant impact on successful treatment in dentistry) Hence, it is important to improve this relationship for superior treatment outcomes, patient satisfaction, and doctor satisfaction.1-6 In a busy practice, it is often difficult to establish a close rapport with the patient. Communicating with the patient may or may not expedite treatment procedures, but there are many more pragmatic reasons for establishing a healthy doctor-patient relationship. With better communication, the patient can relate more information with greater accuracy, thus improving the quality of care. Patient management may be ~Assistant Professor, Department of Orthodontics, University of Oklahoma. bProfessor and Chairman, Department of Orthodontics, University of Oklahoma. CAssociate Professor, Department of Psychology, West Virginia University, Morgantown, W.Va.; formerly at Department of Psychology, Oklahoma State University. Reprints requests to: Dr. Pramod K Sinha, Department of Orthodontics, University of Oklahoma College of Dentistry, PO Box 26901, 1001 SL Young Blvd., Oklahoma City, OK 73190. Copyright © 1996 by the American Association of Orthodontists. 0889-5406/96/$5.00 + 0 8/1/65927
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greatly enhanced when the patients understand the nature of their conditions and the proposed treatment plan or procedure to be performed that will be used to improve their condition.5'6 Patient anxiety, fear, and stress can be allayed by effective communication with the doctor. 6 Poor communication also increases the chances of malpractice suits that probably reflect the patient's feeling that there is a lack of interest and concern on the part of the doctor than of dissatisfaction with actual treatment results. 5-7 The successful practice of orthodontics is significantly dependent on the interaction between the orthodontist and the patient. Doctor-patient relationships in orthodontics can positively influence treatment outcomes by encouraging the patient to cooperate in following prescribed instructions related to appliance wear and maintenance of oral hygiene.2 Successful orthodontic treatment requires active cooperation from the patient throughout the necessary lengthy orthodontic procedures: '9 Adherence by the patient makes it possible to achieve the treatment objectives in a minimum treatment time. Improved cooperation by the pa-
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tient can also result in a reduction of expenses involved in o r t h o d o n t i c treatment. T h e efficiency of care and i m p r o v e d oral hygiene can minimize d a m a g e to the p e r i o d o n t a l tissues, limit the deleterious effects of decalcification, 1°-14 and even frank caries. 1° W i t h a n o n c o m p l i a n t patient, it is necessary to c o m p r o m i s e t r e a t m e n t m e t h o d s and t r e a t m e n t objectives. 8 T h e r e f o r e standards o f orthodontic care can be immensely improved with greater patient adherence. I n the long run, the time invested to establish r a p p o r t with patients will be less t h a n that required to correct the potential difficulties resulting f r o m p o o r adherence. T h e r e is a n e e d for research evaluating the doctor-patient relationship, patient satisfaction, and a d h e r e n c e in o r t h o d o n t i c t r e a t m e n t based on specific orthodontist behaviors as perceived by the patient. This study was designed to evaluate the effects of patient-perceived orthodontist behaviors on (a) the orthodontist-patient relationship as perceived by the patient, (b) patient satisfaction, and (c) orthodontist-evaluated patient a d h e r e n c e in o r t h o d o n t i c treatment. MATERIALS AND METHODS The sample consisted of 199 orthodontic patients from the graduate orthodontic clinic at the University of Oklahoma Health Sciences Center. There were 94 boys and 105 girls, ages 8 to 17 years, who were recruited at the beginning of orthodontic treatment by a member of the research team who was not involved in treating the patients. The mean age of the sample was 14.4 years (SD - 2.4 years). These patients were being treated by eight different orthodontists. The patients were asked to complete standardized questionnaires 8 to 12 months into treatment. Procedure The patients who were enrolled in the research project were asked to complete paper-pencil questionnaires in a room away from the orthodontic clinic. They were assisted by a research assistant who was not an orthodontist and was not involved in the treatment of the patients. The patients were informed that the information collected was kept confidential and was not made available to anyone other than the investigators. These questionnaires pertained to patient-perceived orthodontist behaviors, patient satisfaction, and perceived orthodontist-patient relationships in orthodontic treatment. At the same time, the orthodontist treating each patient completed a standard instrument to evaluate patient adherence. Materials 1. Orthodontist behavior questionnaire. This instrument was used to evaluate verbal communication relating to information given to the patient about procedures, comforting the patient, and reassurances provided by the
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orthodontist treating the patient. It also evaluated a range of nonverbal behaviors of the orthodontist as perceived by the patient. It consisted of 24 items relating to the orthodontist's behaviors as perceived by the patient. These items were identical to those from an instrument designed to assess dentist behaviors used in previous research, 3with the exception that items were presented as gender neutral and that one nonapplicable item ("made me numb") was dropped. Further, all items were written with reference to the orthodontist and orthodontic treatment. This questionnaire was completed 8 to 12 months into orthodontic treatment. All items were scored on a 5-point Likert-type scale with categories ranging from strongly disagree to strongly agree. Higher scores on items indicated a more positive evaluation. 2. Orthodontic visit satisfaction scale. The instrument to assess patient satisfaction was an adaptation of a questionnaire designed to measure satisfaction of patients undergoing general dental treatment. 15 The only change was the substitution of the word orthodontist for dentist. This 10-item instrument for evaluating orthodontic patient satisfaction was also completed 8 to 12 months into orthodontic treatment. This instrument measures patient satisfaction in areas of information-comprehension, understanding-acceptance, and technical competence. All items were scored on a 5-point Likert-type scale with categories ranging from strongly disagree to strongly agree. A total satisfaction score was obtained by summing the individual item scores, with reverse scoring for one negative item. 3. Orthodontist-patient relationship (Table I). These two items were used in a previous investigation z for assessing the orthodontist-patient relationship as perceived by the patient. Responses to these items were obtained 8 to 12 months into orthodontic treatment. These items were also scored on a 5-point Likert-type scale with categories ranging from strongly disagree to strongly agree. Higher scores indicating a positive relationship. 4. Orthodontic patient cooperation s c a l e . 16 The orthodontists treating the patients completed this instrument to assess the level of patient adherence. Slakter et al. 16 found this instrument to have strong internal consistency. This 10-item instrument measures patient cooperation as it relates to keeping appointments, wearing and maintaining appliances, patient attitude toward treatment, oral hygiene maintenance, and parental interest in treatment. It was completed by the orthodontists after completion of 8 to 12 months treatment for each patient. All items were scored on a 5-point Likert-type scale with categories ranging from Always to Never. This instrument consists of five positive and five negative items. Negative items were reverse scored, hence, a higher score is indicative of increased patient adherence. Statistical Analysis The instruments were scored in the following manner. 1. Satisfaction score. This is an aggregate score of the 10 items in the questionnaire.
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Table I. Orthodontist-patient relationship items Item 1 Item 2
T h e orthodontist w h o is treating m e likes m e as a person. T h e orthodontist is concerned about m e and wants to do w h a t is best for m e in the long run.
2. Patient cooperation score. This is an aggregate
score of the 10 items in the questionnaire. 3. The doctor-patient relationship items one and two. These items were scored individually. 4. Orthodontist behavior questionnaire. The individual items from this instrument were used as independent variables and, hence, scored individually for a portion of the analyses. The mean score for the orthodontist behavior questionnaire was also obtained by adding the scores for each of the 24 items for each patient and averaging this score for the entire group. For the mean orthodontist behavior questionnaire score, item 3 (criticized my teeth or how I have been taking care of them) was reverse scored. The scores obtained on each questionnaire were entered in a SAS data set (SAS Institute, Cary, N.C.) and analyzed by using this statistical program. Correlation and stepwise multiple regression analyses were used to evaluate the data. Regression analyses were performed with the individual orthodontist behavior items, as well as the mean orthodontist behavior score as independent variables, and four dependent variables. The dependent variables were (1) the satisfaction score, (2) the patient cooperation score, and (3) the doctor-patient relationship items one and two. RESULTS Correlations
Correlations between the perceived orthodontist behaviors and the dependent variables are presented in Table II. Of the 24 orthodontist behaviors, 23 were significantly correlated with favorable patient satisfaction and both orthodontist-patient relationship items at p < 0.0001. Nine of the 24 orthodontist behaviors were significantly correlated (four behavior items at p < 0.01 and five of the behavior items at p < 0.05) with favorable patient cooperation. Item 3 of the orthodontist behavior questionnaire negatively correlated with all four independent variables: (a) patient satisfaction score ( p < 0.05), (b) the orthodontist-patient relationship item 1 ( p < 0.05), (c) the orthodontist-patient relationship item 2 ( p < 0.01) and (d) the patient cooperation score ( p < 0.01).
American Journal of Orthodontics and Dentofacial Orthopedics October 1996
Significant correlations shown in Table III were found between the composite mean score of the orthodontist behavior questionnaire and the patient satisfaction score ( p < 0.0001), both orthodontistpatient relationship items ( p < 0.0001), and the patient cooperation score (p < 0.05). Table III also shows significant correlations (p < 0.05) between a favorable patient cooperation score, the patient satisfaction score, and the orthodontist-patient relationship item 1. Stepwise multiple regression analyses
Separate stepwise multiple regression analyses were conducted to predict various dependent variables with the individual orthodontist behavior items as predictors. Eight behaviors were found to significantly predict patient satisfaction a t p < 0.05, as shown in Table IV, accounting for almost 80% of the variance in the total satisfaction score. Politeness alone accounted for almost 61% of the variance. Stepwise multiple regression analyses were also conducted for each relationship item. Eight orthodontist behaviors were found to significantly predict the orthodontist-patient relationship item 1 at p < 0.05, as shown in Table V, accounting for almost 79% of the variance in the total item score. The patients perception that the orthodontist paid attention to what the patient had to say, accounted for 63% of the variance. Ten behaviors were found to significantly predict orthodontist-patient relationship item 2 at p < 0.05, as shown in Table VI, accounting for approximately 73% of the variance in the total item score. Of these, making the patient feel welcome, accounted for almost 57% of the variance. Stepwise multiple regression analysis was conducted for the total patient compliance score. Two behaviors, i.e., was polite to me during my visit and criticized my teeth or how I have been taking care of them, were found to significantly predict patient adherence at p < 0.05. These items accounted for approximately 10% of the variability in the total patient compliance score. Evaluation of different age groups
To evaluate differences in response by age, the sample was divided into three subgroups, i.e., those below the age of 11 years, 11 through 14 years, and more than 14 years. All independent and dependent variables were subjected to analysis of variance procedures to evaluate whether differences existed between the means of the different age
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Sinha, Nanda, and McNeil 373
Table II. Correlations between orthodontists' behavior and patient satisfaction, orthodontist-patient relationship and
patient cooperation in orthodontic treatment
t Behavior
Sat~faction
1. Warned me when he/she felt the procedure might hurt. 2. Told me to be calm or to relax. 3. Criticized my teeth or how I have been taking care of them. 4. Showed that he/she knew what 1 was feeling. 5. Worked quickly but didn't rush. 6. Was friendly to me. 7. Encouraged me to ask questions about my treatment. 8. Made me feel welcome. 9. Was polite to me during my visit. 10. Used words that were understandable about my treatment. 11. Told me what he/she was going to do before starting to work. 12. Showed me that he/she paid attention to what I said. 13. Reassured me during the procedure. 14. Asked during the procedure if I were having any discomfort. 15. Had a calm manner. 16. Asked during the visits if I were concerned or nervous. 17. A step-by-step explanation of what he/she was doing. 18. Showed that he/she took seriously what I had to say. 19. Was patient with me. 20. Carried on casual conversation and small talk. 21. Told me that if it started to hurt he/she would relieve the pain. 22. Gave me moral support during the procedure. 23. He/she would do everything he/she could do to prevent pain. 24. Smiled.
0.60:~ 0.545/ -0.16" 0.605/ 0.74:~ 0.69:~ 0.675/ 0.78~: 0.78:~ 0.615/ 0.625/ 0.74:~ 0.685/ 0.725/ 0.635/ 0.585/ 0.635/ 0.765/ 0.705/ 0.70:~ 0.645/ 0.745/ 0.74~ 0.575/
Relationshipitems
'
2
Cooperation
0.535/ 0.475/ - 0.16" 0.60:~ 0.695/ 0.56:~ 0.565/ 0.755/ 0.705/ 0.515/ 0.51:~ 0.745/ 0.555/ 0.695/ 0.555/ 0.53:~ 0.61~ 0.675/ 0.66~: 0.645/ 0.59:[: 0.71~: 0.725/ 0.52:~
0.21"* 0.12 - 0.24** 0.04 0.17" 0.22"* 0.12 0.20* 0.26** 0.06 0.16 O.17" 0.15 0.17" 0.20* 0.03 0.03 0.13 0.12 0.21"* 0.10 0.13 0.14 0.15
I
0.635/ 0.565/ - 0.18" 0.58¢ 0.685/ 0.645/ 0.65:~ 0.765/ 0.695/ 0.595/ 0.585/ 0.765/ 0.625/ 0.705/ 0.63~ 0.605/ 0.62~ 0.76:~ 0.725/ 0.725/ 0.615/ 0.765/ 0.775/ 0.665/
*p < 0.05; **p < 0.01; ~p < 0.0001.
Table III. C o r r e l a t i o n s b e t w e e n t o t a l o r t h o d o n t i s t s ' orthodontist-patient
relationship
behavior score (OBS), total patient satisfaction score,
items, and patient cooperation
I Total OBS Total patient satisfaction score Orthodontist-patient relationship item 1 Orthodontist-patient relationship item 2 Total PCS
(PCS) in orthodontic
TotalPCS 0.18" 0.16" 0.19" 0.15 -
treatment
[
TotalOBS -0.845/ 0.82:~ 0.765/ 0.18"
*p < 0.05; 5/p < 0.0001.
groups. No significant differences were found for any of the variables among the different age groups. DISCUSSION
There is a paucity of studies evaluating the relationship between the orthodontist and the patient and its effects on patients undergoing orthodontic treatment. The nature of today's busy orthodontic practices often results in minimal communication between the doctor and the patient. 5'17'1s Although the treatment provided may be adequate, the patient's feelings toward the practice may become strained because of a lack of effort by the orthodontist to make the patient feel that he/she is being treated like a person. This can
result in a dissatisfied patient, who may not like the orthodontist, has feelings of indifference toward the office and the orthodontist, and consequently, does not adhere to prescribed instructions. This lack of doctor-patient rapport can also lead to malpractice law suits that may prove to be very expensive and inconvenient. 5-7 Patient Satisfaction
Patients generally think that the doctor-patient interaction should be comfortable and warm with a doctor who is technically competent and provides adequate information about the problem and procedures he/she will perform. 1"17-21 Several reports in the literature have suggested that when these expectations are not met, the patients feel disappointed,
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American Journal of Orthodontics and Dentofacial Orthopedics October 1996
Table IV, Summary of stepwise procedure for dependent variable patient satisfaction score*
rioble
['a olR21Mo,'e' l' q"rob F
Was polite to me during my visit. Showed that he/she took seriously what I had to say. Let me know that he/she would do everything he/she could do to prevent pain. Worked quickly but didn't rush. Reassured me during the procedure. Asked during the visits if I were concerned or nervous. Carried on casual conversation and small talk. Gave me a step-by-step explanation of what he/she was doing as he/she did it.
0.6086 0.1151 0.0279 0.0145 0.0060 0.0095 0.0082 0.0053
0.6086 0.7237 0.7516 0.7661 0.7721 0.7816 0.7899 0.7952
0.0001 0.0001 0.0001 0.0024 0.0463 0.0109 0.0162 0.0500
Model R 2
['rob > F
0.6330 0.7121 0.7479 0.7678 0.7789 0.7851 0.7887 0.7930
0.0001 0.0001 0.0001 0.0004 0.0060 0.0374 0.0456 0.0225
*No other variable met the 0.0500 significance level for entry into the model.
Table V, Summary of stepwise procedure for the orthodontist-patient relationship item 1 Partial R e Showed me that he/she paid attention to what I said. Let me know that he/she would do everything he/she could do to prevent pain. Showed that he/she took seriously what I had to say. Smiled. Made me feel welcome. Carried on casual conversation and small talk. Reassured me during the procedure. Asked during the visits if I were concerned or nervous.
[
0.633 0.0791 0.0358 0.0198 0.0112 0.0062 0.0056 0.0072
*No other variable met the 0.0500 significance level for entry into the model.
Table VI. Summary of stepwise procedures for the orthodontist-patient relationship item 2 Partial R 2 Made me feel welcome. Showed that he/she took seriously what I had to say. Worked quickly but didn't rush. Let me know that he/she would do everything he/she could do to prevent pain. Showed me that he/she paid attention to what I said. Asked during the visits if I were concerned or nervous. Gave me a step-by-step explanation of what he/she was doing as he/she did it. Asked during the procedure if I were having any discomfort. Warned me when he/she felt the procedure might hurt. Told me what he/she was going to do before starting to work.
0.5680 0.0693 0.0229 0.0146 0.0095 0.0083 0.0134 0.0112 0.0119 0.0069
[
Model R 2
}
0.5680 0.6373 0.6601 0.6747 0.6842 0.6925 0.7059 0.7172 0.7264 0.7333
Prob > F 0.0001 0.0001 0.0014 0.0090 0.0327 0.0426 0.0091 0.0151 0.0110 0.0498
*No other variable met the 0.0500 significance level for entry into the model.
less satisfied, fail to keep appointments, and do not comply with prescribed instructions. 1'5'6"22-25The psychological impact of a dissatisfied patient may be increased anxiety, reduced patient compliance, and eventually a poor orthodontic result. The results of this study showed strong correlations between perceived orthodontist behaviors and patient satisfaction, thus indicating that orthodontist-patient interactions have strong influences in predicting patient satisfaction. Although all items in the orthodontist behavior questionnaire were significantly correlated with patient satisfaction, eight behaviors were found to be more influential in affecting satisfaction. The most important item was found to be the doctor's polite behavior toward the patient. Other verbal communication behaviors like information, reassur-
ance, and concern were also important. The doctor's calm and confident attitude and an unhurried approach to treatment appeared to increase patient satisfaction. Further, correlations performed between patient satisfaction and a total score for the orthodontist behavior instrument showed that these two scores were strongly correlated. This suggests that orthodontist behaviors, in general, have a strong influence on patient satisfaction. Also, correlations between patient satisfaction and patient adherence showed that patient satisfaction is important for ensuring patient adherence in orthodontic treatment. The Orthodontist-Patient Relationship
In the practice of orthodontics today, time should be invested in creating and maintaining the
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important "patient-doctor bond"? Patients must be treated as people who have malocclusions, not realocclusions attached to people. Orthodontist behaviors such as listening, empathy, and explanation are important in achieving that goal? All orthodontist behavior items as perceived by the patient in this study were significantly correlated with both of the orthodontist-patient relationship items. However, 8 of the 24 behavior items were found to be most influential in predicting the patients' perception of whether the orthodontist liked the patient as a person. The most important of these was the patient's perception that the orthodontist paid attention to what the patient said. Other significant patient behaviors were the orthodontist's reassurance that he/she would do everything to prevent pain, as wel! as friendliness. Smiling and making the patient feel welcome were also important. Finally, the patient's perception of the orthodontist's concern toward the patient was significant in predicting a positive orthodontist-patient relationship. Ten of the 24 orthodontist behaviors were significant in predicting the patient's perception that the orthodontist was concerned about the patient and wanted to do the best for the patient in the long run. The most important of these was the fact that the orthodontist made the patient feel welcome. The second most important of these behaviors was found to be the patient's perception that the orthodontist took seriously what the patient had to say. A concerned orthodontist who listened to the patient and expressed concern while he/she worked efficiently were found to be significant factors. A survey conducted recently evaluated professional qualities rated by patients as being extremely important in their general dentists. This study showed that dentist qualities such as professional competence, reassurance, friendly and patient behavior, and informing patients about the procedures were highly valued by the patients. 1 Interpersonal caring (gentleness, patience, and friendliness) was found to be the most popular dentist behavior among the patients surveyed? Studies have also shown that patients would like to see professional traits like gentleness, friendliness, and professional competence in an ideal dentist. 2~'27 Similar orthodontist behaviors in this study were found to significantly predict satisfaction, the doctor-patient relationship and patient adherence. Patient Adherence in Orthodontic Treatment
This study focuses on the importance of interpersonal relationships between the orthodontist and
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his patient, based on orthodontist behaviors that may have a significant impact on patient adherence in orthodontic treatment. Previous studies in this field have attempted to help clinicians identify potentially noncompliant patients. 9'28-38 Some have reported that in addition to certain personality traits, interpersonal relationships are exceedingly important. 2"28'3°'39-4a Other studies note that once noncompliant patients have been identified, cooperation can be improved through better comnmnication and feedback from the orthodontistY 2-44 Nanda and Kierl 2 have shown that orthodontist-patient relationships have significant effects on patient adherence. They showed that a positive orthodontist-patient relationship resulted in an increase in the level of compliance by the patient. Our study has analyzed correlations between 24 orthodontist behaviors and how they interacted with patient cooperation, individually and collectively, i.e., mean orthodontist behavior score. When the behaviors were individually considered, it was shown that nine specific orthodontist behaviors were significantly correlated with patient adherence. The most important behavior was politeness toward the patient. The orthodontist's criticism of the patient's teeth or how he/she looked after them had a negativ e influence on patient adherence. The doctor's expression of concern about the well being of the patient was also found to be significant in predicting patient adherence. Verbal communication, a calm and confident manner, and reassurance, were also found to increase patient compliance. Patient cooperation in orthodontic treatment has been reported to be influenced by a variety of patient factors. The results of this study, however, emphasize that the orthodontist can influence patient cooperation by trying to establish a good rapport with the patient. Important Orthodontist Behaviors
Some orthodontist behaviors appeared to influence more than one dependent variable like satisfaction, the orthodontist-patient relationship, and patient cooperation in orthodontic treatment. The behaviors that were important in influencing patient satisfaction and orthodontist-patient relationships were related to communication between the orthodontist and the patient and the fact that the orthodontist was perceived to be concerned about the patient. Patient satisfaction and patient cooperation were found to be influenced by politeness and verbal communication showing that the ortho-
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dontist was interested in the patient's concern and alleviating anxiety.
Communication Cooperation Klages et al? 5 found that the orthodontist's verbal behaviors strongly correlated with patient's verbal behaviors. Further, behaviors where the orthodontist encouraged the patient were strongly correlated to patient participation in this dialogue. This finding may be extended to assume that the orthodontist's initiation of verbal communication stimulated an increase in the patient's verbal communication. Communication between the orthodontist and the patient, and reassurance by the orthodontist, was found to be significant in predicting patient satisfaction and the orthodontistpatient relationship in this study. Elliot ~6 found that interpersonal communication was strongly related to reassuring and understanding behaviors. In this study, reassuring and understanding orthodontist behaviors predicted patient satisfaction, the orthodontist-patient relationship, and patient cooperation in following the prescribed instructions. Evaluation of Different Age Groups The sample in our study included an age group with an average age of 14.4 years and a standard deviation of 2.4 years, hence results of this study may apply to this age population alone. Comparing responses based on age groups revealed no significant differences. This indicates that all the patients responded similarly to positive and negative items in this study. Further, age was not found to be a factor in the patients' perception of the doctors behavior. In some instances, young patients perceive their orthodontists as role models 47 and many have been influenced to choose orthodontics as their profession. Therefore orthodontists can influence people's lives in many ways. Yet another pragmatic reason for building a good doctor-patient rapport is the prevention of litigation issues, s-7 Orthodontist behaviors influence patient satisfaction, the orthodontist-patient relationship, and patient cooperation in orthodontic treatment. It is therefore important to establish good rapport with the patient. Time invested to establish rapport with patients will be less than that required to correct the potential difficulties resulting from failure to do so. In other words "An ounce of prevention is worth a pound of cure. ''7
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