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The dentist-patient relationship: mutual perceptions and behaviors
J A D )A _ A R T I C L E S
The relationship between patients’ characteristics and dentists’ perceptions as well as the associations between these dimensions and specific dentist behaviors as perceived by patients are explored. Dentist perceptions o f p atien t sophistication and anxiety were related to several p atien t characteristics, but perceptions o f p atien t likab ility were unrelated to p atien t personal and social characteristics. Perceptions o f p atien t likab ility were associated w ith more specific dentist behaviors than were other dentist perceptions noted by patients. The results suggest that dentists’ views are influenced p rim a rily by those p atien t characteristics manifested during treatment. In general, dentists like patients who are dentally sophisticated and not anxious.
The dentist-patient relationship: mutual perceptions and behaviors Norm an L. Corah, PhD Robert M. O’Shea, PhD G. D onald B issell, DDS
prem ise fro m several behavioral disciplines holds that th e in terac tion o f two people is likely to have a recip ro cal effect— th a t is, w hat eith er p e r son does is both cause an d result o f w hat th e o th e r p erso n has do n e, is doing, o r is ex p ected to do. A n o th er com m on prem ise is th a t p erson-to-person behavior is likely to be affected by th e various social roles each p erso n has. T h u s, it is h a rd to im ag ine d ealin g with anyone in o u r society and com pletely d isreg a rd in g his o r h e r age, g en d e r, ethnicity, o r socioeconom ic status. T h e se concepts o f reciprocity a n d o f m ultiple roles have been in co rp o rated into various m odels o f physician-patient rela tio n s.1,2 T h ey also a re p e rtin e n t to the d en tist-p atien t relationship. H ow ever, lit tle em pirical research has been conducted solely co n cern in g patient-dentist in terac tion an d how p atien t an d dentist personal an d social ch aracteristics affect d en tal care. Less research has been conducted th an th e interaction deserves, especially because m ost d en tal care is delivered o n a o n e-o n -o n e basis in relatively long an d so m etim es in te n se sessions a n d w ithin p erso n al relationships th a t often exten d fo r m any years. T h e aspects explored to d ate have been mainly p atient a n d dentist anxiety, com m unication, an d satisfaction. N ee d ed are social psychological studies o f th e aspects o f the microsocial w orld of opera to ry a n d practice.
A
A re p o rt by C o rah an d o th e rs3 assessed th e way in which p atien ts’ percep tio n s o f d en tist behavior affected th e ir satisfaction and anxiety. Satisfaction increased with d en tist com m unication th a t was accepting and caring. P atient anxiety decreased with rising satisfaction, b u t anxiety clearly was not linked to any o f th e d en tist behaviors ex p lo red in the study. H o o p e r an d o th e rs4 fo u n d th a t patien ts’ age, ethnicity, g en d er, an d a p p e a ra n c e all in d e p e n d e n tly a f fected one o r m o re physician behaviors relevant to com m unication, em p ath y , and responsiveness. E pstein a n d o th e rs,5 studying ch arac teristics o f p atien ts a n d physicians as-
D ental sophistication Believes in good oral care Subscribes to appropriate self-care M aintains oral health Likability Shows respect, is attentive C ourteous, pleasant P atient is a likable person Com pliance O n tim e for appointm ents Follows advice, accepts suggestions Seems to be kind o f person who would pay bills on tim e Fig 1 ■ D entist perceptions o f patient charac teristics.
sociated w ith effective co m m u n ic atio n , f o u n d t h a t c o m m u n ic a tio n b e tw e e n physician an d p atien t was less effective w h e n p a t ie n t s w e re o f lo w e r s o c io econom ic status. Level o f physician tra in in g a n d ty p e o f p ra c tic e w e re n o t as sociated w ith com m u n icatio n , a n d physi cians could n o t p red ic t how th e ir p atien ts w ould resp o n d to them . T w o studies in th e d e n ta l lite ra tu re also sh o u ld be n o ted . F razier a n d o th e rs6 su r veyed families with low incom es an d th e ir dentists an d observed a discrepancy be tw een th e h igh p rio rity placed o n d en tal care by p atients with low incom es an d th e low p rio rity th a t th e d entists believed th a t these p atients placed on d en tal care. T h e a u th o rs suggested th a t low er use o f d en tal services m ight be partly a resu lt o f bias an d negative recep tio n by d entists ra th e r th an a lower-class d ev alu atio n o f o ral health . W einstein an d o th e rs7 fo u n d th a t p atien ts w ho valued d en tal care te n d e d to receive b etter restorative care fro m th e ir dentists. T h ese studies suggest th a t a p a tie n t’s characteristics in fluence th e d en tist’s p e r ception o f him o r h e r, w hich may in flu ence b ehavior tow ard th e p atient. A study by O ’Shea an d o th e rs8 ind icated th a t d e n tist p ercep tio n s o f p atients te n d e d to fall in to th e follow ing th re e b ro ad categories: d en tal sophistication (p atien t has positive a n d a p p r o p r ia te a ttitu d e s to w ard o ral care), in te rp e rs o n a l re sp o n siv e n e ss (is JAD A, V ol. 113, A ugust 1986
m
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congenial, friendly), an d com pliance (ar rives on tim e fo r ap p o in tm en ts, pays bills, accepts tre a tm e n t plan). T h ese ch a rac teristics w ere sim ilar to those described by Wills9 as basic criteria fo r assessing clients se en by o th e r p ro fe ssio n a l “h e lp e r s ” ; nam ely, treatability (is m otivated to be tr e a te d ) , likability, a n d m a n ag e ab ility (cooperates). T h e p rese n t study continues to explore th e association betw een patients’ ch arac teristics a n d d en tists’ perceptions. In ad d i tion, such characteristics an d perceptions are evalu ated fo r results in specific d entist behaviors, as patients perceive them .
sion could ra n g e fro m 3 to 12. T h e scale was p re te sted on 111 p atien ts from an u rb a n g ro u p p riv a te p ractice. C o e ffic ie n t a lp h a s fo r the th ree-item scales w ere d e n ta l sophistication, .91; likability, .77; a n d com pliance, .64. In tern a l consistency, th e re fo re , was satisfactory fo r the first two scales b u t barely a d eq u a te fo r the th ird scale, com pliance. In a d d itio n to the p o o r in te r nal consistency o f th e com pliance scale, two item s (on tim e fo r a p p o in tm e n ts a n d follows advice, accepts suggestions) w ere d e em ed in ap p ro p ria te fo r the hospital clinic setting. C on sequently, only the d e n ta l sophistication a n d likability item s w ere u se d in the p re se n t study. D entists also ra te d th e p a tie n ts’ anxiety d u r ing tre a tm e n t by categorizing th em as belong ing in the highest th ird , m id d le th ird , o r lowest th ird o f th e patients they norm ally trea te d .
Methods Description of sample O u tp a tie n ts in a large public hospital d en tal clinic w ere a p p ro a c h e d in the w aiting ro o m by a research assistant a n d asked to participate. T h e assistant was iden tified as n o t bein g a clinic staff m em ber. Patients w ere eligible fo r participation if they w ere o ld e r th an 18 years, scheduled to receive an invasive p ro c e d u re , a n d not in severe pain. T w enty p e rc e n t o f th e qualified patients re fu sed to particip ate, a n d a n additio n al 5% re fu sed to o r w ere u n ab le to com plete the in te r view a fte r treatm en t. B efore tre a tm e n t began, patients gave p e r sonal d ata, inclu d in g age, g e n d e r, a n d e d u ca tion, a n d filled o u t th e C orah D ental A nxiety Scale (DA S).10 In ad d itio n , it was d e te rm in e d w h e th er the p a tie n t was new to the clinic a n d w h e th er the visit was a scheduled or an e m e r gency one. T h e research assistant also ra te d the p a tie n t’s a p p e a ra n c e on a four-category scale a d a p te d from th a t o f H o o p e r a n d o th ers.4 T h e c ategories w ere as follows: som eone w ho is clean a n d dressed in a suit o r dress, h a ir clean a n d styled (4 points); neat a n d clean but m ore c asually well d re s s e d (3 p o in ts); c lean b u t som ew hat disheveled (2 points); ru m p le d , dirty clo th in g a n d hair, a n d generally disheveled (1 point). Im m ediately a fte r tre a tm e n t, patients com p lete d a q u e stio n n a ire listing 21 possible d e n tist behaviors. By choosing “yes” o r “no,” p atients indicated w h e th er th e d e n tist had show n the behavior; p atients w ere in stru cted to choose “n o ” if they w ere u n certain . T h e 21 item s in c lu d ed den tist behaviors related to in form ation giving, e n c o u ra g in g disclosure o f patien t feel ings c o n ce rn in g tre a tm e n t, a n d w hat dentists said a n d did to lessen anxiety. T h e questio n n aire has been p re sen te d elsew here.3 T h e dentists also ra te d th e ir perceptions o f th e p a tie n ts im m ediately a fte r tre a tm e n t. A scale was d evelo p ed to assess the th ree patien t d im ensions o f d e n ta l sophistication, likability, a n d com pliance fo u n d by O ’Shea a n d o th e rs8 (Fig 1). T h e d e n tist was asked to answ er each o f th e n in e item s with o n e o f th e fo u r follow ing resp o n se s: d e fin itely has this c h aracteristic, probably does, probably does n o t, o r definitely does not. T h e answ ers w ere scored 4, 3, 2, 1, respectively, so th a t th e score fo r each d im e n 254 ■ JA D A , V ol. 113, A u gust 1986
A total o f 231 d en tal p a tie n ts, 107 m en a n d 124 w om en, p articip ated in the study. T h e y ra n g ed in age fro m 18 to 73 years, w ith a m edian o f 28 y e a rs. M e d ia n e d u c a tio n w as h ig h sch o o l g ra d u a te , w ith a ra n g e fro m com p letio n o f th ird g ra d e to com pletion o f 5 years o f college. New patients co n stitu ted 41% o f th e sam ple; 59% h a d visited th e clinic b efo re. E m ergency visits w ere being m ad e by 63% o f th e sam ple; 37% h a d sch ed u led a p p o in tm en ts. O n the day o f th e interview , th e d e n ta l p ro c ed u re s sched uled to be received by the p atients w ere exodontic tre a tm e n t, 53% ; re sto ra tio n s, 22% ; e n d o dontic trea tm e n t, 6%; a n d o th e r trea tm e n t, 19%. T h e p e rso n n el p ro v id in g service w ere sta ff m em bers, 6%; resid en ts, 51%; a n d senior d en tal stu d en ts, 43% . It was estim ated th a t a p proxim ately h a lf o f th e clinic p o p u latio n qual ified fo r M edicaid re im b u rse m e n t.
Results T h e correlatio n s betw een d e n tist p ercep tio n s o f patients a n d several actu al p a tie n t c h aracteris tics a re given in T ab le 1. D entist ratings o f pa tient d e n ta l sophistication w ere significantly (P < .05) associated w ith the follow ing p a tie n t characteristics: being a w om an, h aving m ore e d u catio n , bein g a p a tie n t w ho h a d visited the clinic b efo re, having a sch ed u led a p p o in tm en t,
having a b e tte r a p p e a ra n c e ra tin g , a n d being less anxious. D entist ratings o f p a tie n t likability w ere u n re lated to any o f the p a tie n t characteristics. D en tist ratings o f p atient anxiety w ere significantly ^ a s s o c ia te d w ith p a tie n t c h a r a c te ris tic s o f y o u n g er age, lower e d u catio n , being a new pa tient, m aking an em ergency visit, a n d p a tie n t- ^ re p o rte d anxiety (DAS). T h e th re e d en tist ratin g s o f th e patients also w ere significantly (P < .05) c o rrelated as fol lows: d e n ta l sophistication a n d anxiety, —.24; i sophistication a n d likability, .28; a n d likability a n d anxiety, —.21. In o th e r w ords, dentists te n d e d to ra te patients perceived as a nxious as less dentally sophisticated a n d ten d e d to like p a tie n ts p e rc e iv e d as b e in g m o re d e n ta lly sophisticated a n d low in anxiety. T h e correlations betw een d entist perceptions o f patients a n d the d e n tists’ behavior perceived by th e patients is given in T ab le 2. O nly the follow ing th re e d e n tist behaviors w ere signifi cantly (P < .05) associated w ith d e n tist ratings o f p atien t sophistication: n o t criticizing th e pa tie n t’s oral c ondition, sp o k e u n d e rsta n d a b le language, a n d took seriously w hat the patien t had to say. Six d e n tist behaviors, as re p o rte d by patients, w ere associated w ith likability. T hese six behaviors suggest th at th e d e n tist displayed m o re positive in teractio n a n d p atience tow ard those p atients h e o r she liked. F o u r d e n tist be haviors w ere associated w ith th e ir ratin g s o f patien t anxiety, inclu d in g inquiries ab o u t n e r vousness, anxiety, a n d allergies, a n d bein g seen as less patient. C o r r e la ti o n s a ls o w e r e c o m p u t e d a n d analyzed betw een the p a tie n ts’ social charac teristics listed in T able 1 a n d d e n tist behaviors. H ow ever, only eight o f th e 147 co rrelations w ere significant (P < .05) a n d th a t result could be expected on th e basis o f chance. T h e re fo re , it may be co ncluded th a t no system atic relatio n ship existed betw een the p a tie n t characteristics a n d th e d en tist behaviors perceived by th e pa tients.
Discussion and conclusions T h e results indicate several points co n c ern in g the relationship betw een th e way in which dentists perceive patients an d ac
Table 1 ■ Correlations between actual patient characteristics and three dentist ratings of patients. Patient characteristic Gender Age Education New patient Emergency Appearance Dental Anxiety Scale *P < .05.
Dentist rating of patients Sophistication
Likability
Anxiety
.15* .04 .17* -.15* -.19* .17* -.24*
-.0 9 .08 .10 -.0 2 -.1 2 .01 -.0 9
.09 -.14* -.14* .20* .21* .12 .33*
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T ab le 2 ■ Correlations between dentist behavior ratings by patients and ratings of patients by dentists. Dentist rating of patients Dentist behavior item Asked about health Asked about nervousness Criticized mouth Waited until numb Asked if allergic Worked quickly Encouraged talk Encouraged questions Welcoming Polite Understandable Told procedure Paid attention Reassuring Asked about discomfort Calm manner Asked about anxiety Washed hands Took me seriously Was patient Took me on time
Sophistication
Likability
Anxiety
.04 .13 -.26* .04 -.1 3 .11 .10 .05 .13 .01 .18* -.0 5 .07 .08 -.11 .13 -.11 .08 .15* .07 .01
-.19* -.0 4 .05 .06 .03 .01 .03 .11 .09 .02 .18* .03 .26* .08 .07 .17* -.0 5 .12 .18* .17* .12
-.1 4 .22* .01 -.0 2 .23* .05 -.0 6 .01 .05 -.01 .00 -.01 -.0 3 -.01 .03 -.0 5 .19* .07 .01 -.1 4 .04
* P < .0 5 .
tual p atien t characteristics. It may be con cluded th a t, in this setting, th e dentally sophisticated p atien t is likely to be a b etter e d u c a te d , w e ll-d re s se d a n d g ro o m e d w om an who is a re g u la r patient, is at the of fice fo r a scheduled visit, an d is n o t d e n tally anxious. T h e anxious patient, as p e r ce iv e d by th e d e n t is t, te n d s to b e a yo unger, less w ell-educated person w ho is new to th e clinic, is th e re fo r an em ergency visit, an d is anxious. T h ese characteristics, fo r th e m ost part, are w hat m ight be expected o f the dentally so p h isticated a n d th e a n x io u s p atien t. W hat is su rp risin g in the findings is that dentist p ercep tio n o f p atien t likability a p pears to be u n rela ted to any o f the p atient social characteristics assessed. H ow ever, dentists te n d to like patients w ho are d e n tally sophisticated a n d w ho are not an x ious, b u t this liking is n o t based on the m o re g en eral traits exam ined. F u rth e r, d entists’ likability ratin g o f p a tients was associated with m o re o f th e posi tive d en tist behaviors th an was eith er o f th e two o th e r d en tist ratings on patien ts’ sophistication an d anxiety. Patients liked by dentists te n d ed to perceive dentists as attentive, u n d ersta n d ab le, patient, calm, an d accepting o f w hat p atients said. T hese behaviors are sim ilar to th e type o f d e scrip to rs L iddell a n d M ay11 fo u n d fo r low -anxiety d e n ta l p a tie n ts ’ ra tin g s o f th e ir dentists. T h e only negative dentist behavior fo u n d in the p rese n t study was
th a t the d en tist te n d ed to be seen as im pa tient tow ard those patien ts perceived as anxious. T h e lack o f system atic relationships be tw een p atien t back g ro u n d characteristics an d dentist behaviors in this study is in consistent with th e findings by Liddell and M a y ". H ow ever, th eir subjects rate d d e n tists outside o f th e d en tal setting an d may have displayed m ore g en eral attitu d es to w ard dentists th an was th e case in th e p re sent study. T h e findings in this study also a re inconsistent with those o b tain ed by Epstein an d o th e rs5 w ho fo u n d relatio n sh ip s b e tw e e n p a tie n t so c io e c o n o m ic status an d physician behaviors. H ow ever, those a u th o rs stu d ied p atients re p re se n t ing a b ro a d e r ra n g e o f socioeconom ic status in a contex t th a t consisted alm ost entirely o f verbal interaction. T h e fin d in g s p ro v id e som e evidence that d en tists’ percep tio n s are influenced not by patien ts’ g en eral an d social ch arac te ris tic s b u t a r e in f lu e n c e d by th o se c h a ra c te ristic s th a t specifically a p p e a r d u r in g d e n ta l tre a tm e n t. F u rth e r, the perceptions by dentists are reflected in som e o f th e ir b ehavior tow ard patients. From o n e perspective, any u n eq u al re sponse to patients, fo r w hatever reason, disappoints the professional’s own code of altruism an d self-discipline. H ow ever, the d ata also a re a basis fo r believing th at the practitioners stu d ied acted tow ard th eir patients mostly in ways u n rela ted to the
d en tists’ su m m ary p ercep tio n s o f th e p a tients as b eing dentally sophisticated, an x ious, o r likable. Finally, it is im p o rta n t to qualify these findings an d in te rp re tatio n s by the con text fro m w hich they w ere d raw n — a hos pital clinic p o p u latio n served by dentists in train in g . A ffect co n tro l is a skill th at p re sum ably im proves with exp erien ce, ft is com m on know ledge th a t dentists a n d p a tients have o n g o in g interactions an d th a t a p a tie n t’s c o n tin u in g in a practice o ver tim e rep rese n ts p erso n al choices m ad e both by th e p atien t an d by th e dentist.
----------------------J » D A --------------------Informed written consent was obtained from all pa tients before they participated in this study. This investigation was supported in part by research grant no. De 04494 from the National Institute of Dental Research. The authors thank Drs. S. Fischman and J. D’Ambrosio and the staff members of the Erie County Medi cal Center Dental Clinic for their assistance in conduct ing this research. Dr. Corah is professor, behavioral sciences, School of Dental Medicine; Dr. O’Shea is associate professor, social and preventive medicine, School of Medicine; and Dr. Bissell is associate professor, public health dentistry, School o f Dental Medicine, State University of New York at Buffalo, Farber Hall, Buffalo, 14214. Address requests for reprints to Dr. Corah. 1. Bloom, S.W ., and W ilson, R.N. Patientpractitioner relationships. In Freeman, H.E., and others, eds. Handbook of medical sociology. En glewood Cliffs, NJ, Prentice-Hall, Inc, 1979, pp 275296. 2. Bloom, S.W. The doctor and his patient: a sociological interpretation. New York, Russell Sage Foundation, 1965, pp 235-259. 3. Corah, N.L.; O’Shea, R.M.; and Bissell, G.D. The dentist-patient relationship: perceptions by patients of dentist behavior in relation to satisfaction and anxiety. JADA 111(3):443-446, 1985. 4. Hooper, E.M., and others. Patient characteristics that influence physician behavior. Med Care 20:630638, 1982. 5. Epstein, A.M.; Taylor, W.C.; and Seage, G.R. Effects of patients’ socioeconomic status and physi cians’ training and practice on patient-doctor com munication. Am J Med 78:101-106, 1985. 6. 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. 7. Weinstein, P., and others. Dentists’ perceptions of their patients: relation to quality of care. J Public Health Dent 38:10-21, 1978. 8. O’Shea, R.M.; Corah, N.L.; and Ayer, W.A. Den tists’ perceptions of the ‘good’adult patient: an explor atory study. JADA 106(6):813-816, 1983. 9. Wills, T.A. Perceptions of clients by professional helpers. Psych Bull 85:968-1000, 1978. 10. Corah, N.L. Development of a dental anxiety scale. J Dent Res 48:596, 1969. 11. Liddell, A., and May, B. Patients’ perception of dentists’ positive and negative attributes. Soc Sci Med 19:839-842, 1984.
Corah-O’Shea-Bissell : DENTIST-PATIENT RELATIONSHIP > 255
The relationship between patients’ characteristics and dentists’ perceptions as well as the associations between these dimensions and specific dentist behaviors as perceived by patients are explored. Dentist perceptions o f p atien t sophistication and anxiety were related to several p atien t characteristics, but perceptions o f p atien t likab ility were unrelated to p atien t personal and social characteristics. Perceptions o f p atien t likab ility were associated w ith more specific dentist behaviors than were other dentist perceptions noted by patients. The results suggest that dentists’ views are influenced p rim a rily by those p atien t characteristics manifested during treatment. In general, dentists like patients who are dentally sophisticated and not anxious.
The dentist-patient relationship: mutual perceptions and behaviors Norm an L. Corah, PhD Robert M. O’Shea, PhD G. D onald B issell, DDS
prem ise fro m several behavioral disciplines holds that th e in terac tion o f two people is likely to have a recip ro cal effect— th a t is, w hat eith er p e r son does is both cause an d result o f w hat th e o th e r p erso n has do n e, is doing, o r is ex p ected to do. A n o th er com m on prem ise is th a t p erson-to-person behavior is likely to be affected by th e various social roles each p erso n has. T h u s, it is h a rd to im ag ine d ealin g with anyone in o u r society and com pletely d isreg a rd in g his o r h e r age, g en d e r, ethnicity, o r socioeconom ic status. T h e se concepts o f reciprocity a n d o f m ultiple roles have been in co rp o rated into various m odels o f physician-patient rela tio n s.1,2 T h ey also a re p e rtin e n t to the d en tist-p atien t relationship. H ow ever, lit tle em pirical research has been conducted solely co n cern in g patient-dentist in terac tion an d how p atien t an d dentist personal an d social ch aracteristics affect d en tal care. Less research has been conducted th an th e interaction deserves, especially because m ost d en tal care is delivered o n a o n e-o n -o n e basis in relatively long an d so m etim es in te n se sessions a n d w ithin p erso n al relationships th a t often exten d fo r m any years. T h e aspects explored to d ate have been mainly p atient a n d dentist anxiety, com m unication, an d satisfaction. N ee d ed are social psychological studies o f th e aspects o f the microsocial w orld of opera to ry a n d practice.
A
A re p o rt by C o rah an d o th e rs3 assessed th e way in which p atien ts’ percep tio n s o f d en tist behavior affected th e ir satisfaction and anxiety. Satisfaction increased with d en tist com m unication th a t was accepting and caring. P atient anxiety decreased with rising satisfaction, b u t anxiety clearly was not linked to any o f th e d en tist behaviors ex p lo red in the study. H o o p e r an d o th e rs4 fo u n d th a t patien ts’ age, ethnicity, g en d er, an d a p p e a ra n c e all in d e p e n d e n tly a f fected one o r m o re physician behaviors relevant to com m unication, em p ath y , and responsiveness. E pstein a n d o th e rs,5 studying ch arac teristics o f p atien ts a n d physicians as-
D ental sophistication Believes in good oral care Subscribes to appropriate self-care M aintains oral health Likability Shows respect, is attentive C ourteous, pleasant P atient is a likable person Com pliance O n tim e for appointm ents Follows advice, accepts suggestions Seems to be kind o f person who would pay bills on tim e Fig 1 ■ D entist perceptions o f patient charac teristics.
sociated w ith effective co m m u n ic atio n , f o u n d t h a t c o m m u n ic a tio n b e tw e e n physician an d p atien t was less effective w h e n p a t ie n t s w e re o f lo w e r s o c io econom ic status. Level o f physician tra in in g a n d ty p e o f p ra c tic e w e re n o t as sociated w ith com m u n icatio n , a n d physi cians could n o t p red ic t how th e ir p atien ts w ould resp o n d to them . T w o studies in th e d e n ta l lite ra tu re also sh o u ld be n o ted . F razier a n d o th e rs6 su r veyed families with low incom es an d th e ir dentists an d observed a discrepancy be tw een th e h igh p rio rity placed o n d en tal care by p atients with low incom es an d th e low p rio rity th a t th e d entists believed th a t these p atients placed on d en tal care. T h e a u th o rs suggested th a t low er use o f d en tal services m ight be partly a resu lt o f bias an d negative recep tio n by d entists ra th e r th an a lower-class d ev alu atio n o f o ral health . W einstein an d o th e rs7 fo u n d th a t p atien ts w ho valued d en tal care te n d e d to receive b etter restorative care fro m th e ir dentists. T h ese studies suggest th a t a p a tie n t’s characteristics in fluence th e d en tist’s p e r ception o f him o r h e r, w hich may in flu ence b ehavior tow ard th e p atient. A study by O ’Shea an d o th e rs8 ind icated th a t d e n tist p ercep tio n s o f p atients te n d e d to fall in to th e follow ing th re e b ro ad categories: d en tal sophistication (p atien t has positive a n d a p p r o p r ia te a ttitu d e s to w ard o ral care), in te rp e rs o n a l re sp o n siv e n e ss (is JAD A, V ol. 113, A ugust 1986
m
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congenial, friendly), an d com pliance (ar rives on tim e fo r ap p o in tm en ts, pays bills, accepts tre a tm e n t plan). T h ese ch a rac teristics w ere sim ilar to those described by Wills9 as basic criteria fo r assessing clients se en by o th e r p ro fe ssio n a l “h e lp e r s ” ; nam ely, treatability (is m otivated to be tr e a te d ) , likability, a n d m a n ag e ab ility (cooperates). T h e p rese n t study continues to explore th e association betw een patients’ ch arac teristics a n d d en tists’ perceptions. In ad d i tion, such characteristics an d perceptions are evalu ated fo r results in specific d entist behaviors, as patients perceive them .
sion could ra n g e fro m 3 to 12. T h e scale was p re te sted on 111 p atien ts from an u rb a n g ro u p p riv a te p ractice. C o e ffic ie n t a lp h a s fo r the th ree-item scales w ere d e n ta l sophistication, .91; likability, .77; a n d com pliance, .64. In tern a l consistency, th e re fo re , was satisfactory fo r the first two scales b u t barely a d eq u a te fo r the th ird scale, com pliance. In a d d itio n to the p o o r in te r nal consistency o f th e com pliance scale, two item s (on tim e fo r a p p o in tm e n ts a n d follows advice, accepts suggestions) w ere d e em ed in ap p ro p ria te fo r the hospital clinic setting. C on sequently, only the d e n ta l sophistication a n d likability item s w ere u se d in the p re se n t study. D entists also ra te d th e p a tie n ts’ anxiety d u r ing tre a tm e n t by categorizing th em as belong ing in the highest th ird , m id d le th ird , o r lowest th ird o f th e patients they norm ally trea te d .
Methods Description of sample O u tp a tie n ts in a large public hospital d en tal clinic w ere a p p ro a c h e d in the w aiting ro o m by a research assistant a n d asked to participate. T h e assistant was iden tified as n o t bein g a clinic staff m em ber. Patients w ere eligible fo r participation if they w ere o ld e r th an 18 years, scheduled to receive an invasive p ro c e d u re , a n d not in severe pain. T w enty p e rc e n t o f th e qualified patients re fu sed to particip ate, a n d a n additio n al 5% re fu sed to o r w ere u n ab le to com plete the in te r view a fte r treatm en t. B efore tre a tm e n t began, patients gave p e r sonal d ata, inclu d in g age, g e n d e r, a n d e d u ca tion, a n d filled o u t th e C orah D ental A nxiety Scale (DA S).10 In ad d itio n , it was d e te rm in e d w h e th er the p a tie n t was new to the clinic a n d w h e th er the visit was a scheduled or an e m e r gency one. T h e research assistant also ra te d the p a tie n t’s a p p e a ra n c e on a four-category scale a d a p te d from th a t o f H o o p e r a n d o th ers.4 T h e c ategories w ere as follows: som eone w ho is clean a n d dressed in a suit o r dress, h a ir clean a n d styled (4 points); neat a n d clean but m ore c asually well d re s s e d (3 p o in ts); c lean b u t som ew hat disheveled (2 points); ru m p le d , dirty clo th in g a n d hair, a n d generally disheveled (1 point). Im m ediately a fte r tre a tm e n t, patients com p lete d a q u e stio n n a ire listing 21 possible d e n tist behaviors. By choosing “yes” o r “no,” p atients indicated w h e th er th e d e n tist had show n the behavior; p atients w ere in stru cted to choose “n o ” if they w ere u n certain . T h e 21 item s in c lu d ed den tist behaviors related to in form ation giving, e n c o u ra g in g disclosure o f patien t feel ings c o n ce rn in g tre a tm e n t, a n d w hat dentists said a n d did to lessen anxiety. T h e questio n n aire has been p re sen te d elsew here.3 T h e dentists also ra te d th e ir perceptions o f th e p a tie n ts im m ediately a fte r tre a tm e n t. A scale was d evelo p ed to assess the th ree patien t d im ensions o f d e n ta l sophistication, likability, a n d com pliance fo u n d by O ’Shea a n d o th e rs8 (Fig 1). T h e d e n tist was asked to answ er each o f th e n in e item s with o n e o f th e fo u r follow ing resp o n se s: d e fin itely has this c h aracteristic, probably does, probably does n o t, o r definitely does not. T h e answ ers w ere scored 4, 3, 2, 1, respectively, so th a t th e score fo r each d im e n 254 ■ JA D A , V ol. 113, A u gust 1986
A total o f 231 d en tal p a tie n ts, 107 m en a n d 124 w om en, p articip ated in the study. T h e y ra n g ed in age fro m 18 to 73 years, w ith a m edian o f 28 y e a rs. M e d ia n e d u c a tio n w as h ig h sch o o l g ra d u a te , w ith a ra n g e fro m com p letio n o f th ird g ra d e to com pletion o f 5 years o f college. New patients co n stitu ted 41% o f th e sam ple; 59% h a d visited th e clinic b efo re. E m ergency visits w ere being m ad e by 63% o f th e sam ple; 37% h a d sch ed u led a p p o in tm en ts. O n the day o f th e interview , th e d e n ta l p ro c ed u re s sched uled to be received by the p atients w ere exodontic tre a tm e n t, 53% ; re sto ra tio n s, 22% ; e n d o dontic trea tm e n t, 6%; a n d o th e r trea tm e n t, 19%. T h e p e rso n n el p ro v id in g service w ere sta ff m em bers, 6%; resid en ts, 51%; a n d senior d en tal stu d en ts, 43% . It was estim ated th a t a p proxim ately h a lf o f th e clinic p o p u latio n qual ified fo r M edicaid re im b u rse m e n t.
Results T h e correlatio n s betw een d e n tist p ercep tio n s o f patients a n d several actu al p a tie n t c h aracteris tics a re given in T ab le 1. D entist ratings o f pa tient d e n ta l sophistication w ere significantly (P < .05) associated w ith the follow ing p a tie n t characteristics: being a w om an, h aving m ore e d u catio n , bein g a p a tie n t w ho h a d visited the clinic b efo re, having a sch ed u led a p p o in tm en t,
having a b e tte r a p p e a ra n c e ra tin g , a n d being less anxious. D entist ratings o f p a tie n t likability w ere u n re lated to any o f the p a tie n t characteristics. D en tist ratings o f p atient anxiety w ere significantly ^ a s s o c ia te d w ith p a tie n t c h a r a c te ris tic s o f y o u n g er age, lower e d u catio n , being a new pa tient, m aking an em ergency visit, a n d p a tie n t- ^ re p o rte d anxiety (DAS). T h e th re e d en tist ratin g s o f th e patients also w ere significantly (P < .05) c o rrelated as fol lows: d e n ta l sophistication a n d anxiety, —.24; i sophistication a n d likability, .28; a n d likability a n d anxiety, —.21. In o th e r w ords, dentists te n d e d to ra te patients perceived as a nxious as less dentally sophisticated a n d ten d e d to like p a tie n ts p e rc e iv e d as b e in g m o re d e n ta lly sophisticated a n d low in anxiety. T h e correlations betw een d entist perceptions o f patients a n d the d e n tists’ behavior perceived by th e patients is given in T ab le 2. O nly the follow ing th re e d e n tist behaviors w ere signifi cantly (P < .05) associated w ith d e n tist ratings o f p atien t sophistication: n o t criticizing th e pa tie n t’s oral c ondition, sp o k e u n d e rsta n d a b le language, a n d took seriously w hat the patien t had to say. Six d e n tist behaviors, as re p o rte d by patients, w ere associated w ith likability. T hese six behaviors suggest th at th e d e n tist displayed m o re positive in teractio n a n d p atience tow ard those p atients h e o r she liked. F o u r d e n tist be haviors w ere associated w ith th e ir ratin g s o f patien t anxiety, inclu d in g inquiries ab o u t n e r vousness, anxiety, a n d allergies, a n d bein g seen as less patient. C o r r e la ti o n s a ls o w e r e c o m p u t e d a n d analyzed betw een the p a tie n ts’ social charac teristics listed in T able 1 a n d d e n tist behaviors. H ow ever, only eight o f th e 147 co rrelations w ere significant (P < .05) a n d th a t result could be expected on th e basis o f chance. T h e re fo re , it may be co ncluded th a t no system atic relatio n ship existed betw een the p a tie n t characteristics a n d th e d en tist behaviors perceived by th e pa tients.
Discussion and conclusions T h e results indicate several points co n c ern in g the relationship betw een th e way in which dentists perceive patients an d ac
Table 1 ■ Correlations between actual patient characteristics and three dentist ratings of patients. Patient characteristic Gender Age Education New patient Emergency Appearance Dental Anxiety Scale *P < .05.
Dentist rating of patients Sophistication
Likability
Anxiety
.15* .04 .17* -.15* -.19* .17* -.24*
-.0 9 .08 .10 -.0 2 -.1 2 .01 -.0 9
.09 -.14* -.14* .20* .21* .12 .33*
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T ab le 2 ■ Correlations between dentist behavior ratings by patients and ratings of patients by dentists. Dentist rating of patients Dentist behavior item Asked about health Asked about nervousness Criticized mouth Waited until numb Asked if allergic Worked quickly Encouraged talk Encouraged questions Welcoming Polite Understandable Told procedure Paid attention Reassuring Asked about discomfort Calm manner Asked about anxiety Washed hands Took me seriously Was patient Took me on time
Sophistication
Likability
Anxiety
.04 .13 -.26* .04 -.1 3 .11 .10 .05 .13 .01 .18* -.0 5 .07 .08 -.11 .13 -.11 .08 .15* .07 .01
-.19* -.0 4 .05 .06 .03 .01 .03 .11 .09 .02 .18* .03 .26* .08 .07 .17* -.0 5 .12 .18* .17* .12
-.1 4 .22* .01 -.0 2 .23* .05 -.0 6 .01 .05 -.01 .00 -.01 -.0 3 -.01 .03 -.0 5 .19* .07 .01 -.1 4 .04
* P < .0 5 .
tual p atien t characteristics. It may be con cluded th a t, in this setting, th e dentally sophisticated p atien t is likely to be a b etter e d u c a te d , w e ll-d re s se d a n d g ro o m e d w om an who is a re g u la r patient, is at the of fice fo r a scheduled visit, an d is n o t d e n tally anxious. T h e anxious patient, as p e r ce iv e d by th e d e n t is t, te n d s to b e a yo unger, less w ell-educated person w ho is new to th e clinic, is th e re fo r an em ergency visit, an d is anxious. T h ese characteristics, fo r th e m ost part, are w hat m ight be expected o f the dentally so p h isticated a n d th e a n x io u s p atien t. W hat is su rp risin g in the findings is that dentist p ercep tio n o f p atien t likability a p pears to be u n rela ted to any o f the p atient social characteristics assessed. H ow ever, dentists te n d to like patients w ho are d e n tally sophisticated a n d w ho are not an x ious, b u t this liking is n o t based on the m o re g en eral traits exam ined. F u rth e r, d entists’ likability ratin g o f p a tients was associated with m o re o f th e posi tive d en tist behaviors th an was eith er o f th e two o th e r d en tist ratings on patien ts’ sophistication an d anxiety. Patients liked by dentists te n d ed to perceive dentists as attentive, u n d ersta n d ab le, patient, calm, an d accepting o f w hat p atients said. T hese behaviors are sim ilar to th e type o f d e scrip to rs L iddell a n d M ay11 fo u n d fo r low -anxiety d e n ta l p a tie n ts ’ ra tin g s o f th e ir dentists. T h e only negative dentist behavior fo u n d in the p rese n t study was
th a t the d en tist te n d ed to be seen as im pa tient tow ard those patien ts perceived as anxious. T h e lack o f system atic relationships be tw een p atien t back g ro u n d characteristics an d dentist behaviors in this study is in consistent with th e findings by Liddell and M a y ". H ow ever, th eir subjects rate d d e n tists outside o f th e d en tal setting an d may have displayed m ore g en eral attitu d es to w ard dentists th an was th e case in th e p re sent study. T h e findings in this study also a re inconsistent with those o b tain ed by Epstein an d o th e rs5 w ho fo u n d relatio n sh ip s b e tw e e n p a tie n t so c io e c o n o m ic status an d physician behaviors. H ow ever, those a u th o rs stu d ied p atients re p re se n t ing a b ro a d e r ra n g e o f socioeconom ic status in a contex t th a t consisted alm ost entirely o f verbal interaction. T h e fin d in g s p ro v id e som e evidence that d en tists’ percep tio n s are influenced not by patien ts’ g en eral an d social ch arac te ris tic s b u t a r e in f lu e n c e d by th o se c h a ra c te ristic s th a t specifically a p p e a r d u r in g d e n ta l tre a tm e n t. F u rth e r, the perceptions by dentists are reflected in som e o f th e ir b ehavior tow ard patients. From o n e perspective, any u n eq u al re sponse to patients, fo r w hatever reason, disappoints the professional’s own code of altruism an d self-discipline. H ow ever, the d ata also a re a basis fo r believing th at the practitioners stu d ied acted tow ard th eir patients mostly in ways u n rela ted to the
d en tists’ su m m ary p ercep tio n s o f th e p a tients as b eing dentally sophisticated, an x ious, o r likable. Finally, it is im p o rta n t to qualify these findings an d in te rp re tatio n s by the con text fro m w hich they w ere d raw n — a hos pital clinic p o p u latio n served by dentists in train in g . A ffect co n tro l is a skill th at p re sum ably im proves with exp erien ce, ft is com m on know ledge th a t dentists a n d p a tients have o n g o in g interactions an d th a t a p a tie n t’s c o n tin u in g in a practice o ver tim e rep rese n ts p erso n al choices m ad e both by th e p atien t an d by th e dentist.
----------------------J » D A --------------------Informed written consent was obtained from all pa tients before they participated in this study. This investigation was supported in part by research grant no. De 04494 from the National Institute of Dental Research. The authors thank Drs. S. Fischman and J. D’Ambrosio and the staff members of the Erie County Medi cal Center Dental Clinic for their assistance in conduct ing this research. Dr. Corah is professor, behavioral sciences, School of Dental Medicine; Dr. O’Shea is associate professor, social and preventive medicine, School of Medicine; and Dr. Bissell is associate professor, public health dentistry, School o f Dental Medicine, State University of New York at Buffalo, Farber Hall, Buffalo, 14214. Address requests for reprints to Dr. Corah. 1. Bloom, S.W ., and W ilson, R.N. Patientpractitioner relationships. In Freeman, H.E., and others, eds. Handbook of medical sociology. En glewood Cliffs, NJ, Prentice-Hall, Inc, 1979, pp 275296. 2. Bloom, S.W. The doctor and his patient: a sociological interpretation. New York, Russell Sage Foundation, 1965, pp 235-259. 3. Corah, N.L.; O’Shea, R.M.; and Bissell, G.D. The dentist-patient relationship: perceptions by patients of dentist behavior in relation to satisfaction and anxiety. JADA 111(3):443-446, 1985. 4. Hooper, E.M., and others. Patient characteristics that influence physician behavior. Med Care 20:630638, 1982. 5. Epstein, A.M.; Taylor, W.C.; and Seage, G.R. Effects of patients’ socioeconomic status and physi cians’ training and practice on patient-doctor com munication. Am J Med 78:101-106, 1985. 6. 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. 7. Weinstein, P., and others. Dentists’ perceptions of their patients: relation to quality of care. J Public Health Dent 38:10-21, 1978. 8. O’Shea, R.M.; Corah, N.L.; and Ayer, W.A. Den tists’ perceptions of the ‘good’adult patient: an explor atory study. JADA 106(6):813-816, 1983. 9. Wills, T.A. Perceptions of clients by professional helpers. Psych Bull 85:968-1000, 1978. 10. Corah, N.L. Development of a dental anxiety scale. J Dent Res 48:596, 1969. 11. Liddell, A., and May, B. Patients’ perception of dentists’ positive and negative attributes. Soc Sci Med 19:839-842, 1984.
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