This quarter’s e-newsletter looked at the concept of completing comprehensive exams for new patients and fitting this in to your practice philosophy and current circumstances.
Sometime in the past I think I heard that all “good” dentists completed a comprehensive exam on every new patient at the first appointment. In truth a rigid interpretation of this idea in a private practice setting can be overwhelming and a barrier to changing and improving your new patient experience.
Right after dental school in the 80’s I believed I gave a comprehensive exam to all of my patients, and it included dentition charting, necessary x-rays, and periodontal screening. As I went through more advanced continuing education, my comprehensive exam grew to include a comprehensive periodontal exam, joint & muscle exam and digital photography.
So have I figured out how to have all of my new patients accept a comprehensive exam? The answer is YES, but how I achieve that may surprise you. I have redefined what a comprehensive exam means and looks like, by individualizing it to each patient.
Many of you know that I purchased my practice two years ago. We are in a growth phase, with more open appointments spots available than we prefer. With this in mind I want the opportunity to meet every potential new patient that calls; therefore we put very few barriers in place. Requiring every new patient to have a two hour exam appointment with me can be a barrier for many. Once the practice has grown and I have more patients than time, requiring a two hour comprehensive exam for each new patient may be a very appropriate barrier to put in place, allowing me to spend my valuable new patient time with patients who have greater ownership and awareness of their current needs.
How do I individualize the comprehensive exam? The first step is handled by my team, who must be adept with particular listening skills during that initial new patient telephone call. Based on what they hear, they know to ask key questions which allow them to individualize the new patient appointment including hygiene if appropriate.
The next step to individualize the comprehensive new patient appointment belongs to the Doctor. The best way to illustrate what I do is to give you three different examples of real new patient appointments I had last week:
Linda moved here recently and was referred by her former dentist. She shared on the phone that she is very regular and committed about her dental care and is aware of no current issues or concerns. Based on this information she was successfully scheduled for an extended new patient appointment with hygiene. My hygienist completed a comprehensive perio exam, soft tissue exam and necessary radiographs as well as a pre-clinical interview. I was invited into the appointment whereby the hygienist introduced me to Linda and passed trust to me by sharing what they had learned together. I then completed my pieces of the comprehensive exam. As expected, Linda was healthy and well maintained so we completed her appointment with a prophy.
Whitney was referred to the office by her mother who was an existing patient. Nothing unusual was revealed during the initial telephone conversation, so a typical extended appointment with hygiene was scheduled. However, during the pre-clinical interview, the hygienist learned that Whitney was having issues with her joints and muscles so I was invited in to join the conversation and I performed an initial TMD screening exam. The screening revealed that there was something unusual going on and a complete TMD exam would be helpful for her. I discussed this with Whitney and invited her back for a separate extended evaluation appointment. I explained that we would have enough time to complete a clinical exam and discuss some next steps toward health and stability, which could include appliance therapy. After this discussion the hygienist completed her appointment and scheduled her for an extensive evaluation appointment.
Christina was referred by a local specialist. During the new patient phone call, her needs were clearly more complex than average, so the appointment was scheduled for an hour with me only. Christina and I spent the first part of our time together getting to know each other. She shared with me her understanding of her dental health and goals. We completed a comprehensive exam to gather all of the information I would need to help her understand her treatment options. Christina case was complex, so further thought and discussion will be necessary before specific treatment options can be presented. I asked Christina permission to take some time to think over what we had learned. We scheduled another appointment in a week to complete our conversation and develop treatment options.
For these new patient appointment scenarios to work, the office has had to become comfortable with several things. We should not try to squeeze everything into an appointment just because of the code in the appointment book, or rush or condense the process. We must be very comfortable inviting patients back based on what we learned at the first appointment.
Based on my practice philosophy and our currently schedule openings, having three patients with three individualized new patient processes works perfectly. It would not have worked years ago, we both myself and my practice we different. It might not work in the future as I will change and so will my practice. But we will reinvent the new patient experience from time to time as the practice changes. I encourage every dentist to have a new patient process that “fits” based on who they and their practice is today, and redesign it in the future when the time is right.
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I have thought about this for a long time. In the end I have concluded that my original theory about doing a comprehensive examination on all adults, I feel, still holds up. But not for business reasons—the more reading I do, the more convinced I am that the benefits of doing a comprehensive exam on every patient is well worth the effort. Here are a few:\
The dentist creates the habit—as well as the staff.
The culture is born out of this very important process.
We never know what we will find — even in patients with a history of great dental care (self-reported).
For me the biggest benefit is the chance to get to know the patient—REALLY KNOW—and develop that all important relationship.
Risk reversal–which I discuss in my book -The Art of the Examination.
That being said—I understand why dentists would not want to commit the time — but, in an era where dentistry needs to set a higher standard (so many devalue the examination)—I believe we need to hold the line here.
Great topic Lee.
Alan Stern says
Great comments from 2 of my favorites.
My very humble opinion is that the patient’s perception comes first. A patient whose goal is a ‘cleaning” needs to have a smooth and welcoming entry into the practice. Once the patient is comfortably settled in, we can show them the value of a full exam. This may happen on the first visit, or it may happen subsequently. My thrust is to actively demonstrate that I’m, looking, I’m listening, I’m future focused, and I’m caring. I always ask new patients “If I had a magic wand in my hand and you could have anything you want happen (dentally, of course), what would those things be?” . That gets them thinking and talking and paves the way for a larger discussion
In challenging economic times, I, for one, cannot afford to exclude anyone who doesn’t see the world the way I see it; rather, I feel the need to bring people to that point that Dr Pankey described as “above the line”. Once they hit that point, we can do a whole lot more.
That said, I think that when a person becomes aware that they need someone who can help them think their way through their issues, nothing short of the full exam will do, Lee Ann implies that different people are ready at different times. I think that anyone who asks me for help deserves my attention, no matter what stage of life or readiness they’re in. Some of them will come around. Some won’t. In the sagacious words of the great Dr Polansky… so what! In my world, they all deserve the opportunity.
In Barry’s world, it works differently; our practices are as unique as we are, and that’s totally fine. The understatement of my life is that I would trust either one of you with my health comfort function and esthetics!
Thank you, Lee Ann and Barry
Barry Polansky says
Alan–you say–“I think that anyone who asks me for help deserves my attention, no matter what stage of life or readiness they’re in. Some of them will come around.”
I totally agree with this line of thinking—
Later on in your comment there is a suggestion that in my world patients are different –they are not. All of my patients are of the human variety (although I have done some canine dentistry)—that said they share certain primitive desires like the need to survive. Teeth are necessary for survival in more ways than one…nutritionally – not as much as during the Stone Age. What I have found is that people will respond to the expectations of the doctor — and the culture he or she has built.
Let me also say that these “leadership traits” do not come overnight—it takes years to develop—in the words of Michelangelo—“I’m still learning.”
The key is not to lose focus and give into the standards set by the rowdy—because the rowdy will destroy what they don’t understand. You can define the rowdy.
I had the opportunity to be in the last class taught by one of the Institute’s finest living cadre members–he was retiring at age 65—he told our class that he had mixed emotions because he was “still learning.” I am proud to call him a mentor—and a living example of leadership and commitment to a cause.
Hope I have opened some areas for questions– and Lee — I feel like we are making this a forum—hope yuou don’t mind.
Joseph Salkind says
Correct me if I’m wrong, but aren’t you are all saying the same thing? The confusion lies in the title that implies not doing a comprehensive exam. You are interchanging initial visit with comprehensive exam. An initial visit could be a dental issue, a continuing care visit of a referral, or a patient with or without an issue choosing to become a patient. In that initial visit you are addressing patients expectations and needs for that visit. That is just good business. In the end all of you agreed you do comprehensive exams. A process of treating patients does not imply a cookie cutter approach, for example an emergency walk in with 3 fractured teeth does not get a comprehensive exam. They get treatment to get them out of pain and stabilized. A process is protocol. It is a standard of care. The doctor establishes that. The staff follows that lead. If you fail to follow the process, so will they. That’s why patients leave. They are referred or come with expectations and you can meet them, exceed them, or fail.
Barry Polansky says
Joe….we are saying the sane thing…but different. As far as “initial visit” is concerned, you are right, that doesn’t have to be a comprehensive exam. Felt need is the terminology I use. Emergencies fall into this category as well. But all roads lead to the comprehensive exam. In reading over these comments as well as the comments on Facebook, I began to see a distinction in perspective. I feel it comes down to the difference between management and leadership. For years I was into practice management…and all that it concerned…somewhere along the line I truly began to understand the difference between man agent and leadership. If you want to know the difference review the work of Peter Drucker (All Managenent is Self Management), and John Kotter( Classic article…What Are Leaders For). Essentially Kotter makes the point that leadership is not just about charisma…but more about coping with change, as I implied in my first comment. For me the comprehensive examination process is the keystone…the signature policy and system in my practice that sets me apart in my community. As the changes continue to effect the dental community…it will be this very humanistic process that will separate you from the crowd and allow people to see you as a leader in the dental community.
Informative article , I have gone through this article and learned so many things that need to consider
Alan Stern says
Lee, thank you for opening up this discussion; I hope you’ll indulge Barry and me in throwing around a subject near and dear to all of us.
Barry, what I was trying to say is that your approach is similar but slightly different to mine, which is similar but slightly different than Lee’s. Indeed, our principle-centered practices are as unique as we are.
Indeed, people are people; their needs are universal and their wants are variable. In this very challenging time for health care (as opposed to disease management) in which the doctor is no longer the authority figure and in which the consumer’s mindset is manipulated by those totally uninterested in their well being, each of us needs to find ways to show people a better way to Dr Pankey’s “Big Four”- Health, Comfort, Function, and Esthetics.
To that end, we need to warmly welcome our patients, earn their trust, and guide them to good decisions with our open ears and empathic brains.I am an imperfect practitioner of this art, but I’m stuck to my principles and learning every day. After 32 years, I’ve come a long way and I’m still rolling on.
Lee Ann Brady says
Hi Everyone, sorry for the delay in responding as I have been traveling. My sincerest hope in writing this article was to create some discussion about the new patient experience and our definitions of a comprehensive exam, and that the people who read it would take a moment to evaluate for themselves those definitions and how they have implemented this process. It sounds like I got my wish!
Barry Polansky says
Your wish….is my command. This is a discussion that must continue.
Mary Osborne says
I love this conversation, and as usual I have more questions than answers.
Like Barry my favorite way to bring a new patient into the practice is to spend a generous amount of time getting to know them, both clinically and relationally. After years of seeing new patients during a regular hygiene visit I fell in love with dentistry again when I worked in a practice where we spent that first visit getting to know patients without the pressure of having to clean their teeth that day. I would not want to deny any patients that opportunity. I would proudly offer that option. I also believe that option is not right for everyone as a starting point.
I am not a dentist and so come to the conversation from the perspective of a member of the team. I think your comprehensive exam is one of the things that defines your standard of care. Questions I would have for the dentist/leader would include: What does comprehensive care mean to you? Why is it important? What are all the ways we can help patients understand the value of a comprehensive approach to care? What information do we need to have before we engage in treating patients? What services are we willing to provide prior to gathering all the information we need? Where do we draw the line?
I remember a patient I saw in hygiene who had extensive perio as well as restorative issues. We had seen him for an emergency when he came to us in pain. I asked the doctor why I was seeing that patient in hygiene when he had not yet had a comprehensive exam. The doctor’s response was that he wanted the patient to experience a dental appointment that was comfortable; one that was not based on pain. He did not believe that had ever happened for that man and he wanted him to see new possibilities for himself around dentistry. As a team member that made sense to me. It changed the way I saw my role in helping that patient.
I like Joe’s distinction between the initial visit and the comprehensive exam. I see the initial visit as a structure, a system which can take several different forms. I think the comprehensive exam is more about principles, about the standard of care. My doctor made it clear to me that we were changing our system, but we were not changing our principles. In that practice we knew what a comprehensive exam included, and our patient would have a comprehensive exam before we began significant treatment. I understood that I was not “treating” his perio condition; I was helping to prepare him for that treatment. There are any number of ways we could have done that. This one worked well for the unique needs of that patient.
Articulating those standards and, as Barry says “creating a culture,” requires strong leadership. Without that leadership it is easy for the practice to slide into providing treatment without taking a step back to make sure we gather all the information we need to thoroughly asses the situation. It’s easy for patients to think we just want them to jump through arbitrary hoops before we will treat them. I wonder how we can create new language that, instead of getting mired down in what codes to apply, helps teams and patients understand the principles behind what we suggest and the outcome we are trying to achieve. Those are some of my favorite questions.
One of the things I love about dentistry is that we have all the time we need to influence our patients toward health; we have the lifetime of our relationship with them. Every interaction, by every member of the dental team, with every patient is an opportunity to have a positive impact on their health.
I knew there was a reason I delayed responding to this post. There is so much to think about. Thanks for getting us going, Lee. I Hope there is more conversation here.
VERY VERY VERY well said, Mary. In just a few paragraphs you summed up what I wrote a book about. Truthfully I could write another book about the same topic…because it is so Zen.
The subtlety of a new patient comprehensive exam and all of its nuances is what makes it so special and effective. Yet—the vast majority of dentists want to approach it as another technique – as a vehicle to take them to some magic land of productivity.
The more I read others subjects like neuroscience, cognitive and positive psychology, I see applications in the comprehensive examination.
As you say — the process is just the starting point — like knowing how to sit while meditating.
Loved your comment.
Rick Coker says
Much of the problems that dentists have had with the idea of comprehensive exams for everyone is that some dental guru recommended them, and they followed that meme unthinkingly. It is all about options and the patient understanding what their options are, and letting them decide even if the examination is something they want to explore. Telling people about problems they are not aware of isn’t productive, it is irritating!
For me, I don’t want to have an unsuccessful anything- consultation, treatment plan or treatment, so I want to progress at a speed determined by the patient to a large degree, versus the old way of the doctor dictating the pace of play! All of us have had the unpleasant experience of a patient rejecting our treatment plan because it didn’t meet their felt need, but our own!
I think that if you are in relationship with the patient, and understand what they want, it is easy to proceed to the examination as a natural part of the process. “If you want this, we will need to do this” – that sort of thinking. Easy to understand.
But a comprehensive exam on an unwilling patient is frustrating for both parties, no? That’s what we need to avoid, I think.
I feel obliged to respond to Rick’s comment because some have referred to me as one of those “gurus.” Just want to say that I personally don’t consider myself a guru – especially on this topic because of its complexity (see my Zen comment above).
Rick brings up the concept of memes…(an idea that is replicable, like a virus, and passed from one generation to another). Oh, how I wish the comprehensive examination was a meme. The comprehensive examination has not spread to most of the dental community—or the other forces that seem to have their hands in the pot. Most dentists don’t do any version of a complete examination.—and that’s a shame because probably that is a factor that has allowed other memes to invade our culture. Like entitlement, or insurance dependence or the newest one I have heard that patients are now becoming health care consumers rather than patients. Those are memes. The new patient comprehensive examination — is more of a suggestion…something that has worked for me consistently through the years — and a good way to teach young dentists how to get more control of many aspects of practice. Rick…you are a seasoned professional—we come from the same era- I believe that teaching dentists TO DO the complete examination is a great starting point for success—when they reach “our” age they had modify.
Just my thoughts between patients today…but I really do enjot the discussion — and all contrary opinions are welcome—because it’s good for dentistry.
Alan Stern says
This discussion was rich enough at the beginning; then along comes my hero Mary Osborne with her usual brilliance to get my head spinning. Good thing (?) today is slow and I have time to write (and, perhaps, too much time to think)!
It is difficult to interpret the context in which Rick is speaking- this is a huge difficulty with this form of communication (when I was President of my synagogue, we created more problems than we solved when we attempted to discuss critical issues online. I put an end to e-debating after a few bloody sessions!)
That said, there is a huge difference between a guru and a mentor. Rick, I do agree that drinking someone’s Kool Aid without extensive reflection and even trial and error is merely parroting. But a well developed philosophy of care is important, and growing within our profession both philosophically and technically are also keys to a good career. I would dare say that your philosophy has been developed after years of learning and observing.
What I say to and do for my patients is from my heart and my brain. They reflect my core beliefs which are a composite of my learning from people who make sense to me. Comprehensive dentistry is what most of us would want for ourselves. But there are patients who want good care who have to be gently brought to the point of realizing that solving their issues will take some time, some evaluation, and some extensive dialogue. That may take a while and , in my experience, some dentistry may need to be done before they accept great care. And the way each of us get their patients “above the line” is as unique as we are.
The big problem, as Barry has pointed out time and again, is that consumerism, third party intervention, and the digital age have all come together in a perfect storm to erode the one thing that every one of us needs: the trust of those who seek our help. Earning trust, I find, is taking a lot more time and effort and can frustrate the dentist and/or lead the patient down a path of deterioration while they try to make good decisions in the presence of all kinds of information and misinformation that are readily available. Add to the toxic mix the pressure from third party payers to do it their way and the financial pressures that we all face and lo and behold, the great care we seek to give becomes gravely threatened.
A comprehensive exam in any aspect of life is the way to lead people to their preferred outcome. Some people will follow the lead. Some will not. What we do with/for these people is entirely up to each of us.
Thank you all for indulging me. I hope to hear more from everyone
Barry Polansky says
Alan –great comment as usual. I have been following this discussion on FB and here. Almost everyone’s comments are right on. Hard to argue with anyone. But you bring up a point I have been trying to make…and that is the importance of the doctor-patient relationship and the building of trust. That is what starts with the exam. It will only be those doctors who value that process who will flourish in the future, as our health care system degenerates by devaluing the human factor. It will take courage for the dentist to continue to maintain this standard as pressure will mount to accept the parameters of government, and corporate America. But–as someone once said– the insecure path is the secure path…in the end.
Rick Coker says
I am sorry I wasn’t clear here, my fingers sometimes outrace my brain! What I meant to convey is that everybody who becomes a dental patient, client, friend or guest deserves a thorough examination, but way too many times it is assumed that if the dentist finds a lot of problems through that exam, the patient will just automatically follow through with the treatment, well, just because! Barkley spoke of this in his book and the revelation he received after his high school cheerleader friend had all her teeth removed because she couldn’t afford the treatment he deduced from his textbook examination.
Omer Reed told me years ago that “Getting to do the dentistry is a lot harder than doing the dentistry” and it is true today as ever, as choices and options and insurance plans proliferate. You don’t get to do more dentistry by finding more problems but you may do more by relating those concerns to what the patient wants for themselves, right?
I think the future holds incredible promise for dentists who are willing to listen, to stay current and to provide high levels of care, in a warm and personal environment. But that will include great esthetics- both dental and facial, a comfortable and functional occlusion, and a very high level of continuing care!
Now we’re talkin’ Rick. And BTW—that discussion over on Facebook was getting a little out of hand—when Dan Marino showed up—because I consider myself the eternal rookie.
John Bryson says
Appreciate your comment about the Facebook discussion. I’m happy that you posted on FB though, because it introduced me to this web site of progressive thinkers. We are all rookies and there is always more to learn.
Alan Stern says
There we are! I think we’re all on the same page. To me, it’s about getting that patient to own their own problem(s) and take action based on the information they get from me.
My greatest frustration occurs when people choose to ignore the big issues after a long exam and discussion process WITH photographs.
Alan — I remember when Abbie Hoffman and Jerry Rubin were hippies—leaders of a whole generation. Then that generation changed–poor Abbie didn’t survive but Jerry became a Yuppie—and so a whole generation of people became consumed with a whole new lexicon — and the focus became “productivity.” The examination wasn’t created for the sole purpose of production —PLEASE — explain that to all of the dental consultants out there—dentistry is about more than production.
So then there was Crosby Stills and Nash —who told us to “Teach Our Children Well,” but we blew that…so now the sins of our fathers (I love cliche’s) are upon us.
Maybe we can’t change mindsets—but the comprehensive exam had the same rationale for LD Pankey as it has for us—to collect data—and establish rapport. The rest is another topic.
I like this forum better than Facebook—too many Philistines over there.
Rick Coker says
Everybody’s experience is different, but I look back and often things that I thought were simple are not, and things I thought were complex were simple! But the more you know, the more you realize you are dependent on the patient’s tolerance and that isn’t a fixed value. I agree with you, that getting cocky about what we know is dangerous!
Getting back to the subject at hand- A complete exam is necessary for anybody in my office who wants to be part of the family, but often that isn’t on the first visit!
Like mentioned I think it will depend on the patient and their needs. I agree though that not rushing everything in one appointment is important and inviting them back is a great way to go over everything, the key though with some patients is whether or not they will want to come back as most want to get everything done at one time.