Increasing case acceptance is high on every practice's priority list; however, one factor that often gets overlooked is where the treatment and financial discussions take place. Let's take a look at a common scenario: you deliver a clear and solid treatment plan and the patient demonstrates a strong interest in the treatment but in the end does not reserve an appointment. Instead, the patient's response is, 'Let me speak with my spouse and get back to you' or 'I need to check my schedule first.' Does this sound familiar?
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Patients often judge the quality of care they are receiving by the appearance of the office and their overall experience. A great experience means you are an awesome clinician in their minds. Patients rate that experience as great when they have felt heard, important and had uninterrupted time with the team member. While this seems like a tall order to achieve, simply using an area that is away from the front will help support these objectives. Many modern dental offices have a consultation room but ironically very few teams actually use it as originally intended. It may surprise you to hear that your consultation room is the most important one in the practice. Determining ROI on this room is simple; greater treatment acceptance translates into more revenue for the practice.
Treatment and financial discussions that occur in a safe and private environment build trust and encourage patients to openly communicate any barriers or challenges. Patients may feel uncomfortable and even embarrassed at the front desk to say they cannot afford the treatment, so it's easier for them to give you the common 'Let me get back to you' response. The fluster of activity happening up front when the is ringing and patients are checking in or out can be extremely distracting to both the patient and the team member. A private area lends itself better to a discussion where the patient does not feel rushed. It enhances a more personalized and educational experience that will set your practice apart.
Another benefit of the consultation room is the opportunity to educate patients. Since 83% of learning is done visually, this venue can include a larger screen and tutorials to help patients 'see' as well as hear about their treatment needs and options. So how can your team develop or enhance their skills to help increase case acceptance? The process of engaging a patient in co-discovery needs to be practiced and practiced again. Roleplaying the scenario will help to gauge the team members' comfort level and enhance their communication skills regarding your recommended treatment and financial options. Use the consultation room during your team training so everyone has an opportunity to practice in the 'real' environment.
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In , I proposed 10 quality indicators for clinical consultation (Box 1).1 Some of these are not easy to measure, but we must learn to measure what we value not just value what is easy to measure. My belief is that if healthcare providers placed as much emphasis and resource on my 10 quality indicators for clinical consultation as they have put on venous thromboembolism (VTE) prophylaxis or the 4-hour emergency department (ED) target, we would have substantial improvements in patient outcomes and experience within 2 years. Costs would also come down. It is always cheaper in the long run to get it right first time.
The patient should know what the consultation is to be about. In my outpatient (office) consultations, about half of the new patients do not even know that they have been referred by their general practitioner. None of the others have been given a copy of the referral letter. This means the patient does not know in advance what the consultation is about and cannot even prepare an account of their symptoms or concerns. I believe the patient should have a copy of the referral letter and should be actively encouraged to provide information useful for the consultation. I am sure we could help patients to be better prepared to give an account of their symptoms, concerns, medications, past medical history and tests results. For review-of-progress consultations, I believe there is far more that we should do to help patients prepare for consultations. For example, there is a wide-ranging set of possible problems that a patient with Parkinson's disease might be experiencing and we could help patients to prepare their information. After each consultation, we should provide the patient with a copy of the clinical letter so that the patient can show this to another clinician. The patient should also know what is likely to happen during the consultation ' will they be subject to intimate examination or will the consultation be only a conversation?
The clinical consultation is a serious piece of work; the clinician should be calm, unhurried and mentally prepared for serious work. The clinician should be aware of the whole workload for the session. I prepare for clinic a week in advance by typing an MS Word document that contains known diagnoses, medications and recent results. I can then anticipate the consultation and appear well briefed to the patient. If another patient is slipped into the clinic, I would then spend several minutes reading the notes (charts) before calling the patient in. I do much the same for rounds. I check my patient census on arriving at work and prepare an MS Word document with similar information. I read the current admission notes (or hear the junior doctor present the case) and look up test results etc before going to see the patient. In this way, I can give the patient confidence that at least I know what other clinicians have concluded about their case and I know what to be sceptical about!
I believe this is crucial to correct diagnosis. Knowing the person means asking about the person's job, interests, family and enjoyments. This provides not only an ordinary human connection but makes the person confident that the clinician is interested in them as a person. The patient's account of the presenting complaint is crucial to correct diagnosis. To give their account, the patient must speak. Asking the following easy to answer questions gets the patient talking.
What is or was your job?
What are your interests?
What do you enjoy these days?
Who is at home with you?
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In my experience, the patient then divulges a fuller, richer history of presenting complaint because the patient is confident the clinician is interested and trustworthy. Also, this gives me a memory hook to recall the person and help to be able to recall a whole lot about the diagnosis and treatment. It also often provides interesting conversations at the end of the consultation when I am writing out request forms etc.
If the patient feels hurried by the clinician, they are unlikely to provide a useful history of presenting complaint and will feel that they have not been listened to. When I ask patients to tell medical students 'What makes for a good doctor?' by far and away the commonest answer is 'A doctor who listens.' A seemingly hurried clinician cannot appear to be listening. If the clinician feels hurried, they are distracted at a time when attentive listening and clinical reasoning are essential. In the UK, the emphasis on targets in the ED, wards and outpatients (office) means that clinicians feel hurried the majority of the time. In the long run, it is counter-productive to hurry the first consultation. The patient must have confidence that their assessment has been thorough. I am sure that I can discharge more patients from clinic after one attendance because I try to make the consultation unhurried.
Attentive listening and clinical reasoning require simultaneously doing two high-level mental activities. Even having to write notes takes up more of the brain's attention. This is one reason that I prepare the MS Word documents prior to the consultation, so that I have less writing or typing to do during the consultation. As I get older and more experienced, I find myself writing less and less during the consultation, so my brain is free to listen, observe and think more. This means that I must not be interrupted or I will lose my chain of thought and forget important points when I compose the clinic letter. I also try to make myself put my mobile onto silent, switch off the on the computer and make the room (or ward) as quiet as possible. It must be exceptionally difficult for consultants in the ED to work on diagnosis; I see them constantly interrupted during consultations, and even dealing with interruptions upon interruptions upon interruptions all in the midst of noise. Ward rounds are also subject to constant noise, interruptions and distractions. We expect correct diagnoses and reviews, but provide almost perfect conditions for human error.
This is a combination of external and internal factors. Externally, everything should be done to provide an environment conducive to high-level thinking. Most clinicians will be laughing by now. On the wards, vacuum cleaners are running, phones are ringing, pagers are bleeping, monitoring equipment is alarming, trolleys trundle and rattle by, staff and relatives are talking at the top of their voices to be heard over the background noise, bed managers, infection control nurses etc all charge into the wards and interrupt.
The attention required to handle the computer programs or locate the current notes and nursing charts to find important information can further detract from being able to hear oneself think.
Internally, the clinician has to find ways to try to block out the external factors and any internal or personal issues so that their mind is able to hear itself think. Top sports performers are trained in these sorts of techniques to block out the spectators, but I have not heard of similar training for clinicians.
I believe that better clinicians seek information prior to and during the consultation. I have described how I prepare for the consultation; this fits with the often-given advice of 'Read the notes'. Mostly, the information in the notes is truth but must not be accepted without questioning, at the least the information in the notes tells me what to be sceptical about! During the consultation we need access to information because we cannot hold it all in our brains: what was the pro-brain natriuretic peptide level, the creatinine and potassium level, what did electrocardiography and echocardiography show, should the dose of apixaban be reduced in renal impairment? This information can be readily available in well-filed paper notes, but with the under-provision of ward clerks, clinic clerks and secretaries, well organised paper notes are a thing of the past. I have not experienced well-organised electronic charts. In my previous hospital, I had to have 10 software applications open for an outpatient (office) consultation and the paper notes too! This meant that there was not a ready supply of information into the consultation. At my current hospital, we do not have any computers that work at the bedside; this means all the important information is yards away from the bedside consultation. It is even easy to overlook checking the chest X-ray. The NHS is meant to be National but in Scotland, I cannot access any clinical information about a patient from England, Wales or Northern Ireland and the danger in patient care is palpable.
On NHS wards, there is close to no confidentiality and dignity during consultations on ward rounds. The curtains are usually pulled around, but everyone in the bay can hear the consultation. Dignity is often fairly minimal with patients expected to accept physical examination in front of several strangers. In Sweden, Valdemar Erling and colleagues, have set up ward round rooms which provide greater privacy.2 The consultations that I observed were more like adult conversations between equals than the conversations that happen when the consultant stands towering over the patient in their bed.
Outpatient consultations are usually far better for confidentiality and dignity. However during my career, I have been expected to do a clinic along with about six other doctors and patients all in a room like a railway station waiting room (this was in one of the top hospitals in London). I have also seen clinics where patients were put into gowns and placed on examination couches before the clinician even said 'Hello'.
Refreshments are called refreshments because they refresh the mind, body and spirit. Most clinicians are workaholics and are then subject to performance targets. I know many clinicians who never take lunch and, at the extremes, may work 14 hours without even going to the toilet. The evidence is that a proper refreshment break is needed every 2 hours if we are to maintain performance in high-level mental activity. If healthcare providers want good patient outcomes and patient experience, they have to ensure and insist that staff take full refreshment breaks ' not 10 minutes carrying a coffee, answering emails, making referral calls and chasing tests results ' a proper gossipy break doing nothing else but eat, drink and chat.
Another person can give the patient reassurance and may also contribute useful information toward diagnosis or management. The other person is also a second set of ears. Another person is almost essential if the patient is suffering from dementia or delirium. However, another important person is often discouraged from participating in consultations on ward rounds.
I am sure there are many other quality indicators that could be applied. For example, I am sure that the patient should, by default, be given a copy of the clinic letter or discharge summary along with copies of important results. In , the patient should have online access to, at least, referral letters, clinic letters, discharge summaries and test results.
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