A word about noncompliant

May 1, 2006
We have all experienced the long-term patient who just doesn’t listen to us.

We have all experienced the long-term patient who just doesn’t listen to us. We teach, nag, lecture, and coach, yet this patient appears to show no interest in our efforts. No matter how hard we try, education and behavior modification are not forthcoming. Sooner or later, we write this patient off as “noncompliant.” Guilt is lifted from our minds. At some point in the future, the noncompliant patient is seated in the chair of a colleague, and, for the first time, the patient “hears” something new. The patient thanks the dental hygienist for all the information and asks questions during home-care instructions. Your colleague feels good about the visit, the patient leaves feeling enlightened, and you wonder where you went wrong. What happened to your fine tuned communication skills?

It is human nature to take responsibility for things beyond our control. At times, it is also our nature to place blame where it does not belong. I have been guilty of judging patients. If you look over my past clinical notes, you will find patient labels and judgments. Just last week, I was mortified to find the following note on my recall sheet. “Patient not interested in home-care instructions. Noncompliant.”

Was I trying to cover my butt, or am I really that judgmental? In hindsight, I may have been concerned that another dental hygienist seeing this patient would think that I did not do a good job. There needed to be some explanation for all that plaque. I couldn’t let anyone think it was my fault. Instead, I placed blame on the patient. This particular patient is in the beginning stages of Parkinson’s disease, something he should have declared on his health history. Still, this fact does not excuse my attitude that dripped harshly from chart notes.

It almost makes me shudder to realize there is probably a medical chart somewhere with my name on it and judgmental notes inside. I can assure you my own behavior earned most of the comments. Questions directed to me by my health-care providers are usually answered with short and indirect answers. It must be “white coat syndrome,” because anyone who knows me can attest to the fact that I am blunt, direct, and often long-winded.

Recently, I was forced to deal with an ongoing health problem. I waited 16 months to see my nurse practitioner and even then didn’t give her all the information she needed. When I was seen by my surgeon, he expressed astonishment at my delay given the seriousness of my condition. (It was probably more annoyance than astonishment, but I don’t want to judge.) He tried to impress upon me the danger in waiting so long, but my behavior most likely told him I didn’t care. Nothing was further from the truth. I cared, but fear was directing my actions by that point.

My surgeon would have been justified in giving up on me many times during my treatment. I avoided eye contact, hid symptoms, and ignored advice. I was the poster child for noncompliance. Yet, he kept telling me the same things, kept treating me, and only occasionally showed his frustration with my attitude. Did he know I was really listening, or did he just keep doing his best despite my indifference?

Because of his example, I have made a promise to myself not to give up on any patient. I promise to keep empathizing and educating, and always remember how I reacted when my health was in more immediate danger.

As health-care providers, we need to fine-tune our communication skills and downplay our judging and labeling habits. People communicate and listen in different ways, and we need to keep trying until we find each patient’s communication style. It is up to us to adapt, not the patient. After all, the patient is paying for our services, skills, and knowledge. We should not judge our patients in chart notes or even in the break room during those moments of free chat among the staff.

According to GST Telecom (formally Call America), communication styles can be divided into four categories: Expresser, Driver, Relater, and Analytical. Understanding how each style listens, speaks, and is motivated will go a long way in improving our patient education skills. The other option is to talk to every patient in the same manner and hope most of them “get” our message. The second does not require as much effort, or any effort at all, but is also devoid of real career satisfaction for the quality dental hygienist. (see sidebar)

It takes time to discover which communication style to use with your patients. In my own case, it took a

long and heated e-mail to my surgeon. I described what my role should be in my recovery and what I felt he needed to understand. Obviously, I am a Driver. While I often regret the rude tone of that e-mail, it did open the door for better communication between us. If we take the time to get to know our patients and the style of communication each of them uses, our education and home-care instructions will be received in ways we never thought possible.

It is possible that you might not ever connect with that “noncompliant” patient. Perhaps you are both Drivers and want to be in control of the conversation or education. Maybe you are an Expresser and can’t seem to connect to the serious nature of your Analytical patient. These are situations that call for action beyond fine-tuning your communication skills. In our office, when I just can’t seem to get through to a patient, I schedule the next recall with the other hygienist. Not only do I trust her to give excellent care to my patient, but she and I are on opposite sides of the communication styles. We don’t get our egos bruised when a patient requests one of us over the other, since we know it has nothing to do with clinical skills. Usually the request is made because the patient prefers one personality over the other. We just communicate differently.

No matter what your communication style may be, as the health-care provider, you need to adapt your style to that of your patient. When you do find out which style best fits a patient, perhaps a note to yourself in the chart will help on the next visit. If you discover the light goes on after you praise the home-care efforts of a patient, make a Relater note to yourself for the next visit. And if you find you just can’t get through to a patient no matter how hard you try, let someone else try. You are only responsible for your own efforts, not the lack of response from the patient.

Just yesterday, I broke my own patient communication rules. I am a friendly person and I do chat with patients to learn about their lives, but I am not “mushy” by any stretch of the imagination. I can empathize, but I don’t often console. And above all, I do not hug. Yet, all those “rules” went away when a patient and friend returned for a periodontal maintenance appointment after surgical treatment by the periodontist. During his absence from the practice, his wife passed away unexpectedly. She was a wonderful woman, and he is an outstanding man who really needed to share his loneliness. I even stopped scaling and listened for a few minutes. He shared his feelings and I simply let him talk.

When I finished his appointment and was walking him to the front desk, this sweet man not only hugged me, he placed a slight smooch on my cheek and told me “thank you.” The mortified looks on the faces of my co-workers was almost worth the uncomfortable moment. It felt very good to communicate with this man on an entirely different level. He not only received great dental treatment that day, I delivered pretty good human treatment as well.

Communication is a two-sided activity, yet we can only be responsible for one side at a time. We need to talk to our patients, and we need to assume they hear us. We need to listen to our patients, and leave them with no doubt that we hear them. Most importantly, leave judgment to a higher authority and never give up on anyone.

Expressers, Drivers, Relaters and Analyticals

Expressers are easily excited and like exciting situations. The Expresser does not want to be bored with lengthy explanations or waste time with too many facts. The Driver likes to be in charge of situations. The Driver is efficient and will get things done now. A Relater wants a friendship. Relaters are helpful and need positive attention. The Analytical is a technical being. Analyticals do not make errors and are never unprepared. Of course, this person will be quick to point out your mistakes.

Often, you can determine a person’s communication style by the questions they ask. An Expresser will ask “who” questions. Who is responsible for controlling their gingival problems? Who didn’t teach them the proper way to take care of their teeth when they were young? (The all-to-common blame-the-parent syndrome.) An Expresser will want to “sell” you on their arguments of who to blame. To motivate an Expresser you need to give plenty of applause and positive feedback. Also, give this person challenges that can be achieved quickly. Remember, an Expresser does not like to be bored.

The Driver is apt to ask “what” questions. Tell this person what is wrong and let them take control of fixing it. Drivers are competitive and efficient. Give this person a challenge, as they like to win. Unlike the Expresser, you can give this person plenty of facts. Drivers have strong viewpoints and like to do things their own way. Give this person goals that can be measured by a win-lose system. Losing is not an option in the eyes of a Driver.

Relaters want to know “why.” This is your typical “why me” group of folks. But Relaters are good people with big hearts. They like to be helpful, sometimes caring more about the success of others than their own achievements. Relaters can be ideal patients because they sincerely want your efforts to be successful. Relaters are pleasers.

Analyticals seek the answers to “how” questions. This person wants all the data possible and asks many questions. The Analytical likes to be busy and sees activity as the way to find the answers. This is not the patient who appreciates humor in serious situations and, therefore, most of my jokes are wasted on this person. Once the Analytical discovers how less-than-stellar home care leads to poor tissues, the solution is easy. Tell them how flossing will create better tissue health, and they will floss. It is that simple. Just remember the Analyticals are not comfortable with friendly situations and prefer the health-care provider to be professional and direct. Save your warm side for Relaters.