When was the last time you encountered a patient who said they didn’t want bitewings, or a doctor’s examination, or a periodontal screening, or a fill-in-the-blank? We’ve all had patients who simply ask to defer a service until their next visit due to time or budget constraints. But what about patients who refuse a recommended service or screening because they don’t think they need it, or they’ve simply decided they don’t want it?
Are you prepared to manage that situation and possibly even turn it around? This can be tricky. We work hard to build trust with our patients, and we want to maintain good relationships with them, yet sometimes patients refuse even our best recommendations. What are some strategies to help navigate through these patient refusals?
Avoid the temptation to roll your eyes
Have you ever noticed that while the act of rolling your eyes is obvious, sometimes we communicate an eye roll with our voice? When patients want to dictate their own treatment, there is a tendency to roll our eyes (even figuratively) and respond defensively. After all, we hold the degrees and licenses, and patients should value our clinical judgement. Right?
Here is a tip to help prevent literal or figurative eye rolling: when faced with a situation where a patient refuses a service, pause, take a deep breath, and respond with a confident tone designed to keep the dialogue open. In a worst-case scenario, you might learn that the patient and practice have unresolvable differences and values. However, most objections and refusals are based on patients’ lack of understanding about how the service benefits them, and that’s an opportunity for a conversation.
The art of listening
When a patient states, “I don’t want any x-rays,” an ideal response would be, “OK, but would you please tell me what concerns you have about x-rays?” Before we can educate patients about the value of something they’ve already decided they don’t want or need, we should invite them to share their concerns, and we should really listen.
Irrespective of what the objection is, shifting to the role of a good listener provides the opportunity for patients to express their concerns. Sometimes patients simply want to be heard. Active listening often includes a summary statement such as, “Cindy, it sounds like you think the screening x-rays are unnecessary since you have no problems. Is that correct?” Once you’ve heard their objection, you can formulate a response and often negotiate a compromise.
If Cindy is at low risk for caries and periodontal diseases, updating her x-rays less frequently could likely be done without jeopardizing her health, and you should thank her for sharing her concern. On the other hand, if Cindy had a restoration during the past year due to caries and is in a moderate or high caries risk category, this becomes an opportunity to explain risks and discuss interventions to reduce future risks, including x-rays. The art of listening improves the more we are intentional about it. Asking what, how, or why open-ended questions is a great way to uncover patients’ true objections to our recommendations.
Often when patients refuse services or screenings, they don’t understand their importance, or they don’t see how something benefits them. In order to turn this around, make your screenings interactive whenever possible. Inform patients about what you are assessing or evaluating. If patients hear “everything looks great” every time we update their bitewings, they may decide that they don’t really need x-rays unless something is bothering them.
This became abundantly clear to me a few years ago when I asked a patient to help me understand why he didn’t want me to update his screening bitewings. He said that for the past 10 years after we took x-rays and looked them over, we told him everything’s great, so he decided to wait another 10 years before having more x-rays. Wow! We were unknowingly reinforcing the low value of x-rays. That feedback became an opportunity for me to shift how I examine patients’ x-rays. Now I show them ideal bone density and bone levels compared to areas that are not. I show them what we’re looking for around implants. If I see areas that appear to be early demineralization, I show patients digitally what I’m seeing and then discuss interventions. Identifying and showing patients comparisons using their own radiographs builds value.
When performing periodontal screenings, ask patients to participate and listen for areas that bleed or measure deeper than 3 mm, since both can be indicators of disease. When the dentist is performing a semiannual or annual periodic examination, ask patients how they feel about their oral health and whether there is anything they wish were different. The dental hygienist can provide a synopsis of findings during the examination. Patients should hear the dentist asking the hygienist for a synopsis of findings based on the screenings. This builds value for the screenings and communicates trust in the dental hygienist’s expertise.
At the next team meeting, open the conversation to get your team’s ideas on how to turn around treatment refusals. Refusals of services or screenings should not end with asking patients to sign a refusal form. Under each refusal lies an ideal opportunity to really listen to your patients and increase the value of recommended services. Both reap long-term rewards.
Editor's note: Originally posted in 2021 and updated regularly