3: The conversation with the patient
Wei Qi Zhang; Raewyn Huang; Wei Chen; Sowmya Shetty; and Jessica Zachar
Learning outcomes
- Describe strategies to effectively communicate with a medically compromised patient.
- Formulate questions to determine current state of the medical condition, including the management through primary health care team.
- Formulate questions to record accurate information about the medications the patient is currently on.
General strategies
The medical history of the patient is an important factor for the clinician to consider while creating customised patient centred care plans. The choice to disclose medical history however is at the patient’s discretion.
As an early year dental student, you may find it confusing that patients are reluctant to disclose specific information given the importance this holds in creating a customised dental care plan for medically compromised patients.
It is key to know that patients do not always understand the crucial connection between their general health and dental concerns.
Some medical conditions may also have specific cultural or social stigma such as conditions associated with mental, physical or sexual health. This generic stereotyping that exists in specific communities and cultures, might also affect the patient’s decision to disclose a full medical history.
As dental practitioners, we should be able to foster an environment conducive to open and non-judgmental discourse, thereby encouraging patients to share comprehensive and accurate medical information willingly with a view to collaboratively work on improving their oral health. It is always important to be able to take a neutral, benign stance, avoiding discomfort and stress at the first appointment.
- For the student practitioner, it is key to approach the first appointment to collect medical history efficiently and thoroughly, using an open and honest dialogue.
- The student practitioner should be familiar with common general health conditions and the connections to oral health so that they can explain to the patient about possible consequences of treatment procedures and outcomes.
- The student practitioner can also pause and attempt to restart a discussion at a different time when the patient is more comfortable.
- If insufficient information poses risks, the student practitioner should use referral pathways to a more suitable provider within the clinical placement or seek help from the supervising dentist.
Communication skills to consider developing
A neutral tone, ability to engage in small talk, appropriate body language and eye contact along with appropriate word choices may all contribute to the comfort of the patient and their willingness to disclose information.
Using motivational interviewing principles to paraphrase the information is also encouraged to ensure that the patient has the opportunity to correct any misunderstandings and provide any other relevant details.
The patient dialogue could take a more open route, and the important aspects may be diluted and missed in the clinical notes.
Some patients may just forget to provide all the details. To avoid this, the interview should follow a specific format to ensure relevant details are fully captured.
General questions about medical conditions
- Ask if the patient has a specific condition they are seeking advice or treatment from a general medical practitioner or a primary care team such as at a public hospital.
- Are they on any medications or treatments for an existing condition?
- Is the disease under control or uncontrolled?
- Have they ever been hospitalised?
- Ask about frequency of visits to hospital/ doctor, duration of condition/s, how did it start, the severity and any tests or results we might need to look at.
Specific examples are available through video vignettes created at the School of Dentistry, and are within this resource in later chapters.
Planned questions to explore medical history
To determine the state of the condition declared
- Frequency and onset
- When did it start?
- How long does it last?
- Is it recurring?
- When was the last occurrence?
- Severity
- Is it getting better or worse?
- Is it under control at present?
To determine current management of the condition
- Is a medical specialist looking after your condition?
- Are you taking any medications? (See medication questions below)
- Do the medications improve your condition?
- How have you dealt with any emergencies or do you have a plan?
- Did you bring relief medications (e.g. salbutamol inhaler for asthma, GTN spray for angina)?
- To determine relevance to dental treatment:
- Do you know if your condition affects the dental treatment and vice versa?
- E.g. For vertebral issues: Would it be okay to lie you down?
- E.g. For patients at risk of hypoglycemia: Would you need sugary water to maintain energy? Have you had breakfast/ lunch?
Medication related questions: Dose, frequency and name of medication
- What medications do you take?
- How much and how often do you take it? When do you take it?
- E.g. when is your next scheduled Prolia injection?
- Did the dose recently increase?
- To confirm the purpose of the medication:
- What condition is the medication for?
- Do the medications improve your condition?
Allergies
If the allergen is known: What are you allergic to?
To determine severity:
- Do you get mild discomfort/itchiness?
- Yes: Patient has had antihistamines or no medication or treatment.
- Do you get a serious or anaphylactic reaction?
- Yes: Patient will have an EpiPen if this is the case – always check if they have it with them.
- Unsure: You can call the medical practitioner to find out the nature of the allergy if patient is unsure.
Sensitive questions
Personal questions may be perceived by the patient as intrusive, embarrassing or could trigger post traumatic stress such as a history of HIV, mental health, past physical or sexual abuse. However, it is important to gently explain the direct implications on treatment both during the appointment and after.
This is also so that the clinician is aware of any previous experiences of trauma so that these are not unconsciously triggered during treatment.
Patient may also be reluctant to discuss smoking, alcohol and drug consumption habits. When disclosed, they may be resistant to cessation.
As health care practitioners we should focus on the objective aspects and refrain from being judgmental.
Providing patient with specific information about how the habit affects oral health, and keeping it as succinct as possible is key. For example: While smoking is a personal matter, it does have implications on the dental care and its outcome, as smoking can affect healing negatively, increases risk of cancers and related diseases, and desired treatment outcomes may not be achieved.
Gently encourage quitting through quitting services and emphasising gradual change is perfectly fine. Intrinsic patient motivation is a key factor in quitting habits like smoking.
Key life events are said to motivate the patient more effectively and a dental visit especially if an emergency has an important role in this aspect.
