Altered state

As the Covid-19 pandemic continues, the dentist-patient relationship depends on effective communication and compassion more than ever before.

Dentist and patient

Written over 100 years ago, The Machine Stops is a science fiction novella by E.M. Forster. It depicts a world where humans are socially distanced, confined to their rooms, totally reliant on technology (the machine) through which they experience the real world. Their expectations match their daily expectation of life and they are content. It is only when the machine stops that their lives are thrown into turmoil. The Covid-19 outbreak has upended everything; it has in a sense stopped the machine.
Expectations and experiences have changed and as dentistry finds its path to the next normal, dentists are ethically obliged to adapt and adopt new ways of working. In contrast, patients do not quite know what to expect. They will be aware of PPE requirements but less familiar with the issues practices face with regard to challenges posed by aerosol-generating procedures, operational capacity, and prioritisation of care.
A patient-centric approach to care has set expectations among patients of personalised care. ‘Treat every patient as though they were the only person in the building’ was the first piece of non-clinical advice I was given on day three of my professional career.

Ethical impact
The dentist-patient relationship is a deontological (Kantian) construct. This is how it has always been in normal times. The exigency of the pandemic combined with the scarcity of resources, including PPE, called for a different approach in many parts of the world. The focus went away from the duty to the individual, to the need to consider the greatest good for the greatest number. It was now about utilitarianism and required a recalibration of patient expectations.

Altered expectations
The patient experience has changed in the last 12 months. Gone is the handshake, having survived cultures and civilisations for thousands of years. It was previously a ritual to indicate trust, friendship and openness, and has now been replaced by alternative gestures – elbow-nudging, salutes, thumbs-up and, in the case of one particular patient, the iconic Vulcan salutation of Mr Spock. (PPE may hinder non-verbal communication but my patient was astute enough to recognise a puzzled frown across my nurse’s forehead; he went on to explain its origin and history dating back to the opening episode of the second series of Star Trek in 1967.)
It is not easy to substitute such traditions. A quasi-apology in advance can reset expectations and at the same time acknowledge the break with tradition. For example, to say ‘Sorry I won’t shake your hand because….’ anticipates how a patient might feel, thereby controlling the expectation barometer. Other examples include giving patients advance notice of what to expect on arrival at the practice, for example, temperature checks, social distancing or the clinical aspects of their visit, thereby pre-warning them if there are any restrictions in place about what procedures can and cannot be undertaken. Anything said in advance to a patient will be perceived as an observation; anything said after an event will be seen as an excuse.
Some practices have prepared short videos on their website and encouraged patients to watch these before they arrive. This approach may be compared to Kurt Lewin’s three-step change model – unfreeze, change, refreeze. Some leading researchers in the field suggest that there are three types of expectation:

  1. The desired service – a level that the patient hopes to receive.
  2. Adequate service – this is the minimum tolerable level. Patients will have recognised that the desired service is not always achievable, particularly during times of crisis.
  3. Predicted service – a probabilistic assessment of the level of service a patient thinks they are likely to receive.
Zone of Tolerance

FIGURE 1: The zone of tolerance.

The gap between one and two (Figure 1) has been described as the zone of tolerance (ZOT; Zeithaml, Berry and Parasuraman) and the predicted service is likely to lie within that zone. The model represents the range of expectations and acceptable outcomes. The width of the expectation zone of tolerance is inversely proportional to the degree of importance. The wider the zone, the less the importance.
It is clear from reported complaints to Dental Protection and from conversations with colleagues that patients have demonstrated a very narrow ZOT in some aspects of their dental visits, for example infection control and the wearing of PPE, and a wider zone when it comes to cancelled or postponed appointments. As we head towards the next normal, there are early indications that this zone is starting to narrow as patient expectations rise when it comes resumption of dental services.

Expectancy-disconfirmation paradigm
Efforts at re-setting expectations are important because they impact on patient satisfaction. The expectancy-disconfirmation theory applies:

  1. When a patient visits a practice, they do so with a pre-set level of expectation determined by prior experience. A new patient may have expectations influenced by comments made by whoever has recommended them. Information and images on marketing literature and websites will also play a part in determining expectations. In the Covid-19 context, media images of healthcare workers in PPE will help set expectations.
  2. These expectations are the standard against which the dental team and the practice will be judged.
  3. When these expectations are met, confirmation occurs.
  4. Disconfirmation arises when there is a difference between expectation and outcome.
  5. If the outcome is better than expected, there is positive disconfirmation. Negative disconfirmation arises when the outcome is below the pre-set level of expectation. Positive disconfirmation attracts compliments and encourages recommendations, and negative disconfirmation does the opposite.

Back to basics
In his 2015 lecture, delivered as part of the W.L. Gore Lecture Series in Management Science at the University of Delaware, Prof. Parasuraman, a leading authority in his field, relates his experience when he visited a hotel. On arrival, he was presented with a pillow menu, which offered a choice of nine different pillows. He was not expecting this and his initial reaction was “Wow, this is great”. He had “never seen anything like this before”. He went on to explain that this early experience immediately improved his perception of the hotel and raised his expectation of his stay.
His experience of the basic services was less complimentary as he recalled that “almost everything that should not go wrong in a hotel did go wrong”. This included a failure to make the promised wake-up call. His disappointment had been exaggerated because of the raised expectations set by the initial encounter.
This is a clear reminder that innovation has little value unless basic needs are met, such as the backlog of incomplete treatments and urgent care for existing patients, as well as coping with additional demand from other patients whose own practice has limited capacity.

In their paper, ‘Concordance between patient satisfaction and the dentist’s view’, published in the Journal of the American Dental Association (April 2014), Riley et al. report that there were “large discrepancies between patients’ lack of satisfaction with regard to several domains of communication”. They concluded that “some dentists need to better assess their patients’ expectations…”.
This stresses the importance of effective communication when managing patient expectations when the norm is no more and when we and our patients have to accept an altered state. As the Covid-19 pandemic continues, the dentist-patient relationship depends on effective communication and compassion more than ever before, and when face-to-face contact may be limited, remote consultations remain an alternative means to demonstrate both, to ensure that the machine does not stall.

Raj Rattan

Dr Raj Rattan

Raj combines his work in general dental practice with his role of Associate Dean in the London Deanery. He is also a Senior Dento-Legal Consultant for Dental Protection and has  worked with them since 1993.