You remember finals, don’t you? Of course you do. Your examiners carefully selected a patient(s) for you to examine and diagnose and for whom to present a treatment plan. The finals patients were unlucky enough to have more than one dental problem and you were marked on finding all of them and your ability to determine a set of solutions for the patient.

Afterwards most of us headed off into practice, where a series of “finals patients” are paraded in front of us on a daily basis. Now these patients willingly pay us to make our professional judgements, offer our best solutions and suggest a fee for doing the dentistry.

However, that’s not always what happens, is it?

There’s something that happens in general dental practice (be it public like the National Health Service (NHS) here in the UK, mixed or private practice) that is rarely spoken about in dental magazines, online forums or even at the bar at dental conferences. And it’s this: many dentists consult with, examine, diagnose and treatment plan their patients, not in the way that they did for their finals patient, but by applying some sort of filter—a filter of which the patients are completely unaware. Such filters have several elements and in my 25 years of being a dentist, followed by ten years of coaching dentists, I think I’ve probably heard or seen them all, or at least their effects. The filter may have some or all of these components:

• Will the patient like me if I tell him about all of this?
• Will the patient come back if I tell him about all of this?
• Will the patient think I am over prescribing?
• (For returning patients) If I tell them about all of this now, will they wonder why on earth I haven’t mentioned it before?
• Will the patient be willing to pay for all of this?
• If I persuade the patient to have the big treatment plan, what happens if it goes wrong?
• As long as I make a note on the records, I am keeping myself within the legal rules.

The enemy within here is fear, and not the patient’s but the clinician’s. And so the filter is applied and the patient is offered the treatment plan that the clinician believes is absolutely necessary or the one he feels the patient needs. Presumably, he leaves the rest until it becomes (as he deems it) necessary or needed. An additional filter, of course, is the one that pushes the dentist towards offering treatments that are well paid or earn the most number of units of dental activity. Let me run this analogy past you.

Imagine putting your three year-old, £25,000 car in for a 30,000-mile service. During the course of this, the technician discovers that as well as the regular service items needed, your car also has two sets of worn brake pads. In addition, the front brake discs are warped, rear dampers are leaking and two tyres are nearly at their worn-out marks. As a customer, which of these phone calls would you like the garage to make?

• The call that lists the faults, your options and the costs for having everything put right?
• The call that tells you about the faults they think you will want to hear?
• The call that tells you about the faults that you will be able to see?
• The call that tells you about the faults they think you will be willing to have fixed?
• The call that tells you about the faults that will earn them the biggest margin?

And what will the garage do about the faults they don’t tell you about? Perhaps, put a ‘watch’ on their records and consider telling you at the next service?

Duty of care
I know that some of you will be wincing already at my comparison between a clinician and a mechanic but there’s more mileage in this analogy still to come. After paying for just the service, you drive off from the garage with the faults left unreported. A child runs out in front of your car and you fail to stop in time because of the worn tyres/brake pads/discs/dampers. In the investigation that follows, these things come to light and spark a witch-hunt.

A good garage owner dares not risk this and the inevitable damage to the garage’s reputation. He takes his duty of care seriously and must tell you exactly what the garage has found wrong with your car. So what’s really going wrong when a patient leaves a dental surgery with half a treatment plan? In my opinion, this happens because we’ve lost the simple, straightforward, trusting relationship between patient and clinician that we had as a final-year student. External circumstances such as insurance companies, the economy, the practice finances and probably most importantly, our lack of confidence and self-esteem, have filtered our behaviour so that we agree to compromise our professional skill set and integrity in order to be liked, keep the patient or stay within our comfort zone.

So, how does that sound? Not so great from where I’m sitting and let’s not tell the national newspapers. When I left the NHS in 1992, I decided to get rid of all the filters I had acquired, and simply show and tell my patients what I could do for them as if they were one of my family and money and time weren’t an issue. I’ve used exactly the same approach in my coaching practice. I was lucky enough to be mentored by some great coaches on the idea that you often do your best coaching just before you get fired (for telling it like it is). And that’s what I do for our clients.

In my view, you have to decide what sort of dentist you want to be: either an anxious single-unit one tooth at a time type dentist, forever destined to gross a thousand pounds a day, whilst complaining that patients don’t want your treatment, or a dentist who communicates clearly and straightforwardly with your patients about what you can see in their mouths and the best way to fix it, thereby giving them back their responsibility for their health and leaving the decision about whether to proceed with them.