Are we Training Enough of Communication Skills and Patient Psychology Required in Dental Practice
Varsha Murthy1, Shakila Rajaram2, Sunayana Choudhury3, K.R. Sethuraman4
1 Professor, Department of Prosthodontics, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth University, Pilliyarkuppam, Pondicherry, India.
2 Associate Professor, Department of Prosthodontics and Crown & Bridge, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Pondicherry, India.
3 Assistant Professor, Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Pilliyarkuppam, Pondicherry, India.
4 Vice Chancellor and Professor, Department of General Medicine, Sri Balaji Vidyapeeth University, Pilliyarkuppam, Pondicherry, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Varsha Murthy, Professor, Department of Prosthodontics and Implantology, Indira Gandhi Institute of Dental Sciences, Mahatma Gandhi Medical College Campus-607402, Pondicherry, India.
E-mail: drvarshamurthy@gmail.com
The aim of this review is to discuss about lacunae in the areas of Communication skills and Patient psychology teaching in the dental set up in India. A literature search was performed using various databases and other resources. Data obtained was reviewed to obtain the work done in this field. It was found that there is currently no clear data in literature as to how much and how well students are taught about communication and behavioural skills and patient personality in dental curriculum in India. Pinpointing such lacunae can help dental colleges and universities to focus on the emphasis of their approaches to teaching about communication skills and psychology of the patient. Identification of future research area in this field is the need of the time for future discovery and progress in this overlooked field.
Introduction
In medicine, communication skills are recognized as a mandatory core competency in many countries [1]. Almost equal importance is given in nursing training also [2,3]. Communication and behavioural science education is gaining momentum as a mandated component of dental graduate competence in many countries and is highly recognized and appreciated by patients [4]. Proficiency in communication skills, team-building skills, and global knowledge is slowly becoming an essential part of dental education in India [5].
The undergraduate dental curriculum in India is comprised of two years of preclinical training and two years of clinical training on patients in different departments, with one year of compulsory rotary internship thereby stretching to a span of five years. The postgraduate curriculum involves three years of training of preclinical and clinical training in the particular department. Although the governing body in India (Dental council of India) has outlined the basic portion of communication skill and patient psychology in BDS and MDS dental syllabus [6,7], clarity as to how it will be taught (teaching methodology), who will teach that (qualification and specialization/expertise of teaching faculty), when it should be taken(accommodation in existing curriculum i.e., which year of the course or keeping as credit base choice program) and its evaluation (whether in formative or summative assessment) is not mentioned. Therefore, its application and assessment is not uniform in all the universities across India. In some universities behavioural skills is taught for first year students but their knowledge is not refreshed when they start handling clinical patients from third year onwards. Owing to the increased awareness among patients due to media and internet regarding their rights as well as increase in the misuse of such rights it becomes mandatory for us as staff and students to equip ourselves, in understanding our patients needs, expectations and management of patient dissatisfaction.
Materials and Methods
A literature review was performed using Pubmed and Medline with the key search terms Dental, Communication Skills, Training or Teaching, Psychological and Assessment or Evaluation. The reference lists of relevant journals and “similar articles” search function were also used. A secondary search of the Dental Education Journal Archives, PROQUEST database, Psych test was performed by hand. An additional search of journals, reports and books was made via the World Wide Web using the same key words. Some articles were manually searched to obtain data on Indian perspective on the topic. These resources were manually reviewed by the authors to determine research quality and relevance to this narrative review paper.
How important is communication skill in dental set up?
“Who cannot give good counsel? its cheap and it costs nothing” Unknown
In olden days, barbering and dentistry co existed wherein barbers used crude methods to pluck teeth and relieve patients from acute pain. Dentistry as a field has come far away from the era of barber surgeons to specialized branches in dentistry [8]. Major shift has also taken place from doctor centered to patient centered care. Dentistry is a branch which involves both art and science. A time has come when apart from teaching technical skills we should equally impart soft skills in dental education. An ability to communicate well with the patient, to be able to ask relevant questions, to be able to listen patiently, to be able to answer queries in understandable manner, to develop rapport building, negotiating skills, break bad news, to develop counseling skills, empathy, verbal and non verbal communication, body language, negotiating etc., [9] should be taught to the students during their course [Table/Fig-1]. These skills should then be tested to assess if a student has learnt it adequately (pre test and post test). It has been found that a large number of students found communication skill course more important after finishing the course [10]. Students who had received training in communication skills were rated significantly higher in all aspects of communication and were found to have good effects on doctor-patient correlation and were significantly more likely to explore and recapitulate patients’ statements than the untrained students [11-13].
Challenges and skills to be applied in dentistry.
| S.No | Unique Challenges in dentistry | Communication and Behavioural and psychological skills application |
|---|
| 1 | Patients in rural India have several myths and misconceptions that removal of teeth may lead to blindness or decrease in strength, burying upper teeth in the ground makes the permanent teeth small and throwing towards sky makes the permanent teeth big, placing clove on tooth relieves pain, midline diastema is a symbol of good fortune, cleaning teeth from dentist makes them loose, cleaning with salt makes teeth white and shiny. Due to this patients avoid taking dental consultation and treatment for themselves and their children. | Questioning skills, Listening skills, Counseling skills, motivational interviewing. |
| 2 | Dental phobia | Answering skills, motivation and counseling skills |
| 3 | Trainee or senior dentist’s directly starting procedure to treat patients (without informing about the treatment or procedure) considering them as inanimate objects. | Rapport building skills,Informed consent (treatment options, cost, number of appointments). |
| 4 | For most of the dental procedures, work is done without (complete dentures) or under local anaesthesia (root canal, perio surgeries, implants, extractions) thereby patient being conscious during the procedures thereby having a view of syringe for giving anaesthesia and variety of multiple differently shaped, sharp and blood stained instruments. | Counseling and motivation skills, informed consent |
| 5 | During the procedures, patient tends to be surrounded very closely by dentist, one or more assistants since the procedures have to be done in a small dark area i.e., mouth which, many patients especially females may not find comfortable. | Non verbal behaviour (about pain, discomfort, dissatisfaction should be assessed and addressed), Body language |
| 6 | Increase in patient anxiety because of certain instruments, some of which tend to make noise (e.g., high speed hand pieces, suction) as well as may be hot (border moulding, obturation during root canal). | Behaviour shaping, Psychological counseling |
| 7 | Inability of patient is to speak for extended periods as mouth has to be kept open for prolonged period even if they have pain or discomfort. | Non verbal behaviour, Body language. |
| 8 | Patient with gag reflex feel surprised, confused and embarrassed during impression making and denture insertion | Motivation and counseling |
| 9 | Certain procedures require patients to return to the dentist multiple number of times for completion as well as follow up (root canals, complete dentures, perio surgeries etc.,). | Persuasion skills |
| 10 | Many a times in a college set up, patient does not get the expected privacy while getting opinion regarding the treatment or the treatment itself. | Non verbal behaviour |
| 11 | Esthetic treatments involving anterior teeth or full mouth involve lot of expectations which may be just or unjust since it depends on the patients existing oral condition. | Behavioural skills, Answering skills, Negotiating skills |
| 12 | After procedures like prosthetic rehabilitation (complete dentures, crowns and bridges, implant supported prosthesis, maxillofacial prosthesis etc.,) patients esthetic looks change which may or may not be acceptable by the patient, family or society. | Preliminary assessment of patient psychology, Behavioural skills, Counseling skills |
| 13 | Patient’s adherence and compliance after the procedures for success of treatment. | Counseling and motivation skills |
| 14 | Handling a paediatric dental patient and parents | Listening skills, Answering skills |
| 15 | Advising complete extraction for an young individual, advising maxillectomy or mandibulectomy for an patient) | Skill of communicating prognosis, hope and risk, Skill of breaking a bad news |
| 16 | Repeated complaints of patient after completion of treatment | Behavioural skills, Skills of dealing with patient dissatisfaction, Persuasion skills, Negotiating skills |
| 17 | Difficult patients | Psychological assessment skills, Negotiating skills |
Literature review revealed some Indian authors emphasizing about the incorporation of communication skill in dental education [14], importance of soft skills in dental practice [15] application of communication skills for dental treatment of anxious child [16], and review on the importance of patient-dentist communication [17,18]. In India, sporadic studies assessing the relevance of communication skill training on a cohort of interns and undergraduate dental students have been documented [19-21]. One of the Indian studies has emphasized on the importance of incorporation of language skill training for improving communication skill in dental students [22]. In another Indian study, role play was done for third year undergraduate students to exhibit the effect of acceptable and unacceptable communication between a doctor and patient [23].
However, studies with validated teaching methods and assessment tools exclusively for Indian population and with formal feedback or assessment during formative or summative assessments were not found. Communication skills in India are often ignored because it is not taught as a part of the formal course (in theory or practical). It is supposed to be an inbuilt attitude of a person as to how well he/she can talk to the patient. It is usually copied from seniors or teachers (role models). Relative importance given is less for the communication skill during the tenure of the course and more emphasis is given on the quota or technical aspect. A student is usually given marks for how well he can make impression or a cavity rather than how he/she communicates and handles the patient. If these points are pondered then we may be hand in hand with the ongoing research in this field all over the world.
Importance of patient’s psychology in dental set up
“The basic building block of good communications is the feeling that every human being is unique and of value.” - Unknown
The procedures in dentistry involve fear and high anxiety from the dental environment which may be problematic for the dental team in patient management. Such fear (dental phobia) may present itself as a major barrier to the uptake of dental treatment. Therefore, while administering dental services to such patients due consideration should be given to addressing such fears and inhibitions [24]. Tooth loss generates emotions similar to mourning, where the stages of denial, anger, depression, bargaining and acceptance occur [25]. Depression, stress and anxiety sometimes could result in patients who lost teeth at an early age, consider tooth loss as a major loss of their body part, have inability to cope up with societal pressure reflecting in the acceptance of dental treatment, negative life events, dissatisfaction with dentist or dental treatment and patients with low self efficacy [26,27]. Tooth loss has been found to cause significant change in one’s life ranging from dissatisfaction with physical appearance, loss of self-confidence, body image problems, social isolation or introversion, depression, anxiety, negative self esteem and self image [25,28-33]. It was reported in a group of elderly Greeks that 48% of a population did not accept tooth loss, 88% circumvented going out in public, 75% avoided talking about tooth loss with friends, and a noteworthy 77% did not converse about tooth loss with their dentist, which as a result resulted in social isolation [30]. In dentistry, patients are usually classified as according to Milus M House classification [34]. (Philosophical, exacting, indifferent and hysterical) which is usually applicable to complete denture patients. Other classifications [25] were proposed but never stood the test of time.
Analysis of patient’s psychological makeup is usually ignored in clinical practice. Dentists usually avoid this aspect of a patient’s health history as they feel that they are not trained to approach this topic or because they do not see its relevance to the dental symptoms [35]. It is essential that the dentists consider the psychological consequences of tooth loss to increase adherence to oral health care because the expectations and self-concept directly influence such behaviour [36]. Integration of training in psychology for dental students will be beneficial for students to be able to recognize patient’s reactions and counter or cope up with the same. It was reported that psychologists can be extremely useful in giving consultation in dentistry [37]. Psychologists may be employed in teaching since they may have skills not represented in dentists [1]. With the advent of Liaison psychiatry [38], a branch of psychiatry that specializes in the interface between medicine, dental and psychiatry, usually taking place in a hospital or medical setting there are more possibilities of incorporation of the knowledge of these fields.
How are they interlinked?
“Communication is a skill that you can learn. It’s like riding a bicycle or typing. If you’re willing to work at it, you can rapidly improve the quality of every part of your life.” - Brian Tracy.
The American Association of Dental Schools, 1993 guidelines recognizes core areas of behavioural science as well as communication skills in the dental program [39]. In United Kingdom, the course on behavioural sciences and communication skills was taught by dentist along with little interdisciplinary teaching by psychologists and sociologist [40]. However, there are associated challenges while integrating applied psychology with interpersonal communication skill [3]. The existing curriculum lacks do’s and don’ts in dental communication skill and psychological management of dental patients. Every patient we meet in dental office has different psycho-social needs and tailoring the communication to the patient’s requirements is highly valued [41]. Therefore, the dentist should be able to recognize basic psychological parameters such as fear, anxiety, depression and stress in the patient and deliver appropriate communication skill tool for selection of a more appropriate treatment, understand the expectations, avoid potential psychological consequences and dissatisfaction of patients. For example, in the case of a depressed patient, the dentist should exhibit a cooperative, supportive and non-judgmental attitude, and guarantee the patient that the information collected will be absolutely confidential and will be used only for the benefit of the patient’s health [42]. Various studies have reported that behavioural and effective communication interventions made by the dentist to promote self-efficacy in oral health, dental care planning leads to substantial improvements in patient’s motivation for oral care and willingness to accept the information provided by the dentist [24,43].
Conclusion
There is heterogeneity regarding communication skills and their assessment in dental training at the undergraduate as well as post graduate level in the literature. Especially in Indian dental curriculum, future work can be directed towards uniform development of communication & behavioural skills and basic psychological assessment training programs, tools to be used, method of teaching, its implementation during the training period, method for evaluation during formative or summative assessment of communication skills, and last but not the least, multisource feedback from patient, staff and students etc., to find the lacunae for further modification.
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