Risks and Benefits with Patients

Episode #568 with Dr. Lee Brady

Every dental procedure has risks and benefits. How well are you communicating them to your patients? If you're unsure or don't know how to get started, don't miss this episode! To empower you with risk communication, Kirk Behrendt brings back Dr. Lee Brady, director of education for the Pankey Institute and founder of Restorative Nation. She shares her insight for managing patients’ expectations, reducing fears around procedures, and helping patients take ownership over their decisions. To learn how to advocate for patients through your communication skills, listen to Episode 568 of the Best Practices Show!

Episode Resources:

• Dr. Brady’s website: https://leeannbrady.com
• Dr. Brady’s Facebook: https://www.facebook.com/drleebrady
• Dr. Brady’s social media: @drleebrady
• Restorative Nation: https://restorativenation.com
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Main Takeaways:

Learn how to communicate risks and benefits.

Be mindful of what constitutes a risk for your patients.

You have the gift of time. Slow down your conversations.

Focus on risks and benefits that are most relevant for patients.

Advocate for your patients by giving them information and education.

Quotes:

“I think about all of my communications with my patients as being about risks and benefits. It’s the core of patient communication. And often, as dentists, we do think of that as a technical thing, like one procedure has certain technical risks over another one. But I actually think it’s a much bigger conversation than that because, for my patients, they think of the cost of one procedure over the other. One might be a risk or a benefit. A common one is how long it takes for a procedure to get done. So, with implants, we want all of our patients to do implants. And sometimes, they still ask about doing what we would call an old-fashioned bridge. Well, one of the benefits to a bridge is, chop, chop, you're all done in three to six weeks, where implant dentistry sometimes takes six to nine months. To us, we go, ‘Well, that's a no-brainer.’ We want the best thing, technically. To a patient, that may be a tipping point decision.” (3:26—4:24)

“Some people consider any surgical procedure a risk, no matter how much we tell them it’s easy and straightforward. Or the discomfort. There are a whole range of things that we can put in our risks and benefits box that actually are more tied to the logistics of the dentistry for the patient, or the emotional side of it for the patient, than they are about the stuff we learned in dental school.” (4:27—4:50)

“For me, if I need an informed consent, that says to me that I don't trust that patient, or I don't think they trust me, that there's something inherently not right about our relationship. And then, the question I ask myself is, ‘Should I be doing significant dentistry on a patient that I'm not in relationship with, where we don't have that really solid foundation?’ So, it’s a different way of looking at it. But I kind of grew up at the Pankey Institute, and a lot of what I learned there was about patient communication and individualized care, and that piece of it.” (5:18—5:57)

“Every patient that I talk to, we discuss risks and benefits of, not every possible technical solution, but the ones that would be relevant to them, the ones they're most interested in. We go through the technical risks and benefits, the time, the money, the procedures. And then, I document that in their chart that we had that conversation. But I don't have them sign it that I documented it. With that said, I don't do really complex surgical procedures in my practice. I can see where in some practices, depending on the types of procedures that you do, you could totally make a different choice. And that would be okay with me. I think you've got to do what makes you feel comfortable. If having them sign a form makes you feel more comfortable than not having the form then, by golly, you should be doing that. In my case, the form makes me more uncomfortable, so I don't do it. I think that's the great thing about dentistry. We get to make those choices.” (6:32—7:33)

“I tell people all the time, you can have anything you want. The reality of it is, you can pretty much have anything you want around how you could practice dentistry. And whatever you design, now you have to ask yourself, ‘What am I going to have to do to get it? What are the costs of doing it?’ And often, the cost is you're going to produce less if you work fewer days a week. Or sometimes, it’s funny, you don't. You think that'll be the cost, and the reality is you produce just as much, or you produce more because you're more focused on the days you're in your office. Or if you're actually having a good time, you're enjoying yourself more, you're going to be more productive. But it’s always a give-and-take. It’s always about, there's stuff on both sides of the scale. You've just got to say, ‘Am I willing to give this up to have this?’ But it’s a gift in dentistry that we get to do that. We get to design our lives.” (12:51—13:49)

“That's success, when a patient comes in and they have ownership around the choices they made for themselves based on the options we give them. It wasn't at all about what I'd said. The part to celebrate was that he got, ‘I chose to do this, and I knew what the outcome might potentially be. So, now I'll go back, and I'll make a different choice.’ It’s hearing that somebody has that kind of ownership that makes me want to celebrate, that I'm actually getting better at communication. I'm actually learning how to do this better. It’s taken a lot of decades, but I'm getting there.” (16:07—16:51)

“If I don't do a comprehensive exam, however you define that, if I don't look for all the risk factors — and I don't know what all the risk factors are that the patient has, whether that's technical risk factors, or I get to know them and it’s something that's going on in their lives right now, or whatever it is. But if I don't own those risk factors, I certainly can't have a conversation with them about that. So, it always starts there. And I tell dentists this all the time, and I actually believe this, any time I have one of those uh-oh moments in my dental practice, what I know is there was a risk factor someplace that I didn't uncover on the front end, and it cropped its head up and it showed up in my life.” (17:59—18:53)

“One new learning for me this morning was, this is a patient who’s at the very end of a three-and-a-half, almost four-year treatment plan. Guess when we discussed fees? Three-and-a-half to four years ago. You have all these big, glorious conversations about your treatment plan, and here’s what everything is going to cost, and you lay it all out. And so, one of the things that I realized this morning is, when you start to do this kind of dentistry that spans some time, because it’s interdisciplinary or it’s very complicated, one of the risk factors is — and there are two. I think there are two pieces of this puzzle. One could be that you get to the very end of a treatment plan, and your teeth are looking good, and they're feeling good, and you sometimes forget why you were doing all this in the first place. So, it’s possible that the value proposition, for him, isn't quite what it once was for these last little steps.” (19:39—20:44)

“I wonder if we need to do, not really a new case presentation or a new consult, but for these long cases, if periodically we need to schedule a check-in. The patient and I check in together and catch up, like, ‘Here’s what we’ve gotten accomplished, and here’s what's still ahead of us. Let's talk about the logistics for what's ahead of us, what's still to come,’ so instead of there being a four-year gap between the execution of some pieces in the conversations about that, it’s closer in time so that it doesn't get lost someplace. So, those are risks and benefits. There are big benefits to doing complex dentistry and interdisciplinary care at a dental level and at a patient level. And one of the risks is you can't remember those conversations, always, for four years.” (20:57—21:56)

“One of the pieces of this that took me a long time to get is that they're not my teeth. They're actually the patients’ teeth. It’s the patients’ health, and they are the patients’ choices. And I love that word, that my job is to be their advocate. At a beginning level, my job is to help the patient have the information that they need to be able to successfully make their own choices.” (23:01—23:33)

“I always hesitate to use the words “information” or “education” because sometimes I think we put way too much stock in it in dentistry. And I'm really clear that having the information does not move someone to action or change someone’s behavior. However, if you don't have the information, you have no option for changing your behavior or for making another choice. So, there's a level at which the information is foundational. So, the patient does need to understand the current conditions that are going on in their mouth. The patient needs to understand what their choices are. And in my case, I would say they need to understand the risks and benefits of those different choices, including choosing to do nothing. There's a certain set of risks and benefits to choosing no treatment. And then, once the patient has that, then my job is to support them in that choice. And then, ultimately, the third piece of it is if I'm actually the right person to execute the treatment they choose. Then, my job is to now put my technical hat on and actually execute that care or the phases of the care that would fall into my purview. But, exactly, it’s the patients’ choices. I think that's a better way to think about it for the patient. And I also think it's a better way to think about it for us as the caregiver, as the practitioner.” (23:35—25:05)

“One of the things that I thought in the beginning when I started to learn about a different way to practice, I really had this picture in my head of, ‘I'm going to do these new patient appointments that take two hours or longer. And then, the patient is going to go away, and I'm going to sit down, and I'm going to spend an extended period of time reviewing all their records. And then, the patient is going to come back, and we’re going to spend however much time together talking about all of this. And then, of course, they're going to absolutely want to do everything I recommend. And then, it'll all move forward.’ And first of all, my experience is that model actually doesn't work that way, always. Some patients, it works great. They're ready to make a decision at that first consult or treatment planning. Some people aren't. They need time to process.” (26:01—26:53)

“In dental school, unfortunately, we were taught, ‘Do an exam. Present the treatment plan. The patient says yes.’ You know what? That model works awesome for some procedures. Like, if you said, ‘What percentage of the time does that model work when they need a simple occlusal filling?’ I'm hoping the numbers are reasonably high. If I said, ‘In the average practice, how often does that model work if they need a single crown?’ I'd also expect your numbers to be reasonably high. I can remember a time in my practice where for scaling and root planing your numbers wouldn't have been really high because, at that point, the general public wasn't very knowledgeable about gingivitis and periodontitis. Today, when you tell somebody that they need a deeper cleaning, or whatever language you use, my guess is your numbers are pretty high because people start with a base understanding and a base desire. I mean, the reality is, if they're in our practices, they care about their teeth.” (27:37—28:40)

“One of the things I think we forget in dentistry is we have the gift of time. We have the gift of time. We get the opportunity to see the same patients over, and over, and over over an extended period of time. So, the whole conversation does not have to happen in one appointment. This conversation can be an evolution. I actually think it’s better that way. I actually think it works better if you don't ask the patient to eat the whole elephant in one appointment. Give them a chance to get some information, go home, experience some things for themselves, come back, and then deepen that. So, you're right, you have to spend a little bit more time. But that time could be divided up over a pretty big number of appointments.” (29:02—29:54)

“If you're going to be with the patient and have a conversation with a patient, for that conversation, however long it is, 60 seconds, 120 seconds, five minutes, can you be fully present with that person and actually, in that conversation, get the most out of it so that when that one minute, two minutes, or five minutes is over, the patient has a different level of ownership and understanding about whatever it was you talked about, even if it was one tooth or one old filling? And if the answer is yes, then we’ve moved the ball forward. If the answer is no, in truth, to me, you wasted two or five minutes that could've been super important in your relationship with that patient.” (29:57—30:42)

“What does dentistry need to look like for you to love it, for you to really be empowered and engaged? I know dentists who have come to my practice, and they’ve observed in my practice, who walk away and go, ‘I could never do this this way.’ And I'm like, ‘You know what? That's awesome learning. That was worth you standing here for however many hours, seeing how I do it, to walk away and go, this does not fit my personality. It doesn't fit my philosophy.’ I happen to have a dentist that's a super good friend that I've known forever. He sees probably three to four times the number of patients on any given day than I do. And he does it because he loves it that way.” (31:44—32:25)

“If you're going to try to change your practice, change it slowly. Do not derail a high-speed train because it will not get you to the outcome you want.” (33:08—33:19)

“When you pull up to the office, if you actually have to sit in your car for a minute to get yourself prepared to go in, my intuition is there's something about what's happening in your practice that you might want to evaluate and say, ‘Could I do it differently?’ so that you're not sitting in the parking lot going, ‘Okay, I can do this.’” (34:41—35:02)

Snippets:

0:00 Introduction.

3:06 Risks and benefits, explained.

5:01 Why Dr. Brady rarely does informed consent.

7:36 What Dr. Brady learned after returning to dentistry.

13:51 Get better at communicating with patients.

17:17 Risks around not remembering fees.

22:39 Your job is to advocate for your patients.

25:34 Slow down your conversations.

30:49 Have it your way.

35:34 More about Dr. Brady’s online courses and Restorative Nation.

Dr. Lee Ann Brady Bio:

Dr. Lee Ann Brady lives in Phoenix, Arizona, with her husband, Kelly, and three children, Sarah, Jenna, and Kyle. She owns Desert Sun Smiles Dental Care, a private restorative practice in Glendale, Arizona. Outside of her private practice, Dr. Brady is the Director of Education for The Pankey Institute, recognized for hands-on education programs focused on occlusion and restorative dentistry. She is the founder and lead curator of Restorative Nation, a supportive learning community for dentists.

In 2010, she was recognized by Dental Products Report as one of the “Top 25 Woman Dentists in the U.S.” in the category of dental educators. In 2005, she joined the non-profit Pankey Institute as their first female resident faculty member. Within a year, she was promoted to Clinical Director, and held this position until November of 2008. In 2008, she was asked to join Dr. Frank Spear in the formation of Spear Education and the expansion of his curriculum. As the Executive VP of Clinical Education at Spear Education, she managed the development and delivery of all programs in addition to her teaching responsibilities. In 2011, she left Spear Education to focus more on patient care and hands-on education.

Dr. Brady earned her D.M.D. degree from the University of Florida College of Dentistry. Being a lifelong learner, she dedicates countless hours to studying and understanding occlusion, restorative dentistry, and dental materials performance. She enjoys researching and teaching these clinical disciplines, as well as patient communications, case acceptance, and team development. She is passionate about solving complex cases, understanding the needs and concerns of her patients, facilitating the success of colleagues, and helping dentists find balance in their lives.