Managing patient expectations: The threat perspective

Summary: A patient with unmet expectations leaves your office unsatisfied and tells everyone who’ll listen. They don’t come back, or worse, they come back time and time again in pursuit of the unattainable. And in the worst cases, they take their dissatisfaction to a higher power. When you’ve done everything you can to provide stellar service, this is a tough pill to swallow. Here, we discuss what a recent perspective in healthcare can teach us about managing the perennial problem of unrealistic expectations.

A new perspective on an age-old problem

As a dentist, you’re undoubtedly no stranger to the patient with unrealistic expectations. According to a recent survey conducted by Septodont, this patient group continues to represent one of the most challenging for dentists to manage. A significant number reported treating such patients as one of their least favorite aspects of the job. 

You’re following all the accepted wisdom for managing expectations: you communicate, you show empathy, you try to build rapport. And yet certain patients still insist on the unachievable and end up dissatisfied. Why? The answer might lie in what happens before the patient reaches the chair… 

The journey of the unrealistic patient

Excluding routine care, a patient is usually moved to make an appointment with you for one of two reasons: 

• They’re experiencing pain, discomfort, or inconvenience. 
• They’re unhappy with a particular aspect of their smile. 

In either case, the patient is already feeling some level of distress when they initiate contact. Between then and the moment they reach your chair, many pivotal things can happen without your input. 

By the time you see your patient, they’ve already had multiple points of contact with your practice. They’ve looked up your details, booked an appointment, checked in with your reception team, sat in your waiting room, and perhaps chatted to your staff. 

It sounds fairly straightforward, doesn’t it? However, a 2019 editorial in the British Journal of Medical Practitioners (BJMP) offers a very different perspective on this experience.

The threat perspective

Authors Crisafulli et al. describe how these innocuous touchpoints represent a series of psychological threats for healthcare patients. These so-called “lock-in” situations are those in which a patient feels compelled to comply to achieve the desired care, but feels their sense of control or autonomy is challenged as a result. 

In a dental setting, these “lock-in” situations might include:

• Spending time trying to get in touch with the practice. 
• Experiencing a long wait time for an appointment. 
• Having difficulties scheduling appointments around their other commitments. 
• Navigating a complicated check-in system. 
• Having to deal with a rude or dismissive staff member. 
• Being kept waiting past their appointment time.  
• Having to wear PPE and follow infection control guidelines. 

Seemingly minor on their own, these situations can add up to create a patient who feels a significant loss of personal control. Combine this with the vulnerability surrounding any dental procedure, especially one necessitated by pain or poor self-image, and it’s easy to see why some patients are primed for dissatisfaction before they even reach the chair. 

When they do, Crisafulli et al. cites several further potential threats from the patient’s perspective:

• The patient does not perceive the provider to be acting in their best interests. 
• The provider does not answer the patient’s queries adequately. 
• The patient feels undermined, ignored, or judged. 

This is not to suggest that you’re guilty of the above! But in the absence of clinical knowledge on the patient’s part, they are prone to make assumptions about your motivations and rationale. The more ‘threatened’ the patient feels, the more negative those assumptions will be. 

So what happens when you have to deliver some unwelcome news and bring that patient’s expectations in line with reality? 

According to Crisafulli et al., psychological threats activate coping mechanisms like retaliation against the healthcare provider to regain control. In the dental setting, this might manifest as rejecting your clinical judgment, resisting compromise, and “rebelling” against your recommendations. In other words, refusing to have their expectations managed.

Mitigating threats in practice

Beyond the obvious advice – communicating clearly and building a rapport – the threat perspective offers some useful ways to approach patient management.   

1. Proactively acknowledge and address “threats”

Some of the “threats” described by Crisafulli et al., such as waiting times, are inevitable to an extent. Others, like the training of clinic staff, are well within the dentist’s control. Address the latter, and be open and honest about the former before your patient has a chance to feel their impact.

2. Actively solicit input

Not all patients will feel confident directly questioning or disagreeing with your treatment recommendations. To avoid a scenario where your patient outwardly agrees with you and inwardly seethes, make it clear that you want and value their input by asking questions like:  

“Is this in line with what you were aiming for? Or would you like to hear some other options?”  

“I know that you were hoping for [specific outcome]. How do you feel about [alternative outcome]?”

“Do you have any reservations or concerns about this approach?”

Encourage them to ask questions of you too, so that you can reassure them and correct and misconceptions.

3. Give them some breathing space

If the patient is feeling overwhelmed, they may not be in the best state of mind for a conversation about changing their expectations. You risk them doubling down to re-assert their control, or feeling pressured to agree with a treatment plan they’ll later resent. Let the patient know that they can go away and process your conversation, then discuss how to move forward at a later date.

4. Use the repeat-back technique 

When a patient has their heart set on a particular outcome, risks and limitations present yet another threat that they may seek to “tune out”. Should they materialize, the patient is left feeling blindsided and will often hold you responsible.

To avoid this, have your patients repeat key points back so you can confirm their full understanding and address any dissonance. For example:

“When I say [possible risk/limitation], can you tell me what that means to you in your own words?”

Follow up with:

“How likely do you think that is?”

5. Be receptive to feedback

Despite your best efforts, there will still be occasions when a patient feels their expectations haven’t been met, clinical or otherwise. With threat mitigation in mind, create a culture in which they feel comfortable discussing this with you, as opposed to taking their concerns to social media or regulatory bodies.

Actively solicit their feedback at multiple touchpoints, like your website, social media, and even a good old-fashioned comment box in the waiting room. Every time a patient enters your office, ask them if everything has gone well for them so far. At each point, communicate clearly that you value their feedback, accept it in a non-confrontational manner, and ask them how they’d like to see the situation resolved.

Managed threat = managed expectations?

Managing this barrage of potential micro-threats obviously won’t change your patient’s expectations around the treatment outcome itself. However, it may make them more receptive to your attempts to manage them. 

When it comes time for you to push back against an unrealistic expectation, it stands to reason that you’ll have more success with a patient who feels safe, empowered, and informed. 

Common wisdom aims to achieve this by improving chairside communication, but it fails to address the cumulative dissonance that can happen at many points in the patient journey. Unfortunately, it only takes one such event to color the entire experience, so it’s well worth considering how these threats can be mitigated in your practice.