Patient-centred care: how close to this are we?

1. Understanding motivations and meeting patient expectations

Understanding motivating factors and expectations is fundamental to providing high quality care. Ensuring that patients' expectations are met is a key determinant of satisfaction with the outcomes,⁹ and also enhances a patient's engagement with the clinical process.¹⁰ However, motivation and expectations are complex and developed in a number of different ways.

When starting treatment for any patient, it is useful to think in terms of the problem (or the impact), the motivation and the expectations and these may be, for example:

It is important to stress that the relationship between these three elements is not a straightforward linear relationship and many other factors play a part and mediate the motivation and expectations, for example the type of healthcare system, the influence of family and friends, cultural aspects, etc.^{11, 12} However, all three aspects need to be fully explored to ensure that a treatment plan is likely to meet the individual's expectations and, if there is any doubt as to whether the expectations will be met, these must be fully explored with the patient before commencing treatment. If expectations are not met, this may result in the patient being dissatisfied.

However Zeithami et al¹³ discussed the concept of the ‘zone of tolerance’, where small failures of expectation may be acceptable, depending on the importance of that particular aspect of a service. If the expectations relate to something which the patient perceives as being particularly important, then the zone of tolerance is likely to be smaller than an aspect of care which is not seen as having such great importance. It is therefore crucial that clinicians understand which are the key areas of importance for an individual patient.

A 2012 publication in the orthognathic literature explored patients' expectations and developed a typology classification which allowed a clearer view of some of the complex social phenomena which arose in the qualitative interviews undertaken.¹¹ The authors highlighted that, by being able to classify expectations in this way, it allows a clearer understanding of the patient and his/her expectations and, in doing so, will hopefully enhance patient satisfaction.

Motivations and expectations have also been explored in various areas of the prosthodontic literature.^{14, 15, 16} Marachlioglou et al¹⁴ explored patients' expectations of the aesthetics and function of complete dentures and compared them with those of the dentist and the technician. The patients had significantly higher expectations of their dentures than the dental professionals, although interestingly also provided higher post-treatment scores. The important aspect of this study though was the difference in the initial expectations between the patients and the dental professionals and this is an important factor in clinical practice which must be resolved by ensuring good communication prior to undertaking any treatment and by providing patients with detailed explanations about the potential benefits and limitations of treatment.

McCunniff and colleagues¹⁵ undertook secondary data analysis of four studies which had looked at patients' expectations and post-treatment satisfaction in complete denture construction. Their findings suggested that, although patients' expectations of denture aesthetics were high, their satisfaction usually exceeded their expectations. Men showed higher expectations than women, but there were no other gender or age specific effects. Whilst such findings are reassuring, the paper highlighted the importance of further research to provide a greater understanding of those factors which affect expectations and satisfaction.

Whilst clinicians have some understanding of expectations and their importance in dentistry, there is still work to be done in this area. A better understanding is needed of how patients develop their initial expectations and how expectations change during a course of treatment; a better awareness of how expectations may influence treatment outcomes is also required.^{17, 18} The provision of good information is fundamental in ensuring that patients have realistic expectations and this will be discussed in further detail in the next section of this paper. The ever-important issue of good patient-clinician communication is also key to this aspect of care.

There is little doubt that patients in all areas of medicine and dentistry have increasing expectations of the services and outcomes which can be delivered and managing patient expectations is an important issue for both patients and clinicians. A recent study looking at career satisfaction and work life balance in orthodontists found that those clinicians who said that they found it increasingly difficult to manage patient expectations, had significantly poorer career satisfaction and significantly poorer work-life balance than those who felt that they managed expectations well.¹⁹ It is therefore critical that we continue to educate undergraduates, postgraduates and all members of clinical teams in the optimal management of patient expectations; ensuring this will hopefully have a positive impact for both patients and dental professionals.

2. The patient experience

There has been an increased understanding of the importance of the patient experience in recent years and the NHS has acknowledged this by embedding patient experience indicators into NHS frameworks.²⁰ The patient experience covers a diverse range of aspects of care, including the staff and the environment, information provision and involving patients in shared decision-making about their care.

Elements of the patient experience which have frequently been found to be important include being treated with respect, being included in discussions about their own care and having kind, supportive clinicians and nurses. Recent research has confirmed that patient satisfaction is enhanced when such elements existed in their care.^{21, 22, 23, 24, 25}

The provision of high quality information also plays an important part in the patient experience and links to the previous section of this paper. Ensuring that accurate information is provided goes some way to ensuring realistic expectations and this, in turn, may enhance satisfaction. There is much information available on the internet regarding dental treatment but patients often struggle to know which information is accurate and which is not. A 2011 study by Patel and Cobourne²⁶ looking at internet-based information about orthodontic extractions found that this information had generally poor reliability (41%). It is therefore perhaps not surprising that patients attend for consultations with inaccurate information and potentially unrealistic expectations.

Nason et al²⁷ highlighted concerns about the lack of evidence base and quality control in their study investigating YouTube™ videos about endodontic treatment. A search was undertaken based on three key words: endodontics, root canal and root canal treatment and 20 videos were assessed for quality for each search term. Videos posted by dental professionals and commercial sources were found to be significantly more complete than those posted by laypeople, but only 46% of the videos were actually posted by a dentist/specialist source. The study concluded that the completeness of the videos varied significantly and encouraged professionals to be aware of the information available on the internet and to direct their patients to the higher quality information, thus reducing the amount of inaccurate information they obtain.²⁷

A similar study in the implant literature assessed the content of YouTube™ patient testimonials for dental implants.²⁸ Encouragingly, informative points were included more frequently than misleading information, but the information provided was judged to be limited, with fewer than two points of information per video. Patients were often informed that implants could improve aesthetics and function, but information regarding pain and pain control was potentially misleading. Many of the videos were uploaded by clinicians, although they were patient opinions, and the paper highlighted the importance of clinicians being responsible for the content uploaded under their name/practice name. The paper also noted the importance of clinicians being aware of the limitations in the information present when patients search online and this is an important aspect of future work.²⁸

However, there is evidence to show that, when accurate information is presented appropriately, it can be helpful to patients. Ghanem and colleagues²⁹ undertook a study to investigate the effect of a TED-like presentation (Technology, Entertainment and Design website that provides short online talks by expert speakers) on patients' willingness to accept implant treatment. Patients who were interested in potentially undergoing implant treatment completed a questionnaire before and after the short presentation and the researchers found that respondents were significantly more likely to accept implant treatment after the information had been provided.²⁹

These findings highlight the importance of the profession providing and collating high quality information in different formats and ensuring that it is readily accessible. It is also important that patients are asked how they would like information to be provided³⁰ and the advent of individualized provision of care means that patients' views should be considered when providing this information. Recent years have seen dental research into the provision of high quality information in different formats, including audio-visual,³¹ social media,³² and Apps.³³ Providing information in these ways has been found to enhance knowledge about a condition or treatment^{31, 32, 33} and has also been shown to enhance satisfaction with the treatment process.³³

However, none of these adjunctive methods replaces good quality information from dentists; instead they should supplement the information provided by the clinician. A recent systematic review investigating patient information about replacement of missing teeth showed that clinicians were the most important source of information, followed by the media, family and friends. Therefore, clinicians play a key vital role in improving awareness and knowledge about treatment alternatives.³⁴

National and international societies can also take a lead in producing high quality evidence-based patient information products; for example, the patient information provided by the American Academy of Periodontology (https://www.perio.org/consumer/patient-resources) and the information provided by the British Orthodontic Society about orthognathic treatment (https://www.bos.org.uk/Public-Patients/Your-Jaw-Surgery1). Such organizations should also consider ensuring that their sites appear on the first results page when patients undertake internet searches and this requires a knowledge of the terms which patients/members of the general public use.³⁰ This increases the likelihood that patients will access high quality, evidence-based information regarding their treatment.

A further key aspect of the patient experience is shared decision-making.³⁵ Shared decision-making is essentially a two-way process where the patient and clinician share the responsibility for decision-making and may be defined as when ‘….clinicians and patients work together to select treatment, based on clinical evidence and the patient's own preferences…….. involves the provision of evidence-based information about options, outcomes and uncertainties….’.^{36, 37} Shared decision-making has replaced the traditional paternalistic way of providing treatment and is an area which is a major focus in the NHS. The importance of shared decision-making in dentistry is highlighted in recent research in looking at satisfaction with adult orthodontics, where patients discussed that shared care had enhanced their satisfaction with treatment: ‘They involved me in making decisions… they asked for my opinion, and I felt that I'd come to the right place’.³⁸

A study conducted in both a hospital and general dental practice setting found that patients wished to have a shared decision-making role in their own care but the same patients felt that their current role was passive and they were not actually involved in shared decision-making.²² It is important to acknowledge that this research was undertaken some time ago, but nevertheless it is important that clinicians question how much they involve patients in decision-making about their own clinical care.

Shared decision-making can be enhanced by decision-making aids, which have been utilized in medicine for some time now. These aids can take a number of different formats (leaflets, decision boards, etc) and a recent Cochrane review highlighted the benefits of using decision aids; including, improved patient knowledge, better informed patients, more accurate expectations and allowing patients to be more effectively involved in decision-making.^{19, 39} Interest in decision-making aids has increased in dentistry in recent years and decision aids have now been tested in endodontics⁴⁰ and orthodontics.^{41, 42} An example of shared decision-making is given in Case 1.

3. Effectiveness of treatment from the patient perspective, with an emphasis on quality of life (QoL)

Effectiveness of treatment covers numerous aspects but one which has received much interest in recent years is quality of life. There are many definitions which have been used, including that by the World Health Organization⁴³ which states that Quality of Life is ‘A state of complete physical, mental, and social well-being not merely the absence of disease’. Dental treatment has a number of aims from the patient perspective, including pain relief, enhanced function, improved aesthetics and enhanced psychosocial aspects of life. All of these come under the term ‘quality of life’ and effectiveness of dental treatment therefore often focuses on one or more elements of quality of life. Clinicians see individual patients on a daily basis who report enhanced quality of life as a result of dental interventions and the literature publishes a wide range of dental studies looking at this area of research and showing quality of life benefits. However, the challenge to the profession is in providing high quality evidence of QoL benefits through studies undertaken using optimum quality methodology, systematic reviews and meta-analyses.

In one of the early systematic reviews investigating QoL effects in dentistry, Thomason et al concluded that there were insufficient studies in reconstructive dentistry to reach any robust conclusions regarding QoL effects and called for more studies in this area.⁴⁴ Only a decade later progress has definitely been made and this increasing evidence base is reassuring, but there are still limitations in terms of heterogeneity related to study design, inclusion and exclusion criteria, questionnaires/instruments utilized to measure QoL, duration of follow-up, etc. Overcoming some of these issues is the challenge for future quality of life research in dentistry.

It is important to acknowledge that there are now systematic reviews which have allowed more definite conclusions to be reached and these findings are encouraging. A number of these reviews and their findings are discussed below:

Whilst there are an increasing number of systematic reviews focusing on QoL in dentistry, evidence is still lacking in some areas. However, it must be stressed that lack of evidence does not mean there is no effect, rather that the evidence currently available does not allow definite conclusions to be drawn. This is one of the aspects of research in dentistry which must be a focus for the future.

Case 1

A 21-year-old patient (Figure 1) attended a prosthodontic clinic for advice regarding her severe hypodontia. The patient was given several options regarding treatment but was extremely anxious about the treatment process itself and also about the potential aesthetic and functional outcomes associated with the various options available. The potential treatment options were discussed in general terms initially and then in more detail over a number of visits. The patient was also directed to online resources where she could find out further evidence-based information. The patient's anxiety levels reduced but she still felt unable to make a treatment decision. Encouragement was given that this was not an urgent decision to make and as much time as was needed should be taken to make the right decision. At that stage the clinician also offered the chance to speak to another patient who had faced similar treatment decisions but who had now completed treatment. The clinician was comfortable that the previous patient would give a balanced, informed view and had already offered to speak to prospective patients if this was ever helpful. The two patients spoke by telephone and the potential patient asked a number of questions which she felt that the clinicians would not have been able to answer. After some further time considering the options, the patient felt comfortable making a decision on how to proceed and was ultimately very happy with the outcome (Figure 2).

This scenario highlights the importance of ensuring patients have all of the information they need to make treatment decisions and that they are not rushed into making decisions. It also illustrates how previous patients can be helpful in aiding that process.

Case 2

A 22-year-old patient attended for treatment to enhance the appearance of the maxillary incisors which were affected by hypoplasia (Figure 3) and had previously been restored with composite veneers that had stained. The patient was under the impression that she would have porcelain veneers but a decision was made that it would be more appropriate to replace the composite veneers as this would be less destructive. The patient was upset that she would not be able to have porcelain veneers as that was what she was expecting. The clinician spent some time explaining why this decision had been made and the patient appeared satisfied to proceed with treatment. When the composites were replaced, the patient was upset and clearly not satisfied with the result (Figure 4). It transpired that the patient wanted a ‘glossy finish’ and was not aware that the composite veneers would not result in the same level of gloss as porcelain veneers and she had spent a lot of time on the internet looking at images of the expected outcome.

Although a considerable period of time was spent explaining why composite veneers were planned rather than porcelain veneers, the patient was expecting porcelain aesthetics and the clinician had not been aware of this. The patient was willing to consent for porcelain veneers, accepting the risks of biological damage, and the composite veneers were replaced with porcelain, with which that patient was happy (Figure 5).

In hindsight it would have been sensible to show images of both types of veneers to illustrate the different aesthetics and also to show the extent of the preparation which would be required if porcelain veneers were undertaken. The importance of ensuring that the patient's expectations are fully understood cannot be over emphasized and all appropriate resources should be utilized in an attempt to show patients what the likely outcomes of a course of treatment may be.

4. Patient satisfaction

It is sometimes easy to assume that, if good quality of care is delivered and a good outcome is achieved, then the patient will be satisfied, but as clinicians we all know this is not necessarily the case and other factors contribute to satisfaction with treatment. The factors associated with patient satisfaction are complex and still not fully understood. This is, however, an area of research which is showing increased interest in the medical and dental literature.

There is now good evidence that the relationship between the dentist and the patient is an important factor in achieving satisfactory patient outcomes in a number of areas of dentistry, including prosthodontics,^{24, 25} endodontics,⁶² periodontics,⁶³ implant dentistry⁶⁴ and orthodontics.⁶⁵ This is an important area for all clinicians, especially when considering areas such as staff development and training. It is essential that all members of the team are aware of the importance of good communication skills, effective patient management and providing treatment in a holistic way.

Patient satisfaction is associated with a number of different factors, as illustrated in a recent systematic review of patient satisfaction in orthodontics.⁶⁵ This review separated those factors which were associated with satisfaction and those which appeared to be associated with dissatisfaction. The authors found that satisfaction was associated with the quality of the aesthetic outcome, the quality of care delivered, the patient-clinician relationship and certain personality traits. In contrast, dissatisfaction was associated with treatment duration, pain, retainers and other specific personality traits (eg neuroticism). This review highlighted the importance of ‘internal’ patient factors, including personality traits, when considering the factors which may influence outcomes of treatment.

A publication looking at satisfaction with complete dentures highlighted similar factors. A study of the literature since 2001 showed that factors affecting satisfaction included personality and psychological factors, the patient's perception of the dentist and the care provided, the patient-dentist communication and the actual treatment undertaken (implant-retained prostheses were associated with higher levels of satisfaction than conventional dentures).⁶⁶ The authors highlighted the importance of more research in this area in order to enhance understanding of how to provide the very highest quality care.

Although clinical factors, such as age, bone quality, speech and mastication, have been shown to affect satisfaction with prosthodontic and implant outcomes,^{67, 68, 69} overall the evidence suggests that patients are satisfied with fixed and removable prostheses. However, the effect of neurotic personality traits may reduce those levels of satisfaction^{64, 67, 68, 69, 70} and further research is required to investigate how best to manage such patients effectively.

Interestingly, dentists' satisfaction with the technical quality of their implant and denture work does not necessarily correlate well with the patients' satisfaction. Takeshita et al⁷¹ showed that only half of the implant cases assessed were rated as satisfactory by the dentist, but 96% of patients were satisfied. Additionally, Marachliglou et al¹⁴ found that patients reported significantly more benefits related to their denture treatment than dentists. This shows that patients may well be satisfied with treatment, despite dentists' perceptions of the outcome. This is important to consider when treatment planning, as further intervention may sometimes not be in a patient's best interest if there is unlikely to be a significant improvement for him/her.

The importance of considering personality traits and psychological factors is highlighted in this area of research and it is also important to consider the condition body dysmorphic disorder (BDD) in this section. BDD is a psychiatric condition in which there is a preoccupation with an imagined or minor defect in appearance, which causes significant distress in social, occupational and other important areas of functioning and is not better accounted for by another mental disorder (eg anorexia nervosa).⁷² In the dental context, this is typically patients who attend with excessive concern about a dental problem which is having a much greater impact on their life than would be anticipated considering the relative severity of the problem. A recent systematic review of the dental literature showed that the prevalence of BDD is 5% in orthodontics and the cosmetic dentistry population and 11% in the orthognathic population, compared with around 2% in the general population.⁷³ It is therefore possible that we all see patients with BDD in our clinical practice and should be vigilant to this possibility. BDD is of particular importance in this context for two reasons: first, and most importantly, from a patient safety perspective as patients with BDD are at risk of suicidal thoughts and suicide attempts, so any patient who is thought to be potentially suffering from BDD must be sent for appropriate assessment and care. Secondly, patients with BDD show an increased chance of being dissatisfied with the outcome of care, even if the outcome is good from the clinician's perspective. Physical treatment is rarely the best treatment option in this group of patients and, unless supported by an appropriate mental health professional, will often be associated with dissatisfaction if undertaken.⁷⁴

Recently, Bain and Jerome⁷⁵ identified the concept of patient burnout in dentistry, defined as an emotionally exhausted dental patient. Patient burnout is associated with complex treatment, high and unrealistic expectations, and a focus on treatment rather than care, with less emphasis on diagnosis and treatment planning than on performing procedures. The authors also proposed a two-way relationship between patient and dentist burnout whereby dentists exposed to a number of burnout patients may cumulate in burnout for the dentist. Patient burnout can be minimized by good non-verbal, verbal and written communication, not progressing with complex treatment too fast, under promising and over delivering and keeping treatments simple.⁷⁵

Although patients seek dental treatment in an attempt to achieve enhanced aesthetics, function, and psychosocial outcomes, the factors affecting ultimate satisfaction with the outcomes of treatment are complex and not yet completely understood. An example of patient satisfaction is given in Case 2.

Conclusions

There have been significant efforts in recent years to ensure that patient-centred care in dentistry is provided and the evidence base in this area continues to increase. There is undoubtedely work still to do though and the key areas are highlighted in this paper.

Clinicans want to provide high quality care for all patients and the vast majority of patients appear to be satisfied with the work provided for them. Based on the current evidence, patient complaints and disappointment may be reduced with the practical tips included in Table 1.