SDM PH521 Behavioral-transcript (3) PDF

SPEAKER 0 Good morning. So we're officially, I think, halfway halfway through this lecture. So we're making good progress. But we'll start today thinking about how we can apply some of the concepts that we've already learned. So this week and next week I'm considering like two parts, right? Today we...

SPEAKER 0 Good morning. So we're officially, I think, halfway halfway through this lecture. So we're making good progress. But we'll start today thinking about how we can apply some of the concepts that we've already learned. So this week and next week I'm considering like two parts, right? Today we'll learn some of the basic information about things that you might already be familiar with, but how they apply specifically to this course, how they apply to assignments, and how they apply to your application of these principles in the clinic. So we'll be looking into motivational interviewing and reflective listening for the next two weeks. Now, it's been a week since we talked about Phil, but as you might remember, Phil was my first patient. The first patient I've ever saw that was mine in the dental school clinic. And I mentioned that his mouth was a mess. Now. I quickly realized I was calling Philip or Phil the wrong name, which was definitely something that was impeding our ability to form a formidable relationship. As we think about his course and what we were going to propose, even before I mentioned anything about the specific treatment plan. But I soon learned that Phil, the reason why Phil was in the chair wasn't because he was someone who wanted to go to the dentist or wanted to have the most beautiful smile, but he had a daughter, and that daughter was about a year away from our high school graduation, and he wanted to make sure that he had a smile he was proud of by the time she graduated. I would have never known that if I didn't ask Phil, and if I didn't get to know Phil. So as we think about the context of today's topic, as we think about how we motivate folks, how we gain an approach, motivational interviewing, a big piece of it is to understand what does motivate them. So I want us to answer, what do you think is the number one source of motivation or a motivating factor for our patients in the clinic? Can be generic can be what you think. 17. Now, today we're going to explore motivation in some detail, thinking about how it can relate to our patients, how it can relate to how we approach them, how we can direct them or guide them to optimal health outcomes. But I think it's important that we start today with this question, because it's not always what we think is motivating a patient. That's bringing them to a specific health outcome or why they're in the chair. And sometimes when we ask and often when we ask and we inquire that information, it removes our own personal bias from the situation, right. When I think of Phil and Phil sitting in the chair, I thought he was in the chair because it hurt for him to eat and that he was nervous that if he bit down into something incorrectly, he would lose a tooth. I remember, you know, this is back before we were doing tons of digital dentures and other things that you're learning. In Remo. We had to take a series of preliminary and final impressions, and the faculty I was working with made sure at the time that I did it that I painted each tooth with Vaseline. The reason being, I didn't want to take out his tooth before it was time for phase one or phase two extractions. So the reason why I did this, and I put this on a word cloud today, is not for us to think very carefully about every word that's up there, right? But when we do a word cloud, typically what happens, right. There's maybe 2015 responses in certain words get bolded. Did that happen here? That's because motivation in particular, is something that's going to be very tailored to an individual's experience, and I want us to keep that in mind as we go through today, is that we can go into this with our own bias, our own ideas of what might be motivating that patient. And maybe it's pain, right? Pain's kind of in the center, and maybe that's the one that's boldest and largest in this diagram. But in pain comes across. A couple other times I see two. But the idea is that there's more than just what we might imagine as clinicians, as dentists, as healthcare providers, is motivating our specific patient. So before we dive too deeply, at least while you're still listening, because research suggests that the first five minutes I can make the biggest impact. That written assignment one is due on Sunday, right? And there are a couple things that we've had some questions, and I know a lot of you have done a really great job so far. Of looking at the FAQ, I want you to make sure that as we talk about things in today's lecture, today's lecture starts moving from collecting information from a medical history to providing counseling. So I was talking to a few of your classmates at the beginning kind of thinking, well, we realized when we started scripting things out, we were actually doing assignment two first. So assignment one focuses on collecting information from a medical history and making sure that you have every piece of detail that you need to be able to then make recommendations. Right. So that's collecting factors that will be influential to what they're actually going to use. So there was an example that one of your classmates said, well, they were talking about maybe some of the different lectures you've had this year. So maybe Doctor Penny's lecture thinking about types of toothpastes. Right. And which one has the best active ingredient to be the best health outcome for the patient? You all remember that it's been a while since I've had that lecture, but the idea is if you want to make the most impact in your communication, what do you have to ask in your eliciting information questions? What type of toothpaste do you use? Right? This assignment I should be able to know or foresee what you're going to then recommend in assignment two. And we start learning how to make recommendations today after we focus on motivation. Okay. So there is if I see or watch your video, read your paper and all you're doing is saying you need to do this or you need to make sure you're brushing in them modify based technique twice a day for two minutes with the blah, blah, blah. It's not quite what I'm looking for in this assignment, because my hope is that when we break these assignments into two parts, the first step you'll do when you meet a patient in clinic is get to know them, get to know all of the information you need so that your communication and messaging is tailored to them. Does that make sense? So thank you. So I think that when we think about those assignments, we want to make sure that we're following the rubrics. If you go back to the first PowerPoint series, it shows you how to go into the assignment tab and click on the rubric. I'm sorry blackboard kind of hides it but it's there okay. Make sure you're doing everything you need to. That includes posting requirements. A couple questions have come through there on the FAQ. I don't need you and your partner to submit your video on the discussion board, but I need you and your partner to submit the video on blackboard so that I can check to make sure it's there, and it helps me in grading. There are 214 of you and only one me greater. So make sure that your links are functioning and that your papers and work are there. Because if I have to ask you, by the time I get to your paper in the list of 214, there's likely going to be a deduction, okay? Because that takes energy away from me being able to provide meaningful feedback, which is my ultimate goal from this assignment. Okay. So I got that all out. We'll cover it a little bit again. So back to kind of today's topic. There are a series of learning objectives that are on the screen. Remember these learning objectives are the guiding forces and factors that will create your exam questions. So these are the things I want you to focus on today. There's going to be more information that what we present in these objectives as we think about motivation, how we incorporate it into our ability to then tailor and personalize our approach to patient counseling. Now. Motivation itself. And why are we talking about it here today? Is that motivation? Is our reason for behaving in a certain way. And this is a behavioral science course. So it makes sense that we're looking specifically at what motivates our patient. And I want us to keep that in mind because we know that as we consider an approach motivation, motivation needs to be tailored to each person. What's going to work for you might not work to the person sitting next to you, right? So in order for us to tailor, we need to do what we're doing in assignment one, right? We need to be able to elicit information to then find out what's important to the patient, what they currently do, and kind of what they're willing to do. What's their approach to change in order to then be able to make specific recommendations? Okay, so there's some research, but I will say, you know, research in general as it relates to patient motivation in the dental setting isn't super robust. And I think some of you have learned that through your discussion boards, one and two. Patients in general in a health care setting. Can be categorized in different ways. And we've talked about this topic before where we talked about what is your own personal style. Right. Because I think it's important not only for you to know your tendencies, but then to be able to see where do your patients fall in this gamut. So we've talked a little bit about the risk assessment, right. The risk assessment categorizes folks based on a series of questions into different categories dominant influencer compliance or steady state kind of different factors. And our patients can be oriented in some of these directions. It doesn't mean you're a true north or a true you know, you can be a combination of a D that's a leading or a D that C leading as we do this. So there's not one specific place, but I found this article which is a little bit outdated from 2007. Pretty interesting as we think about our approach. And as I've thought about the patients that I treat in private practice over the last couple of weeks. And the first style is a dominant style of patient. For those of you who have treated patients before or maybe back on apex, have you encountered this type of patient? Don't waste my time. Yesterday I had a patient in clinic and her veneers fractured. Right. She had it done maybe ten years ago. I don't know exactly what happened. I guess she went to another dentist. She used to come to us, then came back and I was talking about all the factors that could have caused this veneer to fracture, which obviously, I don't know because I've never met this patient before. But I think about, oh, we need to get you in a night guard. We need to start thinking about, is this material too thin? Should we be doing a full coverage registration? But honestly, she wanted nothing to do with that. She wanted to know what am I going to do? Her veneer over and how much is it going to cost? She was by far a dominant style patient in the room who thinks they're a dominant style patient when they go to a health care setting. One. Only one person. Two. Three. Four. Five. Not that many. Now, research actually suggests that healthcare professionals are more likely to be a dominant style patient when they're a patient themselves, because we don't have time to waste. Right? We want to get in, we want to get out, and we want to know what we're doing. Now, what's interesting about these types of patients, I think, is this, this factor about innovation, right? We go to a dental school that's very digital, and we know that a majority of dental practices don't have quite as much access to digital dentistry as we have here, right? They like innovation. And I think that when you get into your clinical care and the patient chair, there's going to be options, right? And sometimes as you think about learning about patients, as they think about crafting treatment plans, it's also important for you to think about and to know, does this patient like things that are new or do they like the tried and trusted, true version of something before we do it right? And that can factor how you do different treatment planning and how you present that as you talk to your group practice leader as you talk to your general supervising faculty. These factors actually relate to the person's own style. So as we move from the dominant style, we go to the influencing style. I'll give you a second to read kind of the types of characteristics of these types of patients. But I think if you were to guess, this is probably my style. Huh? These patients like to be heard. They're attuned to emotion and they like personal testimonials. Has anyone ever heard them say, if you were my brother or sister, mother, family member, I'd recommend this treatment. Has anyone ever said that? Have you ever heard that as a patient? Yeah. When you hear that as a patient, how does that make you feel? Pretty. I got some thumbs up. Right? It lets you connect to what's going on and humanizes what you're presenting. Right. So a lot of patients might not be true influencing style patients. They don't care if you're totally attuned to them. But because I'm an influencing style individual, I like undivided attention. I like to ask a lot of questions. I want to make sure that what I say is being heard. I'm open to what you think is best, regardless of if it's new or not. But I want to hear what you would do if I was your relative. And I want you to know what I could do better. Now, like I said, not every patient falls into each of these buckets concretely, right? It doesn't mean that they're not that. And I think that sometimes when we think about the way that we engage with and motivate our patients, it's never a bad idea to keep some of these factors in mind. Because these are the ones that are more emotionally leaning. Now this is the furthest from the type I am but a steady state patient, right? They're agreeable. They're friendly. Have we treated these people? Yeah. Of course. Lets do whatever you say. Do you think that every patient that's a steady style patient is a steady style patient in every setting? Why not? I got some emphatic no's. Why do why not? Uh. I love that. Patients who feel connected and feel like there's an established trust between the provider in the patient can go from one of these other styles to someone who becomes a true follower of that particular clinician or practice, right? If I tell patients that I know, like in our practice, and I know those of you who have been to it, maybe on Apex Alley, you can probably mention that there's patients that say they want specific providers because they feel better with continuity. And maybe those of you who have provided clinical care in the past, you're very familiar with that. And if you say, hey, you need a filling on this tooth, they're going to book the appointment in your next available slot, right? Or they might even be the patients that maybe you have an opening in your chair and hygiene is full. And then, oh, there goes the opening. You fill it with the patient that it's there already to do the procedure that day. Just because someone is a steady state patient. Some people might. This would be their natural tendency doesn't mean that they can't transition. And that really has to do with a lot of factors that we're talking about to this, to this factor. And this is something if you know that someone's really agreeable, they might be agreeable, but they're really risk averse. So if you get your first patient in the dental school and you learn, oh my gosh, they were so happy to be there, they I told them all the cavities they needed filled. And they were like, yeah, perfect. But just because they say something doesn't mean that's how they're going to follow up or act right. They may be more cautious. They may be outwardly agreeable. But we have to think about again what factors are motivating them and what can we do? To kind of move the needle forward in our desired treatment outcomes and goals. Now lastly, there's cautious patients. They're ones that are always on edge right. Do you think we see a lot of patients like this in the clinic? Yeah a lot. And I'm sure those of you who have treated or seen on apex, this is a common patient because whether you like it or not, no one tells you this when you apply to dental school. But most people aren't going to love what you do to them on a daily basis, right? So these it's more common for us to know that these patients exist, but it's important for us to categorize them for a couple reasons. I think one of the most important reasons is that with threats or with any type of approach or fear that's coming in the chair, patients can be paralyzed. They can be paralyzed by giving too many options. They can be paralyzed by the idea that they need to choose and that they're an active participant in this process. So what's the best thing to do for a patient that maybe is paralyzed by fear in our chair? Give them time. A lot of things that we think about in the dental chair, especially when you get into clinic, is going to be, well, I have to finish my data collection today because if I don't finish my data collection today, I'm not going to get my points, and then I'm not going to be able to do the filling next month that I'm going to be off track for my graduation requirements. Right? But with this particular patient, which is very common in the area and place that we work, sometimes slowing down, presenting options, giving space and space could mean a longer appointment. Space could mean doing less in an appointment to then be able to do more down the road. This is very common, so I want you to think about how we can use time as we start to categorize the types of patients that we see entry in our chair. Now, as anyone ever heard, that patient who has a dog. I know there are some of you who have dogs, right? It's no lie that owners tend to look like their dogs. Is that true? Yes. Yeah. Like, over time, I looked a lot of research. Right? So the reason why I put this here is because maybe you're one of these types of dogs. Maybe you're one of these people. But as a provider, as a clinician, as a dentist, you're going to attract naturally patients that are like you. Right. You're going to treat every type of patient because we can't say, I only want to treat that dog, or I don't even know dog types because my wife's a cat person. I'm like, okay with anything? But are you this. Are you the goldendoodle? Are you the other? You're the other type of dog. How can I make sure that my approach is going to best work? Mhm. Logical, systemic and data driven. Does anyone want to cover that question? Was it mean to be logical and data driven? When something's data driven from the beginning to the end. We want evidence. Right? So systematic. They like steps they want to follow based on what is recommended. Through evidence, whether that be literature or evidence on radiographs. They want to know why you're doing something more than everything else. Because immediately with a cautious patient, because that's what you're referring to, right. They feel that this is a threat. So if you don't give them a good concrete reason why they have to do something by showing evidence in support, they're not going to want to do it. Mhm. Good question. So as we think about now, knowing the types of styles of personalities of our patients, we have to think about how we communicate and the three main types of communicating styles. And these are directing following and guiding. Now directing. We've all been directors at some point in our lives, right? A directing style of communication is when an individual delivers expert advice, and you're going to know more information inherently about how to care for your oral health, then the patient in the chair. Almost always right. This is what we think about is a more common approach to how healthcare providers deliver medical information. And it only works best in situations like what Wanda was describing. When patients feel comfortable, when there's an established trust between them. But regardless of the fact, when we think about when we're going to provide directing information, we know that it needs to be well timed, that it needs to be personally relevant, which is another way of saying tailored to the person, right? Of value to them in their own situation and delivered in a way that's engaging. So again, I'm going to bring you back to a conversation I was having right before class. And this person may be or may or may not have oral hygiene as their in written assignment. Number one. And they're already thinking about writing assignment number two when they provide counseling. And they suggested, well, hey, I'm going to get a model and start brushing. That's a little more engaging than saying you need to brush in careful circles, 45 degrees to the right and giving too many specific examples. I want you to think about ways in which you can take that information and make it more relevant to the patient, but also in a way that they want to learn it and understand it. And it goes a long way, because often in order to do that, we have to tailor our specific message to our person, right to the patient that we're treating. Make sense? So when we think about directing style, does this seem like where we should spend most of our time when we're getting to know our patients and providing counseling and communicating with them? I see some nos. Why? Why not? Do we have to throw it away or we never going to use this? We can't throw it away, right? In fact, it's going to save you a lot of time. Once you have established trust with patients and you want to get a quick you're doing a quick hygiene exam. You don't have a lot of time. But you know, that patient, you spent a lot of time with them before. They understand why what you're doing is important and why it's relevant to them. And you can draw on that experience pretty quickly through a directing style and a two minute exam in a hygiene room. Right. Our tendency as health care providers, as learners, as students, is to favor this style. Because that's what I do to you. And I want you to start realizing that we need to move a little bit, especially in our first couple patient interactions as we get to clinic to other styles. This style is following. Now I can't possibly listen to all 214 of you first before I do a lecture. That wouldn't be efficient, right? But on a one on one interaction, we can start thinking about how we're going to integrate or think about what the patient's saying. So as you think about your written assignment scripts, as you think about what you're going to do for written assignment number one, who do you think should be doing a majority of the talking? The patient, right? Because you're eliciting information. Your job is to carefully follow what they're saying, to pull out facts, to then say, well, I'm going to ask about that, right? Now. Some providers will start with a following type of communication, but then realize it's taking too long, right? Have you ever been there? And the stories go and like, wait, why am I talking about your aunt? Right? Why are we talking about something super specific that doesn't actually relate to to what your health outcomes are, right? Or why do I know where you vacation every April? Some of these factors are still important, but we need to learn how we can think about having a following style right at the right times. And according to research, research suggests that a following style is best, especially in sensitive situations. Now, if we have a lot of nervous patients in the chair, we've learned that they're the ones that are already fear. Their approach to everything is that they're in fear. They're fighting. They're worried about kind of what we're doing. It makes sense, especially with patients, to start by listening. Right. To use that in our approach. Now, just like the assignments in this class, it was influenced by research. Our goal when we start a following type conversation is not to immediately fix the problem, right. Our goal and our goal is providers is to eventually get there, restore our patient to health and form and function. La la la. All the things that we learn in every other dental school course. But we can't do that in a single visit, right? For many of you, you might not even be able to do that in the 1 or 2 years you're in clinic, right? Probably won't for all of the things that you'd want to provide. But the idea is that you're on a direction and that you encourage the patient and have them understand that you're listening and you know that that's important. Now, this particularly works best when there's bad news. So as dentists, do you think you're going to be delivering bad news? As dental students, you think you're going to be delivering bad news? Yeah. So this brings me back to a patient that I saw in like day three of residency. So I did the AGD program before it is no longer existing. I was the last class at Bu before they did this whole beautiful expansion and renovation project in 2017. And my first patient that came in, it was like Labor Day. It wasn't Labor Day, it was 4th of July weekend and I had to do a pop ectomy because she was in so much pain. I did the perspective. It went well. The patient was out of pain. I brought her back. I took a follow up X-ray, and then I realized this tooth really wasn't restored able. And I gave her way too much hope that it was the first time that I talked to her. And that's because we took one X-ray. My assistant, bless her, wasn't the best X-ray technician. And I wasn't there to think about. Oh, should I be favoring this too much? Should I be giving her too much hope? So at the second visit, where after I did a pretty good job of getting her out of pain, I had to then say the tooth needs to come out. I didn't want to do that. And I had to think really carefully about how I was going to deliver that. And how you deliver that information can really impact the way that that patient then goes and continues to work with you. And that's a patient I treat on Tremont Street now. So when we think about directing and guiding a middle ground or directing and following a middle ground is guiding. And that's when, once you've collected enough information from a patient, you can start taking those comments that are starting to turn a corner that we don't want to go on to and push them back a certain way. This type of communication style takes skill and practice, and that's why we're working on some of these sentence starters. You've probably already thought, well, every class I come in, we start talking about what would I actually say? And that is my big goal for you as you walk out of the class, is to think carefully. At the end of this eight weeks, what are you going to say and how are you going to say it? Because we know when people work together through a guiding style, when they work in partnership, they're going to be more successful into achieving their goals. In this particular type of style is best when we talk about behavior change. Anyone have an idea why? It comes back to what we started the class with today. It's thinking about motivation, right? What are they actually willing to change? And how can we provide little suggestions to get them there? Now guiding communication style is really what I want you to think about. Is this the really reaching gold standard? What we try to get with most patients and the way that we can get there is through 3 or 4 specific factors by asking open questions, providing affirmation, reflective listening, and then summarizing. And we'll go through each one. Open questions. When we ask questions to patients, especially when we start and we get ready to start listening, we don't want to ask a closed ended question. Does anyone know what I mean by a closed ended question? Yeah. Tell me. Yes or no questions, right? Those are conversation enders, not conversation starters. Right? It doesn't count if you ask a question, do you brush your teeth twice a day and they say no. And you're like, well, I listened, right? I want you to think about how you can ask questions that allow them to explain their own lived experiences, right? Because you want to know what they actually do so you can understand how they work, what motivates them, and then guide them to a specific behavior change. It's okay to ask questions that really allow individuals to reflect and think about it. But you don't want you want to make sure that those questions are delivered clearly and without any judgment. Right. Because we've talked about this even in class one, when you ask a judgy question, how does it make you feel? Or a question that could be interpreted as judgy, even if you don't mean it to. It's going to shut a patient down when the goal of asking open questions is to open them up so that they'll talk more, so you get more information, just like written assignment number one, to then be able to provide the counseling tailored to them. The second seems a little like why is this second right? We want to be encouraging and offer affirmations. This is when we acknowledge what the patient's currently doing. This could mean if you know you have a busy patient that maybe is a single mother, has two kids, is making time to come to the dentist, and it's really hard for her to get there. And even though she's 20 minutes late, she's there, right? She drove an hour and a half or two hours to get there to do what she was supposed to do. Sometimes acknowledging these, and what research suggests is acknowledging this and providing an affirmation to realize you recognize someone's efforts, even saying you did a really nice job keeping this area clean. In between our temporary visit and final segmentation of this crown. Little comments like that can go a long way to start establishing trust, encouraging perseverance, maintaining your report with your patients, report with your patients, and really demonstrating that you're reflecting on what they said, which ultimately suggests you know what they're listening to and what they're doing. Now. Reflective listening is the third step, and reflective listening goes beyond just listening to what the patient says. But using this kind of confusing diagram that can be summarized pretty easily, right? What you hear is not always what the speaker is saying, right? If you take your own voice and you record it and you put it into one of those like bots online, and then it speaks in a different way, the same message that you're saying based on your tone and inclination can be totally changed, right? So in order to ensure that what you're saying is heard and interpreted from a patient's perspective and really from yours in the same way, is to consider this circle of reflective listening, in which you're making sure you create space and time for that individual who's doing the hearing, to then be able to repeat and understand and summarize what you're learning. So it's a cycle. I hear that you're saying, this is this kind of what you meant, or is this reasonable to say? And we'll see some examples of this in the next couple of weeks, specifically as we start thinking about populations that are more vulnerable or populations that we want to provide even more care, attention and detail to. And that leads us to our last point, which is part of the reflective listening process, is once you've collected the information and maybe you've summarized what they said, it's important for us to then be able to summarize comprehensively what that individual is thinking, right. What are the takeaways from that visit for you, and how do those takeaways move the needle to where we're going and how we're motivating and bringing the patient back to do kind of what we're thinking we need them to do. Now as we think about these approaches, these are all strategies. We're building your toolkit of what we're going to use in the approach that you're going to use as we start thinking about moving towards providing patient counseling. Now, when we provide counseling, there's a approach that research suggests is the best way for us to then understand and deliver our motivation in a way that a patient can then relate to and put into practice. And that's the elicit, provide, elicit method. Right. So in this method we first want to know what they know which again relates this isn't a discrete concept to anything else we've talked about right. We've talked about listening to the patient first. We've talked about understanding what motivates them. And that's the same piece of this counseling model, right. Where we start looking at what the person knows. Then we make sure we create space to see if we can provide information, right? This is when. What type of toothpaste do you use? Oh, is it okay if I start talking about like, maybe the different types of toothpaste that might be best for you based on what's in them? And then it's providing that information after you have an agreement, when you provide that information and then saying, what did you take away from this? How does this work for you? And this model really relates to a lot of the different factors that we've been talking about on how we can best communicate with our patient. So I don't want you to think I'm only doing a guiding style here. Right. But doing a guiding style often includes everything that you see on the screen. Right. Listening, providing. Redirecting. Shaping the conversation so that you can then explore someone's response to what you're providing or what you're saying. This again comes down to that reflective listening, creating intentional space. And that intentional space is going to allow you to better understand, better assess, and think about what's going to work personally as you tailor treatment plan or an approach for a patient. And that's through this idea of motivational interviewing, which I know you've learned about in other courses this year. When we think about motivational interviewing, we need to make sure that everybody understands that this message is personally relevant and that there's trust established with the doctor for this to be effective. In all of the steps that we've talked about so far in the first three and a half weeks of this course are ways to establish and build trust. And when we establish and build trust, we can then get to the point where we're finding out, we're asking questions. We're eliciting, providing and eliciting information. That then allows us to tailor a specific treatment plan. And there are four principles of me. And a lot of these motivational interviewing principles are things we've already talked about or words that we've explored. The first we won't dive into much deeper, but that we're expressing empathy because we've already learned at the very beginning of this course that being empathetic is the number one, research driven approach to building connections with patients and actually moving the needle and behavior change. The second is develop, where the discrepancy occurs. This is not designed to say I am right, I know where you're doing something wrong, but rather finding a specific gap in someone's information, knowledge or approach that can be addressed or that you can target, and how likely they be able to be. To think about how these gaps or changes relate to their specific goals that, again, are tailored to their own experience and what they want to do to change their behavior. So once you express your empathy, you develop where in this process there is any type of discrepancy. You then can understand that you're going to have to roll with resistance. Have you guys heard this term before? Yeah. From preventive class. Right? When we think about rolling with resistance, you think you're going to be resisted here? Yeah. Yes. I think I can with this. Did I do it right? Yeah. So developing discrepancy just means what does the patient think or what are they doing that doesn't align with their specific goals? There's something right. There's a piece of the puzzle that you want to do this, but you're doing that. I gotta change the. That to get you to what you want to do to get this. So you have to figure out exactly what are the pieces of the puzzle that they're missing. Because you tell me you want to have beautiful teeth. You want to be able to go to your daughter's graduation. You want to be able to live till you're 110. But these habits, these activities, these approaches aren't getting you there. And you have to figure out the more specific, specific the specificity that you provide and you're developing discrepancies going to allow you to better tailor counseling. So in your medical history review of your assignment one. Right. What's your topic? Smoking cessation. So it still is, right? Because it's the whole topic, this whole class. Right. Smoking cessation. You look and see, well, does this patient want to quit if the patient doesn't want to quit? We got to talk about this right. Because we're going to have to roll with them not wanting to quit. And that's very common. But we have to develop what was their specific goal. They want to be as healthy as they can be or they want their teeth to be. They don't want their gums to bleed anymore or other factors that are associated on that list. Well. We know that smoking actually prevents a little bit of bleeding, but it can cause periodontal disease, right? So it's a little not great of a cell. But what we can do is think a little bit more about how that behavior of smoking is getting in the way of making sure that they have the healthiest mouth that possible. Right. So your discrepancy is your actions don't align with what your value and goal is. Makes sense. Cool. Anyone else have questions about that? Yeah. Mhm. Mhm. Mhm. Mhm. So did everyone hear that question. You can only develop discrepancy on a patient that's in contemplation phase. So what do we know about contemplation phase. They're thinking about it, right? They're not, like, totally unaware of it, but they're ready to make a choice that fair. It's not really. Mm mm. Who agrees with Wendy? She's. She's been. She said, I think each phase has some discrepancy involved with it. Each phase. You agree? Okay. We got some wisdom coming from the front. What do you think? Other people agree. I think if we think about relapsing right, there's this one discrepancy there that's very obvious right. When we think about action right phase. Maybe not as much discrepancy because we've addressed it. So that cycle, that theory of what we're using is still guiding a lot of the terms and influencing what we're doing. It's important, again, to collect the information. And I want you to think about the trans theoretical model of behavior change as a way to identify where a person is in that cycle, because once you know where a person is in that cycle, if they're in total maintenance phase, are you going to spend a lot of time building discrepancy and understanding what they're doing wrong to fix it, identifying that factor that might not get to their goals? No right. But if they're in contemplation phase, they're thinking about it. You're probably going to spend more time understanding what's in your way. What's your pros cons list, right? What is actually the things that you're weighing? What information can I provide? And then this is what you say you want. Well, if this is what you say you want, we really should be weighing that heavily in your in your pros list. Does that answer your question? So I think that it relates and that's where everything's kind of umbrella under different topics. And really for this course, this is probably the last session that we provide new information to you. Once we provided this we're going to start piecemeal, seeing all of the different ideas and concepts from different lectures into what this looks like in practice and how it can influence your work in the treatment center and beyond. Right. Which is our goal. So resistance. We're going to see some examples and we'll practice that. But then we have to do this. And we started this class talking about self-efficacy. Right. What selfefficacy again. Nobody. That's not good. I know you've had a couple tests since then, but you should still remember what self-advocacy is. You all wrote about it. It's the factor that says I. Can do it right. So the final factor of motivational interviewing is making sure you're supporting your patients to understand they can do it. And remember when we ranked all of these different psychosocial factors in week one. And a lot of you put self-efficacy is number one right. Is that fair to say. We did a little poll pretty much. Was that self-efficacy we want to support for our patients so that we can tell them, encourage them, let them know that we believe we believe they can do that right. And when we support, they can do it. And we give them hope, which essentially is what optimism is, right? We're going to help move them to where we want them to go, or to guide and facilitate a specific behavior change. Right? So before we do this, we just have to take. You guys are going to love this based on your reaction to the video last week. But we'll do a quick attendance I know. And the rest of the class. You won't listen to me quite as much. It's 45. I'm going to leave it up till 48. It's on the main screen. We're taking attendance, so get in there. SPEAKER 1 I don't want to meet emails. Oh, you could hear me when I did that, huh? It's just. SPEAKER 0 Software. What's that? All right. SPEAKER 1 Y'all. Mhm. SPEAKER 0 Across the board. All right. Give me a second. It's going away because there's a software. I'm going to try something different. Okay. SPEAKER 1 It's like so. Mhm. Would. You like to. SPEAKER 0 Try it now. Did anybody get through or. No. Oh, you got through. SPEAKER 1 Okay. So. SPEAKER 0 Work for you. Come to the front. I'll get your names. Okay. I'm going to put it to the side too, but I'm going to play a video in a second. I think I muted this image. SPEAKER 1 There. SPEAKER 0 So. Before I maybe start kind of what we're doing, we're going to see two different examples for the remainder of class and doing a lot of talking to the person sitting next to you. This person doesn't need to be your partner for an assignments. The idea is that there's not a ton of really exceptional examples of this online. And I know that last week when we saw the video, there was some laughter. You'll probably get some laughter with the accents here. But the idea is, I really want you to think about what she's saying. SPEAKER 1 What? SPEAKER 0 But we're going. We're going down under, if you know what I mean. SPEAKER 2 Hi, Josh. Great to see you. How's everything going with you? SPEAKER 3 Yeah, fine. Thanks. SPEAKER 2 Great. Okay, so before we get started, are there any changes to your medical history, such as any new medications you might be taking or any serious operations since the last time I saw you? SPEAKER 3 Um, no, not that I can think of. SPEAKER 2 Anything worrying you about your teeth or gums? SPEAKER 3 No. Not really. SPEAKER 2 Okay. So what would you like me to do for you today? Would you like me to simply do a checkup, let you know what I find, and perhaps help you to have a healthy mouth? SPEAKER 3 Yeah. Checkup sounds good. Sure. SPEAKER 2 Okay. Let's lie you back. There is some decay in one of your lower molars. So unfortunately, Josh does look like you're going to need a filling. I would like to try to help you so we can determine just how you got this new hole. May I ask you a few questions so we can avoid it from happening in the future? SPEAKER 3 Can't you just put a filling in it and just fix it? SPEAKER 2 It sounds like you're keen to get healthy. I like your practical attitude. The new feeling will fix this hole, but it won't stop new holes from occurring. As I said, I really would like to try to help you so we can avoid you having to get any feelings in the future. On that note, it would be really great to try to get to know what you've been eating and drinking. SPEAKER 3 Look, I know I've got a real sweet tooth. I don't need you to talk to me about that. SPEAKER 2 You obviously know yourself pretty well. Thanks for this helpful information. SPEAKER 3 Look, I know it's bad for my teeth. Can we just get this feeling done? SPEAKER 2 You're right that it's bad for your teeth. Could I possibly give you any more information? SPEAKER 3 Yeah, sure. SPEAKER 2 The bacteria actually use the sugar that's in your mouth to create acids. And it's these acids that eat through the tooth surfaces to cause holes. So you could say the more the teeth are coated in sugar, the more likely it is that you're going to get holes. If we're able to chat a little bit more about your diet, I might be able to help you so that we can reduce the risk of you needing fillings in the future. SPEAKER 3 I don't really want to chat about my diet right now. Can we just get this feeling done? SPEAKER 2 Okay, it sounds like you're not ready to chat about this today. Is it okay with you if we have this conversation at some point in the future? SPEAKER 3 Yeah, sure. SPEAKER 2 Okay, great. I'll make sure I make a note it's okay with you next time you come in, where we left off today. You've got a lot really want to overwhelm you. Some people in your file, and then if we might be able to pick up in your mind, and I don't actually like to jot down the sorts of things they've been eating and drinking and bring it into the next visit. Or I've actually seen some really great apps on smartphones where you can record this sort of information really easily. It's up to you, of course, I'll leave it to you to think about. SPEAKER 0 Remember that I said I didn't want to make robots, right? That's not a goal for this course or what we're thinking is definitely some ideas that felt a little robotic. I want you to turn and talk to your someone sitting near you. What worked well and what would you do? So I heard some good things. So now, as you can imagine, this whole experience, this Australian example, right, is prefabricated. She's trying to follow a specific model. And this creates a little bit more of a robotic approach. But I heard a couple of things. A couple people did. Some like little eye rolls. They said that this patient didn't want to know more. Right. And how many times did she ask? More. More than she. More than she should. You all feel really strongly about that, huh? Really strongly. So I had a little bit of a communication thought. Right. And the communication thought was that does all communication with a patient need to be verbal? Gabby said no really fast. She probably said it fastest. Why? Gabby? SPEAKER 4 Right. If I were the patient, I'd feel better if I. SPEAKER 0 So there's a point when you need to feel heard. And that's what I'm hearing from Gabby, right? If we push too far. And I heard that in the back of the room, too, right? If we push too far. Someone said I would get annoyed. If you were the patient, would you be annoyed? This lady was persistent. And you see her eye contact. Her eye contact was good, right? Eye contact can be a very important piece of this nonverbal communication, right? How we hold our body, how we facilitate ourselves. If we stood there and said, I'm going to tell you about it. Right. And I heard a little bit of that down here. This body language is much more closed. Right. And when we have it could feel offensive. Is that what someone sent you. SPEAKER 1 Said. SPEAKER 0 Defensive. Right. Like I need to tell you why. And that comes down to things we just talked about. Right. When we talked about how we need to create space to provide. So we look at that elicit, provide, elicit model. Right. What does it ask you to do in the middle there? You say, hey, can I. SPEAKER 1 Talk to you a little bit about. SPEAKER 0 This and. SPEAKER 1 See? SPEAKER 0 And if a patient is resisting you, we move right into that idea. That's not part of that elicit provider listen model. But we roll with the resistance. Oh, I heard you right. I don't I understand that that's something you don't want to talk about today. We'll circle back on it. Right. I'm not going to continue to poke because if I continue to try too hard, that might not work. Now, I mentioned something that I want to pose to the class. As dentists, we are uniquely able to make our patients captivated listeners, right? Because when we're working on them, can they talk to us? So I wonder. And again, this comes back to establishing trust in providing trust for the patient in a comment I got in the back is you can't assume that then because you're doing what they asked you to do, you can create that space, but you can say, hey, when I'm working on you, mind if I just talk about a couple different things that might be helpful for you to know, talk back because, like, what did you say? Especially with the rubber dam. Okay. They can give you a thumbs up. Thumbs down. What did we talk about in one of these styles? Like how to make it engaging? I don't know if like talking to them about how cavities form, which I think she actually did a pretty good job of here. Right. And I think a lot of patients have misconceptions about how cavities form. So that's why sneaking it in is important to this overall message and kind of what we're getting across. Right. But finding the right space and asking, right? Because when you overstep as a provider, do you think that establishes trust? Builds trust. And I get what she was trying to do because she's following this model. But I don't think for a majority of my patients that kind of. Three times approach to the same question would be a successful. And for many of you, I think if you were the patient, it probably wouldn't be successful for you either, based on what I've heard. So we're going to move from one accent to another. Okay. And we're going to look at this second example. SPEAKER 5 Okay, so why don't you have a rinse, David? How are you feeling? Okay, good. Here, take a look. See what you think. That feeling and the colors. Okay. You know, there is quite a lot of staining, so, um, I'm just wondering about, um, some concerns about smoking. Possibly going to get that again. Coffee? Tea? Yeah. You've heard this before, I'm sure. Above you. Um, so, you know, the smoking is going to be related not just to some of the other negative consequences. You know, physically it affects dental caries, dental cavities. Yeah. Um, healing. Yeah. In your mouth. Okay. Sure. SPEAKER 6 So I've heard it all, but I just want to get my teeth fixed. SPEAKER 5 Yes. And I really want to be helpful. I really want to, you know, my commitment is to your oral health. So there are lots of medications out there, David, that actually take away a lot of the cravings. They're they make quitting so much easier. SPEAKER 6 So I did try it like I did try and I just did the pills and they didn't work. Um, did was it was a waste and it caused more side effects. No. SPEAKER 5 But David, it's not a waste. Research shows that people take, on average, about seven tries before they quit smoking. So think of it as your one step closer to quitting or seven. SPEAKER 6 Lectures along the road. SPEAKER 5 Well, I don't think I'm giving you a lecture. I'm certainly not what I meant. SPEAKER 6 I know, I just feel that way. I get really I get very defensive about it when they because I get it from my family doctor, my cardiologist, everybody. Like, I'm not a complete fool. I am for smoking. SPEAKER 5 Well, there's there's a reason that people are concerned to quit. No, but as I said, these medications. So you've tried the medication, you've been willing once. Then can I write you a prescription for the medication? Can we talk about how you could use it? Because this is something that that's very important, not just for your overall physical health. Yes. SPEAKER 6 I got to really want to. And things I've tried usually caused me more problems than they helped. SPEAKER 5 Oh, no, the smoking is going to cause you more problems than the than anything else. I can promise you that, David. The side effects from the medications are nothing compared to what can happen from the smoking. Like that's the I think thing to really consider. SPEAKER 6 Okay, well, can I go now? SPEAKER 5 I'm okay. But you know, I know. SPEAKER 6 What I know, I know, doc what you're trying to do. I just don't want to get into that right now. SPEAKER 5 Okay. Well, thanks for listening. And honestly, I am really worried about the smoking, so. Okay. I appreciate. SPEAKER 6 Your care. SPEAKER 5 I'm here to help. Okay? Okay. SPEAKER 0 So I heard something. I had a great conversation in the middle of the room, and they were saying that both videos push to person, right? True. We agree. Would you be here in this room if you were not pushed? As providers. Do we need to push our people? SPEAKER 1 A little bit. SPEAKER 0 I got a little bit. That was a nice I was saying that a little bit. If we don't push someone or they ever going to change usually no. Sometimes. Yes. Right. There's other factors than just us influencing patients behaviors. Right. It could be what they see on Instagram that TikTok, the other stuff. Right. What they see could actually influence their behavior in a totally different way. That has nothing to do with us. Right? Because if you watch one of those videos of someone getting scaled on one of those platforms, you might say, oh, I don't want that to happen, right? Or motivate someone to get to a chair. But I think that both videos and I think what I've learned is that pushing is important. But both of these videos didn't break down the way. I want you to think about communication, communicating with your patients as kind of separated by the two assignments, right? In this video, she's providing some counseling at the same time as she's collecting information. Right. Because I heard someone say, well, the patient didn't talk much. Right. Would you agree in either of these situations? Now, is the patient supposed to talk a whole bunch when you're providing counseling? I heard some yeses and some nos. Who's right? No. So when we provide counseling, it's our job to use that model, right, of saying, okay, I'm using motivational interviewing, I'm ready to provide my counseling. I've asked them I create space. It's really that provide element of the elicit provide, elicit that is your main counseling component. Can I talk about this? Can I direct you how this works? And then can you repeat to me or tell me kind of what you've learned from what we've talked about. Right. Which is that follow up piece at the bottom. In the actual counseling portion, which is your routine assignment. Number two, the provider should be talking a little bit more because they should be providing context and specific tailored counseling based on all the stuff they learned in the first part of the assignment, which is when we elicit more information and more information that's available on a medical history. Right? You're all going to get a medical history form when you enter clinic for your patients, and you're going to have to go through each question. But sometimes these questions and what I hope that you realize through this whole assignment, is that the information we collect on that medical history is not enough to provide meaningful, tailored counseling for every patient that fills out the form. Right. So before you can do anything to provide counseling, I think personally, but, you know, I'm biased to my own approach, is that if they had collected information first, say for this man that was a smoker, what's a piece of information that would be super important to provide counseling based on what he said? He wants to quit. Okay, that's a piece. How long ago did. He tried to quit. Or when do you do the pills? Right. Because as she went into it, she didn't really know that he had done that based on her reaction to that comment. Right. Her reaction right away was like, well, you know, it takes seven to blah, blah, blah times to actually quit, which is actually a nice piece of information, right? But if she flipped the script a little bit, right. And this video doesn't have like an exemplar version of what exactly we should do. But if she flipped it to create space to first know that he'd done this before, she can be more empathetic in her approach and her delivery of that actual, really interesting piece of information, right? Because that promotes optimism, right? It promotes self-efficacy. If we take a second and share. Oh, like, I understand you've tried this before, but you're not alone. It really takes x to x number of times for individuals to quit. That is letting the patient feel heard, right? Which I think from my conversations and what I heard is that that's a big problem in some of these videos, right? Is that the patients not getting out what they want before we're actually telling them what they should want. So as you go through different assignments, as we think about what we're doing, as we think about where we're going or how we're moving, kind of first I want you to think about what information can we collect before we start providing counseling, because if we don't provide counseling in this pattern collection, first ideas later, we can come across with that judgy we can come across like we're not motivating. And that often based on the conversations and things I've heard can shut a patient down. So just like how I promised every class we will have a test question. Here's your test. Oh, jeez. Sorry. Don't yell at me. SPEAKER 1 I'm trying my best up here. Okay. SPEAKER 0 I don't know why. There's two ways. SPEAKER 1 Okay. SPEAKER 0 Who's right? Which one's really wrong? So whenever you take you guys have. You're very smart students, right. So usually in multiple choice there's ones that are really wrong. Which one's the really wrong one. See you think b b because B's not one of the communication styles we learned, right? Okay. So cross that out. Which one's the second most wrong. SPEAKER 1 Ay ay ay has the. SPEAKER 0 Second most amount of votes. So let me move this. When we think about kind of when we're if we're directing. SPEAKER 1 Right. SPEAKER 0 We're telling we're. We're the cruise ship director, right? When we're following we a passenger. When we're guiding, we're like, you know, the copilot. Copilot? They're doing it together. SPEAKER 1 Okay. SPEAKER 0 What was this doing? Following. Okay, now my intent by asking you multiple choice questions like this is this is one of the harder ones on the exam. It's for you to be able to. It's like this. It's not the same thing. So don't quote me. The idea here is not necessarily that I need to make sure I know this is an example of following is I want you to be able to realize when you're having these conversations. Am I guiding? Am I directing or am I following too much? Because all of these different factors need to be in equal weight to be equally as successful, and we need to move towards guiding because we know that that's the most effective. But often in order to get there, we need to use other communication styles. Okay. All I got for you is your assignments due on Sunday and have a good weekend.