Tumultous times, tough conversations: the Internet’s influence on communication

Pat Mc Bride, PhD, CCSH, discusses how the online world can affect the orthodontic practice

The Internet and social media has forever changed the way we obtain and use healthcare information for ourselves and our families. It is commonplace for dentists and orthodontists to have made significant modernization in their offices to utilize website and social media platforms to educate, engage, and attract patients. The downstream effect of these changes means that the quality and style of communication and information “pushed” out to the public has significantly more intrinsic influence on patients’ perceptions about specific dental issues, possible therapy interventions they may want or need, and the skill set of the dentist or orthodontist in particular.

With just a few clicks, impressions from images, content, or posted reviews can modify patients’ decisions or shift perceived credibility in a provider or a treatment plan that has been discussed or already embarked upon. Not surprisingly, the largest proportion of patients using the Internet to obtain dental and orthodontic information are urban and suburban dwellers versus rural patients. This issue of inequity remains a universal problem across most of medicine and dentistry, and is not mitigated simply by income, but also by access to Internet services and quality care demographically and geographically. Doubtless, this implies that providers in urban or suburban areas will be more heavily impacted by and have more challenges dealing with patients empowered or in some cases viewed as entitled by online health information, blog commentaries, reviews, podcasts, and misinformation. Gone are the days when patients and families acquired “intel” from friends, relatives and neighbors about their local care providers.

With the Internet, information comes from all angles, at high speed, from multiple, and often conflicting, sources. There is no end to what people can find if they dig deep enough. It is like watching multiple channels on multiple screens, all at once. Trying to digest too much information at once can be stressful and overwhelming to most individuals. Orthodontic treatment is lengthy, and the path can be bumpy as difficulties can arise throughout treatment concerning adherence to protocols, patient and parental expectations, communication breakdowns and misunderstandings, possible switching of providers, social anxiety, and concerns for temporary facial changes by the child, and a host of other possible issues. Unless the practitioner becomes the communication leader, the door is open for questioning, concerns, and doubts. Now more than ever, it is essential that the practitioner and patient create a relationship of collaborative trust and open exchange before, during, and after treatment.

At its very best, the Internet has the potential to be one of the very best self teaching platforms, as long as the information accessed is appropriate, creditible, and verifiable. The easy availability of dental and orthodontic treatment information is not an issue per se; the real dilemma is the authenticity of the information. “There is no system introduced on the Internet to check whether information is reliable or not. Patients don’t check the source or authenticity of content, and a big chunk of online information isn’t regulated. The common user believes anything they read online.”¹ This can lead to confusion, anger, loss of credibility for the dentist or orthodontist who may not agree with the information the patient considers to be accurate, and/or failure to meet patients’ expectations based on the information they’ve acquired and believe is 100% correct. There is no means available for balancing the dichotomy of information and opinions.

With just a few clicks, impressions from images, content, or posted reviews can modify patients’ decisions or shift perceived credibility in a provider or a treatment plan that has already been discussed or embarked upon.

Also, the information can be incomplete, based on insufficient scientific evidence or misleading, particularly in regard to online support groups, where sensational anecdotes and unbalanced views are common.² As evidenced by a recent  television news exposé on the failures of an adult expansion appliance for sleep apnea, parents of young children were misled into believing that all pediatric orthodontic devices should be FDA approved. The sensationalization of the reporting and massive Internet blogging led to many anxiety-ridden and sometimes hostile calls to orthodontists across the country from parents fearful that their children were being harmed by treatment — that their child was not actually undergoing.

Internet and social media use by patients, and parents in particular, affects professional and parent communication and relationships bidirectionally “by leading to more equal communication between the patient and provider, and harmonious relationships on the one hand, and increased switching of providers, and suboptimal interaction between the patient and provider on the other.”³ So, it can be a bit of a minefield for providers.

Providers and patients are increasingly caught in the crossfire of miscommunication in the prevailing battle between traditional orthodontic treatment plans which include extraction and retraction treatment provision, and the rapidly growing movement of providers who embrace whole-health dentistry. Whole-health orthodontics focuses on airway development, quality sleep and breathing, improved overall functioning, and robust brain and body development to improve the trajectory of every child towards achieving their optimal potential.

Internet blogs, podcasts, and websites providing conflicting information does empower patients and families, but it also creates a lot of communication chaos. Empowerment can be a double-edged sword as we all know. Knowledge empowers patients to ask comprehensive questions and make decisions with better understanding of the risks and benefits of any particular treatment. On the down side, it can be confused with entitlement which places the providers in the uncomfortable position of defending their methods or treatment recommendations to the patient. This disempowers the entire concept of collaborative communication.

Regardless of whatever camp you are in as a provider, communications with your patients across all areas of dentistry and particularly orthodontics under the influence of the Internet is challenging. An understanding of some of the hidden obstacles to transparent and collaborative communication can help ease anxiety and provide a solid foundation for potentially tough conversations. For example: everyone knows that thousands of patients have sought clear aligner treatment — online with no dentist involved — for a few hundred dollars rather than seek the care of qualified professionals who will safeguard their dental, occlusal, and periodontal health while aligning the teeth.  Why? Because those individuals don’t want the hassle of dealing with “going to” the dentist — it’s cheaper, gets mailed to the door, and saves time. On the front end, that’s absolutely correct. On the back end, it’s like the patient who declines a necessary root canal. When it all goes sideways, the bite is off, or periodontal issues develop — they’ll be back, and it’ll cost a whole lot more to undo the damage.

Or, what about the child in expansion therapy whose parents read in a mommy blog about “this great other” appliance for their child? They announce without understanding how it actually might affect their child’s clinical issues or treatment, that “this is a better way to go,” then try to direct a major change in treatment plan, expecting no change in costs for treatment already in place for several months. You’ll be running towards the fire extinguisher to put out your hair.

Every provider wants to be “that someone” people come to see and obtain treatment from. Communicating well through obstacles and barriers may very well help your practice thrive even if the conversations are difficult, contentious, or stressful. Understanding there are some general barriers running across most demographics including the disabled and underserved may help in planning and executing meaningful conversations.

It should be no surprise that regardless of how much information people acquire, there is always fear of the unknown. They may not know you, or whether you are there to supply a wide variety of treatment options or only “what you do.” There is a general mistrust of healthcare providers post-COVID, which no amount of education and reassurance can completely assuage. Cost or perceived costs compared to others may force a conversation where patients demand justification for fees. Or, patients may have conflicting opinions obtained from previous provider consultations or from conflicting ideologies/methodologies they have read or watched online, through podcasts and blogs. How can you reassure them that what you say and offer is valid for them personally, even if a previous provider told them, for example, that early intervention for their child has no merit? There will always be concern for “What if it all goes wrong? Or wrong, again?”

Unfortunately, when people have had harmful prior treatment or no treatment, foundational anxiety may subconsciously make them want to direct care. This is when real empathy and honesty from you and your staff is paramount. If the patient’s issues are beyond your skill set or confidence, honest assessment of your ability to help may be an initial disappointment, but appreciated in the end. There is no shame in admitting that you don’t know what you don’t know, cannot or will not do what you do not do, and hold whatever beliefs you have to be true.

What about the question of time? Time or the lack of it, or patients’ sense of entitlement to it can be a real deal buster. A patient/family who has an hour or longer consultation, then goes home and fires off an email with 50 questions requesting immediate, detailed reply because they feel entitled to it, is going to take an inordinate amount of everyone’s  time. Boundaries regarding communications in all forms need to be set. Your office must have a written protocol regarding communications of this nature that the patients must agree to from the start. It can also be implemented with existing patients to help control the floods of emails into the office. The protocol should include what is appropriate content for an email, how to be clear and identifiable to protect privacy and follow HIPAA guidelines, who in the office will be reading and or replying to emails, and when a charged online additional consultation may be required to answer detailed or lengthy questions.⁴

The Internet is a remarkable thing, and the beauty of a well-educated dental or orthodontic patient or parents is that the flow of information can be as easy or hard as everyone wants to make it. Use that number one skill you have — listen, listen, listen, then reply with honesty and empathy to all questions. Allow that there can/will be disagreement in philosophy or desire, or plan, and decide collaboratively if what you offer and how you offer it is in sync with the patients’/parents’ expectations, ability to commit to, pay for, and understand. If parents are uncomfortable or unwilling to accept your observations, allow for a graceful exit, offer other resources such as referral to specialist pediatrician, ENT, or sleep medicine MD if appropriate.

Remember if a child is the patient, including them in every aspect of the conversation that is appropriate to their  development and understanding is also crucial. They are, after all, the ones going through treatment, and must be on board. Allow for time to digest your thoughts and treatment plan prior to asking for commitment. Encourage second or even third opinions if parents seem unsure. If your team is relational and not transactional, it will allow for everyone to be sensitive to needs both expressed or unexpressed of all concerned.

And finally, you need not be a casualty of Internet and social media over-consumption by patients and families. Educate where you can, clarify where you must, and always do what’s right for them and for you. If you do so and communicate in a way that quiets the “noise,” you and your patients will be in a great place to move down whichever treatment pathway is best for all.