Word of mouth with Paul O D’wyer BDS MSc (Healthcare Mgmt)

In some recent literature, Campbell and Tickle (2013) in the UK, explored reasons why patients chose to attend their dentist. They found that the top three reasons for attending a particular dentist were: trust, access and cost. Importantly, these three factors were in that order. This seems fitting and proper. As a profession that can, on occasion, be invasive (e.g. surgical extraction), this idea of trust is central. Access comes a close second – with many practices adjusting their opening times to facilitate those at work in 9-5 jobs. With a full employment statistic in our workforce, appointment times can prove a challenge for working patients. And finally, cost – which, for general practice, assisted (to a limited degree) by both DTSS and PRSI in general practice. For specialist practice, the medical insurers can also help defray expense and reduce barriers to attendance.

Over the past number of years, we have seen medicine, dentistry, opticians and pharmacists like other professions, become tinged with shades of commercialism – somehow attempting to translate a health service into a product. It’s important to draw a distinction here: a service is something you do for someone, whereas a product is something you sell someone.

The population at large has become accustomed to moving service providers: think electricity, phone, home insurance etc. This leads to the following question: are we, as a society, chasing the lowest cost, the most convenience, the best service or the highest quality? Are those things mutually exclusive or can they be achieved simultaneously? Or are we as a society, prepared to withstand poor service or suboptimal outcomes for convenience and lowest cost? Is there a danger that the budget airline model is seeping into healthcare? And if so, which of the parameters is most affected: cost, convenience, service or outcome?

In the past, this column has looked at issues surrounding patient care – in particular, ways in which we can attract and retain patients. Ultimately, the “Friends and Family” rule applies. Simply put, it means that we all aim to provide a service that we would provide to our friends or our family. Dentists do this instinctively and this is reinforced during dental school.

We also know that “word of mouth” is the most potent form of advertising. Typically, people will still ask their own friends (or family) about which dentist to attend. Recent surveys suggest that, like Campbell and Tickle, most people respond with “… Dr. XX is a great dentist, very gentle and I got an appointment really quickly…” You’ll notice that the cost/fee is not mentioned in the first responses. Cost can appear on subsequent probing/questioning – but usually it’s level of service/outcome, and ease of access – and ultimately: trust – that is the main driver.

Dentists the length and breadth of Ireland pride themselves (quite rightly) on their clinical skills and abilities. They also ensure that they have adequate opening times and after care for their patients. Yet more will go that extra mile for their patients – often undertaking post-operative phone calls or even domiciliary visits for long-standing patients of their practice. Dentists position themselves in the best location to provide the best service – relying on their high quality clinical outcomes, best patient care and accessible opening times to encourage attendance.

In thinking about specialist practitioners it can, however, prove even more challenging to ensure patient attendance. There are more hurdles for patients to jump. Specialists are dependent on referrals from general practitioners. If it’s a complex bridge, a raging periodontitis, an extra mesio-buccal canal in an upper 6 or an infected wisdom tooth – these can require specialist treatment. Specialists, like general practitioners, are almost exclusively sole traders – and unsalaried. However, the specialists’ ability to attract new patients is severely limited due to the very nature of their specialised work – usually one course of treatment and then discharge. A referral letter (or email) is usually a pre-requisite for medical insurance companies to cover costs associated with specialist treatment. And therefore specialists are totally dependent on this physical referral to treat patients.

With that in mind, the drivers involved in referring these patients are not unlike the choices facing patients choosing a dentist. What are their clinical outcomes like? When can I get an appointment? And finally, is it expensive?

Importantly, these specialist Prosthodontists, Periodontists, Endodontists and Oral Surgeons are often a vital resource for specialist advice and counsel for busy dentists. Ease of access, swift appointment times and predictable clinical outcomes all play a key role in specialist selection. Most specialist practices have adapted to the ever-changing world we live in – and some are fortunate to understand and facilitate speedy appointment times. Some are fortunate to have had experience in general practice to better appreciate and respond to the ever increasing demands of treatment needs.

As clinicians we have an obligation to demonstrate the clinical values we hold. To show that a healthcare service is not a health product. Just as we pride ourselves in general practice on our proven predictable clinical outcomes, level of service and committed patient care, these too should be the drivers to specialist selection – rather than easy parking, short journey or the very lowest fee. I don’t seem to recall those as being clinical indicators for the treatment of complex bridge work, gingival recession or infected wisdom teeth? Crucially does the specialist referral pass the “Friends and Family” test?

We are all practitioners, dependent on our patients to attend for treatment, allowing us the ability to showcase our patient care and clinical skills. Trust, access and cost are drivers for every level of service – both in general practice and specialist practice.