38.1 Patient Communication and Shared Decision-Making
Key Takeaways
- Information should be given to a patient sitting upright at eye level before the chair is reclined, not to a supine patient in personal protective equipment.
- Chunk and check means giving information in small pieces and confirming understanding after each, rather than asking whether it all makes sense at the end.
- The BRAN questions cover benefits, risks, alternatives and doing nothing, and a plan that omits any of them does not meet the Montgomery standard.
- A professional interpreter must be arranged where English is limited; using a family member, and particularly a child, is not acceptable and the interpreter's use must be recorded.
- The Equality Act 2010 makes discrimination on protected characteristics unlawful and requires reasonable adjustments for disabled patients.
A Blueprint Topic in Its Own Right
"Communication and interpersonal skills" is a named Paper B blueprint topic, and Preparing for Practice devotes an entire domain to it. Outcomes 3.1 and 3.2 require communication that is appropriate, effective and sensitive, including with anxious or challenging patients, when referring, and in difficult circumstances such as breaking bad news or discussing alcohol, smoking or diet. Outcome 5.1 extends this to spoken, written and electronic communication.
GDC Standards Principle 2 — communicate effectively with patients — turns these outcomes into enforceable professional obligations.
Verbal and Non-Verbal Communication
Non-verbal communication carries a large share of the message and is under the clinician's control:
- Position — speak to the patient sitting upright and at eye level before reclining the chair. A conversation held over a supine patient wearing safety glasses with a mask on is not a conversation.
- Eye contact and open posture, adjusted for cultural expectations.
- Active listening — allowing the patient to finish, using silence, and avoiding the reflex of interrupting to offer a solution.
- Reflecting and summarising to confirm accuracy.
- Barriers — masks, personal protective equipment, hearing impairment, language, noise from suction and handpieces, and the physical barrier of the operating position.
Structuring a Consultation
The Calgary-Cambridge framework, widely taught in UK healthcare, structures the consultation as: initiating the session, gathering information, providing structure, building the relationship, explanation and planning, and closing the session. The two most examinable elements are:
- The golden minute — allowing the patient to describe the problem uninterrupted before questioning.
- Chunk and check — giving information in small pieces and confirming understanding after each.
Shared Decision-Making
Shared decision-making is a legal requirement flowing from Montgomery, not a communication nicety. It means the clinician contributes expertise about options and risks while the patient contributes their own values and priorities.
The BRAN questions give patients a usable structure:
- What are the Benefits?
- What are the Risks?
- What are the Alternatives?
- What if I do Nothing?
A plan that has not addressed all four has not met the Montgomery standard.
Adjusting Communication to the Patient
| Situation | Adjustment |
|---|---|
| Limited English | Use a professional interpreter, not a family member and never a child; record that an interpreter was used |
| Hearing impairment | Face the patient, remove the mask when safe, reduce background noise, use written information, consider a British Sign Language interpreter |
| Visual impairment | Describe what will happen before touching; offer information in accessible formats |
| Learning disability | Use easy-read materials, short sentences, one idea at a time, and involve the person's supporter while still addressing the patient directly |
| Children | Address the child as well as the parent; use age-appropriate substitute vocabulary; Tell-Show-Do |
| Cognitive impairment | Short simple sentences, familiar environment, consistent clinician, assess capacity for the specific decision |
| Anxious patients | Agree a stop signal; give a running commentary; offer control over pace |
Using a child as an interpreter for a parent is specifically inappropriate: it places an unreasonable burden on the child, risks inaccuracy on clinical detail, and compromises confidentiality.
Cultural Competence
Cultural background influences beliefs about the cause of disease, expectations of treatment, attitudes to tooth loss and to pain, dietary patterns, fasting during religious observance, and views on who should be present during a consultation. The professional obligation is to ask rather than assume, and to document any adjustment agreed. The Equality Act 2010 makes discrimination on the basis of the protected characteristics unlawful and requires reasonable adjustments for disabled patients.
Exam link. A stem in which a patient's 12-year-old child is offered as an interpreter is testing whether you know to arrange a professional interpreter instead. Convenience is not a defence, and the use of an interpreter must be recorded in the notes.
Communication as a Regulatory Duty
Communication is not simply a soft skill in UK practice; it is enforceable. Principle 2 of the GDC's Standards for the Dental Team requires registrants to communicate effectively with patients, and Principle 3 requires that valid consent is obtained, which is impossible without it. The standards specifically require that information is given in a way the patient can understand, that patients are given the opportunity to ask questions, that costs are explained clearly before treatment begins with a written treatment plan and estimate, and that communication needs — language, hearing, sight, learning disability — are identified and met, including the use of professional interpreters rather than family members where a sensitive or complex discussion is involved.
Techniques That Improve Understanding
Several practical techniques are examinable because they appear as the correct option in a scenario. Chunk and check gives information in small pieces and confirms understanding after each. Teach-back asks the patient to explain the plan in their own words, which reliably reveals misunderstanding that "do you understand?" does not. Plain language replaces "caries", "periapical" and "extraction" with words the patient uses. Written reinforcement, diagrams, models, intraoral photographs and radiographs shown to the patient all improve retention. Signposting tells the patient what is coming — "I'd like to examine you first, then talk about the options, then discuss costs" — and reduces anxiety. The single most powerful behaviour is allowing the patient to complete their opening statement without interruption.
A patient who speaks very little English attends for extraction of a lower molar and brings her 12-year-old daughter, who offers to interpret. What is the most appropriate course of action?