Funnels and Fear

How to Use Principles of Ethical Persuasion to Increase Your Case Acceptance Rate

In dentistry, a low case acceptance rate is a tragedy. Not for the doctors–we can always do more consultations or work longer hours to make up for an anemic acceptance rate. No, the real victims in this tragedy are our patients. When we recommend a treatment, it’s because we know it will make the patient happier and healthier and save them money in the long term. When we do a lousy job presenting our cases, we have a whole crowd of patients who will be unhappy and unhealthy, and they’ll be paying big money for that privilege. Learning how to use the principles of ethical persuasion in your case presentations is essential if you want to provide the best possible care for your patients.

Cialdini 101

Dr Robert Cialdini studied how salespeople, speakers, and leaders ethically persuade their audiences and summarized his findings in his first book, Influence: The Psychology of Persuasion. The six principles of persuasion, according to Cialdini, are liking, authority, consistency, scarcity, reciprocity, and consensus. These principles are universal, cross-cultural, and ethical. They make sense to people around the world, and they depend on honesty.

These methods of persuasion aren’t intended to trick people into making bad decisions. They simply help us make good choices more obvious via effective use of verbal and nonverbal communication. By applying these principles in your communication strategy, you increase the odds of people choosing your practice, accepting your treatment plan, and holding up their end of the behavioral and financial bargain.

Today, we’re going to focus on just two principles: scarcity and consistency.

The Truth About Scarcity and Case Presentation

The principle of scarcity is rooted in the idea of loss aversion. We’re more likely to take a risk to avoid losing something than to have a chance at gaining something. This is why products on will often include the tag line “Only five left in stock, order now!” Sellers know that if we’re thinking about buying that umbrella stand some day and it’s always in stock, we may never buy it. Conversely, if it appears that the stand might sell out, we’re more likely to snap it up just in case. So when it comes to the scarcity of loss, here’s the truth: If our patients knew what we know—that not moving forward with our treatment recommendations today will cost them more time, visits, pain, and money—the majority would prefer not to let that happen. They would find a way to reprioritize our recommendations and not delay treatment.

When a patient listens to you presenting treatment, he or she begins with the mindset that the scarce resource is money. They’re primed to say no because every treatment has a price, and they’re more averse to losing their money than they are inspired by the idea of recovering their health. Our goal is to get them to a place where they recognize the benefits of treatment and judge our presentations based on their medical issues, not on cost alone. To do this, we must change what they perceive to be the scarce resource in the conversation.

As clinicians, we know the resource that’s truly scarce isn’t money—it’s health. To get your patients to reframe their perspective and shift their attention, always start by acknowledging the option that seems to have no cost (although in truth it has one of the biggest costs): the “do nothing” option.

Let’s imagine that a patient named Ms Smith came into my office missing a tooth. I could begin my presentation of her options by saying, “Ms Smith, your first option, as always, is to do nothing. On one hand, that route won’t cost you anything right away. However, with a missing tooth, you’ll lose bone in your jaw, your teeth will shift, and you’ll start having trouble chewing, which could lead to further tooth damage and loss. The future treatment of these problems will cost you X dollars at today’s prices.” Suddenly Ms Smith’s attention has shifted. Now she’s motivated by scarcity—the risk of losing bone, teeth, and the ability to chew, and having to pay significantly more down the road to fix the problem—all the things we know are going to happen. By reframing her perspective, I have turned a dental need into a dental want. Now she’s in the right mindset to discuss her options and to consider my advice for solving the problems we see today.

Preparing for Consistency

The principle of consistency describes the natural human desire to match our actions with our public statements. No one wants to be viewed by others as being inconsistent or hypocritical. When we make statements about ourselves and our intentions, we strive to make them true. To use this principle in our case presentations, we must first encourage our patients to recognize and acknowledge that they value their long-term oral health today.

In my own practice, I start this process before patients even step into the operatory for the first time. My new patient questionnaire includes the question “When it comes to your oral health, do you prefer to be a proactive or a reactive person?” Most patients choose to describe themselves as proactive because it places them in the best possible light. When the time comes to present the case, I then remind them of their commitment to being proactive by saying, “On your new patient survey, you said you like to take a proactive approach to your health, is that right?”

Once the patient repeats their commitment verbally, I can refer to their preference as we discuss their options for treatment. When I lay out the consequences of not accepting some form of treatment today, a person who committed to being proactive would behave inconsistently with their stated beliefs if they chose to do nothing. In this way, I set the stage for them to choose one of the treatment options that will address the problem in a proactive fashion.

The Paradox of Choice

Studies show that, first and foremost, humans need choices. Without choices, people aren’t really committing to taking any kind of action. So, for the principle of consistency to work, the patient needs to make an uncoerced choice and commit to a course of action. That choice must be spoken or written in a public forum and, ideally, accompanied by a physical or monetary sacrifice in order to secure it. When we combine all of these factors in our case presentations, we have a powerful tool that can turn our patients’ dental needs into dental wants. When they decide that they want treatment, our patients are more likely to accept our recommendations, book appointments, make payments, and follow through on the treatment we’ve laid out for them.

This concept of giving patients choices, in the form of more than one treatment option, often presents the biggest hurdle for many practitioners. We feel strongly that there is one “correct” treatment option, and that is what we present. When given just one option, however, the patient feels backed into a corner with no control over their situation. That frustration tends to lead to denial of the problem or procrastination in addressing it, and the result is that they don’t return for treatment. One option is never enough—we have to present at least two options in these scenarios: the “do nothing” option followed by the consequences of choosing that, and then your “ideal” treatment scenario to tackle the problem today. By structuring our presentations on this two-option model, we give the control back to patients. They don’t feel pressured or cornered and are more likely to say yes to our ideal treatment scenario.

So where is the paradox? It is that the more options we present our patients, the less likely they are to choose any of them. As they are given more options, people lose the ability to distinguish between them, which creates questions or doubt in their mind and usually results in their leaving without committing to any form of treatment. Yet ethically, we have to present multiple options. Let’s go back to the example of a single missing tooth. Typical treatment options include doing nothing or replacing the tooth with a removable partial denture, a fixed bridge, or a dental implant with abutment and crown. With all of these options to choose from, how do we help our patients overcome the paradox of choice?

The Consistency Choice Funnel

To help our patients properly differentiate between our options and commit to one of them, we must create what I call a consistency choice funnel. How does this work?

First, we need to identify one important feature that distinguishes each option and be prepared to present those features in the form of a two-option question. So, using the earlier example, we can start by identifying the biggest difference between the first two options—that is, the removable partial denture versus the fixed bridge: The bridge stays in the patient’s mouth whereas the partial comes out. Then we state it as a two-option question. “Ms Smith, we’ve reviewed all of the options to replace this missing tooth along with their pros and cons. Let’s take the first option: Do you want a solution where the dental appliance goes in and out of your mouth, or would you prefer one that doesn’t leave your mouth?”   

If Ms Smith chooses the fixed bridge, then I continue up the treatment option ladder and help her differentiate between the fixed bridge and the implant-supported crown. Obviously there are several important distinctions between these options, so to narrow them down to just one, I think back to how the patient answered the value question on the new patient questionnaire. For this illustration, let’s imagine that conservation, or limiting dental work on teeth that remain functional, is what Ms Smith expressed. “For the fixed bridge versus the implant option we spoke of earlier, both of these solutions stay in your mouth, but there are some big differences. For the bridge, we would have to cut down two good teeth to put three teeth in the area of the missing tooth, whereas the implant can be placed between the existing teeth and we wouldn’t need to cut them down.”

If Ms Smith selects the implant option now, it is after I have ethically educated her, reviewed the pros and cons of each option, and helped her make an informed decision. By offering patients two-option choices to help differentiate each treatment option, we funnel them down into selecting one of our treatment options and solidify their commitment. The good news is, I often find that this process influences patients to select my ideal option. Ultimately, however, the purpose is to prevent them from being overwhelmed by information, so regardless of which choice they make, they will leave in better oral health than when they entered.

The key is to respect their decision—this is how we keep ourselves on the ethical side of the line. We’ve outlined the options, reviewed the pros and cons, and really helped our patients understand the differences in the choices and allowed them to choose a plan that they committed to every step of the way. And with each commitment made, they are more likely to follow through and get it done now rather than later.

My goal has always been for every patient to leave my practice in better oral health than when they arrived. If they do nothing, then I’ve failed in that endeavor. Take some time and retool your case presentations to turn your patients’ dental needs into dental wants. Apply the principles of the scarcity of loss and people’s desire for consistency in their actions and you’ll see your acceptance rate skyrocket. You’ll be able to help more patients leave in better oral health than when they arrived and make your role in case presentation a more pleasant one.