I recently spoke with a Dentist regarding a case that had been referred to me for symptoms of Cracked Tooth Syndrome. The patient had a mandibular molar tooth with a subgingivally fractured disto-lingual cusp that I removed during my initial examination. The depth of the fracture and the extensiveness of the previous restoration suggested that elective endodontics might be required prior to crown restoration. Furthermore, in order to have proper biologic width and a manageable crown margin in the fracture area, crown lengthening would be necessary prior to restoration. I offered to refer the patient to a Periodontist, who just happens to be in my building. In that way, we could possibly coordinate the appointments so that procedures could be performed concurrently, under one local anesthetic. This would be more convenient for the patient, would save the patient a second visit and minimize treatment/recovery time. The referral said the he did not want the patient referred to a Periodontist because he resented having the patient "passed around" from one specialist to another. He implied that once specialists got involved with the patient, he lost control of the case. I was shocked at the response. I said that I would be happy to return the patient to him after I had completed the endodontics and that he could proceed as he wished. I put down the telephone and wondered what could have possibly happened to this dentist to convince him that referral to a specialist was a "liability", something to be avoided if possible.
After 17 years of specialty practice I find that referrals' attitudes generally fall into one of two groups:
1. In the first group, the referral is made with the tooth indicated on the referral pad, the appropriate boxes checked and one or two paragraphs written on the slip (or better yet - an E-mail note/letter and photo/radiograph). The planned restoration is clearly indicated and restorative treatment has been discussed with the patient prior to referral. (Frequently there is a phone call and 'heads up" when the patient is difficult, requires TLC, can't open wide etc.) The referral regards the specialist as an integral part of his treatment team. He wants to provide as much information as possible even though it may take him or his staff a few extra minutes to provide it. He does this because he understands that this time is profitably invested. This few minutes of time investment is returned many times over when the patient returns, ready and eager to complete the suggested restorative treatment. Furthermore, this dentist is open to suggestion by the specialist. Is the opinion of another specialist indicated? Is there possibly a better way to treat this patient? This attitude DOES take advantage of the resources offered by the specialist to reinforce the referral's modified treatment plan and to help him sell the Generalist's treatment plan. The patient gets the best treatment possible because of this team effort.
2. The attitude of the second group is totally opposite. The referral is made by circling a tooth on my referral pad and writing one brief line saying " Please do endo on tooth #X." There is no indication of the restoration to be placed or whether this has even been discussed with the patient. There is no information about any other planned treatment in other areas of the mouth, about the attitude of the patient toward treatment, hygiene history, history of compliance, or anything else. The patient has a problem/toothache etc. and the referring dentist wants someone else to deal with it as soon as possible. That's all. Patients arrive in the office uninformed, apprehensive and with many questions that the specialist frequently cannot answer.
This group regards my services in the way that a Physician regards a pharmacist. In essence, the Endodontist is required to "dispense" one endodontic treatment and ignore the rest of the patient's needs. These other areas not "my concern". This referral could actually get offended if I mention something other than Endo related treatment. His attitude is "Just Do It" (JDI).
Rather than regarding the specialist as part of the team that can reinforce HIS treatment plan, he feels intimidated by having a specialist review his treatment plan (and possibly make suggestions). Referral consultations with other specialists are frequently rejected because he believes he will lose control of the case, or that these suggestions may make him look bad. He wants to be the captain of the ship and the specialist is just there to fulfill a specific need as only he sees fit. Unfortunately, this attitude fails to take advantage of the resources offered by the specialist to reinforce the referral's treatment plan, to offer viable alternatives and to help him provide the best care for his patient. He just doesn't "Get It".
Working Together for the Best Results- Comprehensive Care
In order to have team with your specialist, you must provide the information necessary for him to reinforce your goals for the patient. The Endodontist, Periodontist or Orthodontist may benefit from knowing what restorations you have planned for the patient. (Note: When referring a single extraction to an oral surgeon, it may not be necessary.) This means:
1. Providing a definitive Comprehensive Care Treatment plan that has been formulated for each particular patient. A photocopy of this should be sent to the specialist upon referral- EVEN IF PROPOSED SPECIALIST TREATMENT IS JUST ONE TOOTH.
2. The Generalist has discussed the treatment plan with the patient and has arrived at a level of treatment that is comfortable for the patient financially and that takes into account the level of the patient's hygiene care.
Once this treatment plan has been made, it is a simple matter to transfer a copy of this information to the specialist by fax, e-mail or regular mail. Why is this done? This is done because it gives the specialist a better overall perspective on the direction of treatment and the needs of the patient. Most importantly, it allows the specialist to REINFORCE the treatment plan in the mind of the patient. Patients will frequently wonder if the Generalist's suggested treatment is right for them. Your specialist can help you by saying (for example) " I see that your dentist has a bridge/implant planned to replace that lost molar on the opposite side. I think that is an excellent treatment and it will help preserve the function and position of the teeth on that side. Your dentist really knows what he is doing." When patients hear that from a second, unbiased source (and especially from a "specialist"), it gives them reinforcement and makes you look better as a clinician. That translates into greater awareness of your overall treatment plan by the specialist and potential for greater case acceptance by the patient. If your specialist is not doing this, then perhaps you should consider someone else.
However, the only way that you can accomplish this is by providing this information to the Specialist BEFORE THE CASE IS REFERRED. And that means you MUST spend a few extra minutes writing out or indicating to the specialist what you have planned for this patient. You do not necessarily have to do this yourself. Your assistant or Front Desk staff can easily send this information on your behalf. In this manner, you can use the Specialist as a resource, rather than just regarding the specialist as someone who "takes away production" from your practice.
Lets examine two typical scenarios:
(1) A 37 yr. old male patient is referred to the Endodontist for treatment or retreatment of #46. The tooth has been circled on a referral pad but no other information has been provided. The tooth had a crown with serious subgingival distal decay. The restorability of the tooth is in question. Both #47 and #45 virgin. We could consider Endodontics/Crown lengthening/osseous recontouring/Post and Core/new Crown. Or we could consider extraction and implant or 3-unit bridge. Before we initiate treatment, several questions need to be answered:
1. What is necessary to make this tooth restorable? I.e./ endo/crown lengthening/crown may NOT be indicated in a patient with a history of perio problems or poor hygiene. Is it worth it in this particular case?
2. Is an implant a viable alternative? (Financially? Hygiene-wise?) In a case with virgin abutments, why cut down two perfect teeth? Have alternatives been discussed with this patient? What is the best decision for this patient? How is the Endodontist supposed to know?
(2) A 30-year-old female patient arrives for treatment of a #16 that has symptoms of a cracked tooth. During the initial examination symptoms are confirmed and treatment of this molar is explained. I notice that the patient's smile is acceptable but that diastemas are present in the maxillary anterior teeth. Her smile is not unattractive but could certainly be greatly improved by the placement of porcelain veneers to close the spaces. I ask the patient if he has discussed this with her. She says that her Dentist mentioned it at one time but never followed up. While she is in my chair, I show her some photographs of before and after pictures that the referral has sent to me from cases he has done (or on his web site), use an intra-oral camera and suggest that her excellent hygiene would make her the perfect candidate. The patient completes endodontic treatment of #16. As she is leaving I again suggest that she discuss veneers with her dentist and I mention this on the Endo report. Several weeks later the referral calls me to say that the patient now has 6 anterior maxillary veneers placed and is thrilled with the results. Teamwork has paid off and now this Dentist has a spectacular cosmetic success as a walking advertisement for her practice.
The General dentist needs to regard the specialist, not as someone who "removes revenue from the practice" but as someone who can enhance the practice by providing expertise and by reinforcing the treatment plan that the Generalist has provided for the patient. This can only happen if the referring General Dentist is willing to make the Specialist a part of his treatment team, to include the specialist in his treatment planning decisions and to take the time to communicate his plans for the patient to the treating Specialist. Successful, confident dentists regard the Specialist as a valued practice resource, rather than as someone who is to be avoided or consulted only in difficult or troublesome cases.