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Ethical Dilemmas in the Specialist-Generalist Referral Relationship
The Specialist relies upon referrals from the general Dentist for his livelihood. Because of this, the referral practice can often present the Specialist with difficult practice situations. The Specialist can occasionally be placed in a very uncomfortable position. He must not only consider what is best for the patient, he must also remember he is dependent on the referring dentist for his caseload.  The loss of a single referring dentist can mean the loss of literally tens or even hundreds of thousands of practice dollars in the course of a career.

Certain ethical dilemmas can occur in specialty practice that may not be readily apparent to referring general dentists. Because I am an Endodontist, I will focus on this specialty.

Here are some examples of the questions faced by the Endodontic Specialist on a daily basis:

(1)    Is it ethical to complete Endodontic treatment on a single tooth or teeth, knowing full well that there are other areas of the mouth that require immediate attention (generalized active caries, grossly faulty restorations or prosthetics, serious periodontal problems, etc.)?  Should the Specialist merely "dispense" the procedure, knowing that the other areas of oral disease may be left without necessary treatment?
(2)    Is it the Specialist’s job to prioritize such treatment especially in cases where the patient’s financial resources are limited? (This may mean that Specialty treatment is postponed, delayed or canceled in favor of treatment of higher priority)
(3)    Is the role of the Specialist to assist the patient and referring dentist in “recognizing” the relative need for other treatment? How does the Specialist do this in such a manner as to not embarrass the referral? 
(4)    Does the Specialist in this situation have an obligation to directly tell the patient of his findings? Is communication with the generalist (informing the referring dentist of the Specialist’s concerns) enough? How much must the patient be told for adequate legal protection of the Specialist?

These scenarios may seem remote to most general dentists but they can present significant problems in some specialties, especially in the case of treatment failures.

Retained roots after oral surgery, endodontic perforation during access or questionable margins in patients with limited opening are all examples of clinical situations with understandably less than optimal results. These occur because of factors beyond the control of the clinician and often cannot be helped.  Clinical errors are made because (1) we are all human and (2) we deal with the complexities of the human anatomy.  On the other hand, there are situations in which the “right thing to do” may not coincide with the treatment that has been planned. When should the Specialist say “This is not the correct treatment for the patient at this time?” Does he even have the right to say that when the Generalist has told the patient that treatment is required? What are the financial implications of such comments for the referral based specialty practice?

As the cost of endo/post/core/crown treatment continues to increase (as opposed to many insurance plan benefits that seem to remain static) complete rehabilitation of a single tooth is slowly beginning to consume an entire year’s worth of insurance benefits for many patients. Faced with a decision of rehabilitating one tooth or extraction, some patients have begun to use their benefits toward more general oral care or less expensive removable prosthetics. For many patients (those with lower dental IQ, lesser hygiene capability or poor appreciation of complex dentistry) the decision is simple. In certain cases, sacrificing one tooth for the benefit of the entire mouth may be correct.  In other cases, it may not be.  Unfortunately, because Specialists may only see the patient once or twice, it is often impossible for them to know whether this is the correct decision for the patient. This is why it is important for the referring Generalist to consider the referral treatment in context with the overall needs of the patient BEFORE making the referral.

As an Endodontist, I am faced with these types of decisions every day.  Here is a good example:

A patient will be referred to me for emergency endodontic treatment of a molar tooth.  Their general overall condition is fair-poor. They have many old multi-surface patched or pinned amalgam restorations or leaky composites that need to be replaced. Their oral hygiene is less than adequate and they may have a history of multiple extractions in the same arch. In some patients there is even history of unrestored or inadequately restored previous endodontic treatment. However, they are in pain and are in need of emergency endodontic care.

Although the chances for endodontic success are extremely high, the likelihood that the tooth will be properly restored (i.e./ Well fitting core/crown within a reasonable time) is low. Recurrent decay is a significant risk, and with it the chances of contamination of the canal contents and endodontic failure. In the case of inadequate restoration, failure to provide cuspal protection can lead to catastrophic fracture or split tooth. Ultimately, some end up back in my office for retreatment, surgery or extraction.  If this occurs relatively soon after treatment, the patient is very likely to be upset. In that situation, who is financially responsible?  Many difficult questions will be asked of the Specialist by the patient. Why did the case fail? Who is responsible? Did my dentist make an error in not adequately restoring the tooth?   The tactful Specialist’s standard reply remains a noncommittal “That’s not the way I would have done it”.

 How can we avoid these ethical problems?

(1)    Learn how to provide rudimentary diagnosis and emergency treatment in your own office before considering an endodontic referral. A DMD or DDS degree means that you should have the skills to perform a pulpotomy or pulpectomy procedure in the case of the acutely ill patient with an obvious pulpitis. Not only does this generate revenue for your practice and provide positive public relations, it eases the emergency burden on the Endodontist. If you are not confident in your emergency management technique, ask your Endodontist. They will be more than happy to help you. Visit his office for an afternoon and observe how he handles endo emergencies. The tricks you pick up will easily pay for the lost production time.
(2)    Once the patient is made comfortable, schedule an examination appointment. Examine why this problem has occurred and suggest steps to prevent recurrence. (Merely devitalizing a pulp does NOTHING to assist the patient who has rampant caries.) Provide a comprehensive treatment plan that places the treatment in context with the patient’s overall oral health needs. Explain restorative and hygiene requirements to the patient before referring them. Patients do not appreciate being told that they need will need the tooth restored with a crown AFTER they arrive at the Endodontist’s office.
(3)    If you find that other, higher priority treatment is required, attend to it first.  For example, once the acute pulpitis has been treated, referral of a patient for endodontic treatment is contraindicated in cases where chronic severe periodontal disease or rampant caries is present. Triage the patient!
(4)    When the patient agrees to treatment, assess the level of difficulty of the case and decide whether a referral is indicated. If it is, take a few extra minutes and have you or your staff talk with the patient about what to expect. Give them a brochure or a web site URL. Refer a well-informed patient with a positive attitude who understands what is involved in treatment and what is required of them after Specialty treatment is completed.
(5)    Encourage patients to return for Specialist recall appointments. (Most do not charge for this service)  Monitor treatment areas carefully, especially where crown margins and expensive prosthetics are involved. Take bite-wings regularly!
(6)    When referring a patient for diagnosis or treatment, provide the Specialist with as much information as possible.  It is both unfair and unacceptable to circle a tooth on a referral pad and expect the Specialist to be adequately prepared to treat the patient.  Take just a few moments to note any information that may be of assistance in planning treatment. This includes a history of treatment performed in the area, trauma, exposure as well as the usual personal information i.e. / Patient is apprehensive, on medication, has limited ability to open, is in mid perio treatment, has limited finances etc.
(7)    Communicate effectively with the Specialist. You know the patient much better than he does. Decide whether the treatment is right for the patient before referring the case.

Unlike general practice, where the clinician’s main concern focuses on the patient, successful specialty practice demands that both the patient and the referring dentist must be satisfied. Good communication and proper patient preparation are the keys to maintaining a successful referral relationship. Yes, that sometimes involves using the Specialist to “bail you out”. But try to make it as easy as possible for him by following his recommendations, providing good patient information and restoring the tooth promptly.