The Interdisciplinary Referral

The only constant is change. There have been approximately 800 generations of mankind. It is estimated that we have learned more information in the last generation than the previous 799! No one person can know it all. Dentistry is no exception. In order to produce the optimum patient result, particularly in complex treatment plans, a team of specialists can provide the confidence and experience the joy that frequently results from treating these challenging cases with very successful outcomes.1

Interdisciplinary treatment in dentistry creates a relationship triangle made up of the referring doctor, the referred patient, and the specialist(s) (Figure 1). The value of this coordinated diagnosis and treatment approach is for everyone in the triangle to win. How can this be done? Is it worth the effort? After all, a patient can lose in the interdisciplinary process when they do not receive timely treatment, correct treatment, or when they do not receive treatment at all. Patients lose if they do not understand the treatment choices, and advantages and disadvantages of these options. A successful treatment plan requires that all the members of the interdisciplinary triangle agree on the vision for the patient, and that the treatment is sequenced and coordinated. This does not just happen; it is an intentional outcome. The general dentist or the specialist can lose by losing the patient, by having a treatment failure, or by losing self-esteem in the referral process. The general dentist or the specialist can lose when “inheriting” a problem that makes it difficult to make the other doctor appear competent to the patient.

Figure 1. The interdisciplinary relationship.

How do we put ourselves in each other’s shoes so that the entire interdisciplinary team wins? In order to answer this question, the interdisciplinary process can be divided into three key principles, six factors, and three desired outcomes from the generalist–specialist connection.

PRINCIPLES OF THE INTERDISCIPLINARY REFERRAL

Trust/Responsibility

The patient has given trust to the general dentist. The general dentist must earn that trust and accept the responsibility to uphold it. In the interdisciplinary referral, the conscientious general dentist accepts the responsibility of referring the patient to a specialist, and recognizes the profoundness of that transfer of trust. Psychologists tell us that trust is transferable.2 As with the general dentist, the specialist must recognize and accept the important responsibility for that transfer of trust. In order to have a successful relationship, the general dentist, the specialist, and the patient must trust each other.

Over time, trust is built for the entire interdisciplinary network, including the referring doctor, the specialist, and the patient. The principle of trust needs to be a thinking and action process of the entire treatment team at all times. For example, the specialist is responsible for affirming the treatment plan and trusting that the team can achieve the vision that the patient has for his mouth.

Equality, Judgment, and Confidence

Often the general dentist and the specialist do not believe that the other is a professional peer. The generalist has a fear of exposing treatment inadequacies to the specialist because the specialist is going to judge them. The generalist believes this is a one-way judgment and that the specialist can judge the generalist, but the generalist is not qualified to judge the specialist. The referring dentist feels inferior to the specialist because the specialist may believe he has more knowledge in a particular discipline and the general dentist does not know enough to even know what to ask. It is like turning someone over to a person saying, “Take care of this person. I don’t know how to communicate with you about what my concern is (fear), I just know something is wrong in this mouth, or with this tooth, or something needs to be done, and I do not even have enough knowledge to dialogue with you.” The specialist, in response, does not communicate on a professional peer basis with the generalist because of a belief that the general dentist does not care about the treatment or is not qualified to understand the treatment. In a successful interdisciplinary relationship, this must change. The generalist needs to develop confidence and realize that generalists and specialists are professional peers, subject to each others’ critical, professional evaluation.

Teamwork and Leadership

Teamwork and leadership are essential in the successful interdisciplinary referral. The general dentist, however, is the professional who knows the patient best and must take the lead in developing the treatment plan and its sequence and coordination. The general dentist must take accountability for each of these stages. The generalist needs to view the relationship with the specialist(s) similar to that of a team. The generalist is the quarterback of the team and the specialist(s) is like a running back or lineman who has very skilled talents, and knows his own position, very, very well. The specialist knows a lot about a limited field. The generalist facilitates the development of the diagnosis and comprehensive treatment plan for the patient with the assistance of the specialist(s). The generalist/quarterback coordinates the execution of the treatment plan for the patient, using the clinical skills of the specialist(s) and his area of expertise, and then manages the continuing care of the patient.

FACTORS AFFECTING THE INTERDISCIPLINARY REFERRAL

The “Give/Get” Relationship

The general dentist sees “giving” and not getting anything back. This is a problem when the general dentist sends a patient to the specialist and does not see the patient again, or does not get any input back from the specialist, or the specialist tells the patient what needs to be done without first informing the general dentist and getting agreement. If managed appropriately, the generalist does get a return from the specialist. They “get” a comprehensive diagnosis, an optimum treatment plan, and an interdisciplinary approach to create a predictable aesthetic and restorative result. “You can’t treat what you don’t see, and you won’t see what you can’t do.”1 The true benefit of the interdisciplinary process is that the patient receives the most comprehensive treatment possible toward his vision of his mouth looking good and feeling good. The specialist also shares the responsibility with the generalist for the success/failure of the patient’s treatment. The specialist and the generalist must both be responsible so that the “give/get” relationship has a balance to it.

The Specialist as a Role-Player

The specialist needs to be part of the general dentist’s team. This is not demeaning to the specialist at all. When the specialist sees himself or herself in the team role, this can establish a meaningful relationship with the general dentist and the patient, and build an exceptional aesthetic and restorative interdisciplinary practice. When the general dentist indicates an interest in teaming with a particular specialist, the first meeting might be to sit down and have a conversation about each other’s philosophy of practice and expectations. First, the general dentist says what (s)he wants and then the specialist says what (s)he wants from the relationship. It may be immediately clear whether they are able to function successfully together on the same team as professional peers. The specialist and the general dentist need to educate each other as much as possible so that each can develop a feeling of at least equality, if not superiority, for the comprehensive treatment plan. The sense of the general dentist as quarterback needs to be enhanced, and the education needs to be open and honest. If the specialist sees the general dentist doing something wrong, then the specialist should tell him or her. For example, “I think this is a problem. How can I help you? Here is what I have seen done.” The specialist should be stroking the dentist’s back for “giving” the patient. If a problem develops within the specialist’s office, or the patient has voiced a negative comment about the general dentist to the specialist, the specialist needs to call the dentist and inform him by reporting the facts and saying, “This is what your patient is saying to me, ie, he is unhappy with your receptionist or unhappy with you, etc.” The reverse is true if a patient reports to the general dentist that he is unhappy with the specialist. This is information without judgment.

A relationship with staff and each other affects and influences the patient’s perception of value. In the interdisciplinary referral process, complaints by a patient should be celebrated because that tells us what is wrong and what needs to be improved. In this way, you can be assured that the patient is not playing a double-edged sword and complaining to the specialist about the general dentist or vice versa. Sometimes the patients play both parts against the middle. Do not play this game.

Communication Protocol

There is a substantial amount of time and effort in the process of the referral, information transfer, and tracking. The specialist and the generalist each must do his share in this networking process. There is also a necessary time commitment that is required for the specialist and the generalist to communicate about shared patients. The communication process between the generalist and the specialist must be handled with a defined protocol. The purpose of this protocol is to develop a logical and efficient communication for the generalist and the specialist. It is to the advantage of both parties to quickly and clearly define this communication protocol in order to reduce productivity loss and increase the opportunity for open and honest communication. Ultimately, the specialist and the general dentist need to see the very same vision for the patient as well as the sequence to achieve that vision. Once this point is reached, and each interdisciplinary member understands the needs and desires of the other, then the quantity of communication can be reduced. Until that point is reached, there is a necessary time commitment that needs to be met by both parties, even if it involves some down time in office productivity. Once each interdisciplinary member has identified what their needs, wants, and desires are, open communication and a lifetime interdisciplinary relationship are nurtured.

Multiple Specialists

If there is a problem that develops and a specialist needs help from another specialist, it is the first specialist’s responsibility to go back to the general dentist and ask for the general dentist to refer the patient to the next specialist or to ask him if he agrees to see the next specialist. This keeps the general dentist in the proper position of quarterback, calling the signals, and coordinating the treatment plan. It is essential for all the members of the interdisciplinary team to understand that patients may feel psychologically “torn apart” when more than one specialist is involved. At this point it is essential that the general dentist gives the patient the confidence that (s)he is in control of the treatment plan. Otherwise, instead of “interdisciplinary dentistry,” the patient experiences “multidisciplinary dentistry” where each specialist is performing his own self-serving procedures without any sequencing, coordinating, or regard for the vision of what is possible for the patient’s mouth.

Educating the Generalist and the Specialist

The specialist needs to educate the general dentist as much as possible during the diagnostic evaluation, treatment plan development, and during the treatment itself so that the general dentist can develop a feeling of being a professional peer in the specialist’s limited area of expertise. The general dentist’s responsibility is to teach the specialists the “big picture” and to have them answer the questions, “What can you do for me in this patient’s situation? What are the upsides and downsides of your treatment? What are the alternatives?” The general dentist must convey to the specialist the criteria that must be met to enhance the success of the treatment plan. This education must be open, honest, and nonjudgmental. If the specialist sees diagnosis/treatment that the general dentist is performing inappropriately, the specialist must say so. If something inappropriate develops within the specialist’s treatment, the general dentist needs to tell the specialist. The key to the success and rewards of the interdisciplinary relationship is in honest communication.

Each person involved in the interdisciplinary approach must bring four crucial elements to the process:1

1) Time. The treatment approach initially takes more time in planning and will continue to do so until this process becomes second nature to all of its members. In the beginning of an interdisciplinary relationship, it often means that a group must meet to review the patient’s vision, history, study models, radiographs, and intraoral and extraoral photographs.

2) Trust. Each member must be free to express ideas without worrying about hurting feelings or being a threat to someone else’s knowledge or credibility. If the patient’s vision is the driving force, then this process becomes easy to accept.

3) Commitment. All team members must arrive at a consensus concerning the treatment plan and its sequence.

4) Support. Help is required for the patient and the team members to remain focused on the treatment vision.

It is important to tailor each other’s individual expectations and preferences. The specialist and the generalist need to collect data from each other regarding preferences concerning the following3:

•Do they want to be contacted before you start treatment if there is a problem?

•Do they want you to explain (in what level of detail) the need for follow-up treatment?

•Do they want your office to set up the appointment with their office for follow-up treatment?

•Do they want to develop mutual expectations regarding emergency availability and scheduling?

•Do they want to learn how to render emergency treatment?

•Do they want you to notify them if a patient has a problem during treatment?

•Do they want you to call the patient after treatment and see how they are doing?

•Do they want a call to review progress after treatment?

•Do they want you to call if there is a problem between offices?

•Do they want you or your staff to call or visit to explore how to work better together?

Other appropriate questions include:

•Could you tell me if your patient has any emotional or financial problems?

•Do you want me to inform your patient of any needed dentistry or do you want me to call you first?

•How can I keep you? What are your needs, wants, and desires from an interdisciplinary team member?

•Do you want this patient back?

•What can you do for me?

Specialists’ Referrals to Generalists

The responsibility of the specialist is to be strongly supportive in the referral process. When a patient comes to the specialist, the specialist should compliment the patient about the general dentist. This is important because the patient may be uncomfortable about the referral process and feel rejected. In addition, the specialist has a priority to marry the patient back to the general dentist who referred the patient. It is the professional responsibility of the specialist to refer general dentists any “unattached” patients they may see. Many times the specialist has a nonprofessional social situation where people ask, “Who is a good dentist?” This is a wonderful opportunity for the specialist to give them the name of one of their top dentists in their interdisciplinary network.

DESIRED OUTCOMES OF THE INTERDISCIPLINARY REFERRAL

The Restorative Dentist Wins

In many ways the specialist can be the general dentist’s least paid assistant, educator, and motivator! The specialist has the opportunity to constantly focus on the total possibility or vision for a patient and his mouth. The question, “If you could change anything in your mouth, what would it be if it did not require time and money?” can be repeated throughout the specialist’s treatment. A patient will always act out of his own self-interest, and if he is educated about the benefit of improving his mouth, he will act out of this interest.4 The specialist has the opportunity to lead the patient toward comprehensive aesthetic and restorative treatment.

The specialist, therefore, can help build the quality of the restorative dentist’s practice. Then, everyone wins: general dentists, specialists, and most importantly, the patient.

The Patient Wins

In any given interdisciplinary treatment plan, one of the team members may not have the sufficient skill to produce the desired outcome. This could be either the generalist or the specialist. If all the principles and all the previous factors have been honored, then this gives the possibility that the best team can be in place for this particular patient. This may mean confronting either the generalist or the specialist. For example, if the specialist believes that the treatment plan is too complex for the skill, care, and judgment of the generalist, then it is the specialist’s responsibility to call the general dentist and suggest a prosthodontist, for example. Again, this is an unemotional judgment call and consistent with the vision of doing what is best for the patient. If done correctly, the general dentist will usually welcome this recommendation with relief. For most of us, nothing drains energy more than feeling or actually being inadequate, having inadequate capacity to successfully treat a patient. Specialists in an interdisciplinary team should not be immune to this process either. Even among specialists there are those who have a particularly high skill level for a particular procedure and, in the name of what is possible for the patient and in order to achieve the vision, it is sometimes a necessary and appropriate step to call them into the treatment plan. Again, it all comes down to honest communication. It is not about the treatment team member, it is about the vision. Once the vision of ideally treating every patient who has the values of ideal treatment is realized, then everything else neatly falls into place (Figures 2 and 3).

CONCLUSION

The interdisciplinary referral process does not just happen. It requires vision, commitment, time, and energy, and putting the patient’s needs, wants, and desires before dentists’ needs, wants, and desires. The question is, “Is it worth it?” The members of the Northwest Network for Dental Excellence, in which we participate, have been involved with this question for 17 years. Without exception, each of the members would suggest that interdisciplinary aesthetic and restorative dentistry has enabled us to all experience being at the top of our “dental” game. This has benefit for the dentists that we have had the privilege to serve, the patients that we have treated, and the joy and satisfaction of day-in and day-out exceptional dentistry.

Acknowledgment

The authors are indebted and thankful for other members of the Northwest Network for Dental Excellence:

Mark D. Carlson, DDS, MS (Oral Surgery)

Robert E. Dunley, DDS (Oral Surgery)

Vincent G. Kokich, Sr., DDS, MSD (Orthodontics)

Dave Mathews, DDS (Periodontics)

Frank Spear, DDS, MSD (Prosthodontics)

David R. Steiner, DDS, MSD (Endodontics)

Robert Winter, DDS (Prosthodontics)

References

1. O’Connor RV. The exciting world of interdisciplinary dentistry. Int J Periodontics Restorative Dent. 2000;20:334-335.

2. de St Georges JM. The art of effective referrals. CDA J. March 1992. 65-68.

3. Silverson J. Keys to Success With Referral Sources and Patients. Practice Building through Human Relations. Cambridge, MA. American Association of Endodontists. Videotape. 1993. Americus Inc.

4. Wilde JA. Create a bond of trust in only two minutes. Dent Econ. 1995;7:54-57.

Dr. West is founder and director of the CENTER FOR ENDODONTICS… “Pioneering New Possibilities in Endodontics” in Tacoma, Wash. He currently serves as a trustee of the American Association of Endodontists Foundation, has served on the Educational Affairs Committee and Committee on Dental Care and Clinical Practice for the AAE, and is an international lecturer and teacher. Dr. West is a member of the American Academy of Esthetic Dentistry and the International College of Dentists. Dr. West is an editorial board member of The Journal of Esthetic and Restorative Dentistry and scientific editor for Boston University’s Communiqué. He is affiliated associate professor at the University of Washington School of Graduate Endodontics and clinical instructor at Boston University Henry M. Goldman School of Dental Medicine, where he earned the 1995 Distinguished Alumni Award. He was senior author of “Cleaning and Shaping the Root Canal System” in Cohen and Burns’ 1994 and 1998 Pathways of the Pulp, is a contributing author to the 1995 edition of Goldstein and Garber’s Complete Dental Bleaching, and coauthored “Obturation of the Radicular Space” with Dr. John Ingle, in Ingle’s 1994 and 2002 editions of Endodontics. Dr. West maintains a private practice in Tacoma, Wash. He can be reached at (800) 900-7668 or johnwest@centerforendodontics.com.

Dr. O’Connor has practiced general dentistry for 40 years. He is the founder of the Northwest Network for Dental Excellence, which is composed of each specialty in the field of dentistry. For 30 years, he was a postgraduate lecturer on practice management at major universities and US dental societies throughout the United States, Canada, and Mexico. He was the president of the American Academy of Esthetic Dentistry in 1991. He is a practice management course advisor to the dean at University of Washington, and also a guest lecture for the senior class. He can be reached at (253) 588-5088.

Dr. Cook has practiced in Lakewood, Wash, specializing in pediatric dentistry, since 1972. He has been active in serving his local and state components of the ADA. He is a past president of the American Academy of Dental Practice Administration, and a member of the Evergreen Pediatric Dentistry Study and Research Club and the Northwest Network for Dental Excellence. He is a diplomate of the American Board of Pediatric Dentistry, a fellow of the American Academy of Pediatric Dentistry, and the facilitator for the Southwestern Washington Maxillo-Facial Review Board. The American Academy of Pediatric Dentistry named him to the first editorial board of the clinical section of the AAPD Journal of Pediatric Dentistry. His passion for dentistry and commitment to learning and teaching have led him to lecture extensively throughout the United States and Canada on the topics of pediatric dentistry and dental practice administration. He is an instructor in the University of Washington graduate program in pediatric dentistry. In 1983, the Washington State Dental Association named Dr. Cook as “Dentist Citizen of the Year.” He can be reached at (253) 582-2626.