Part of what is great about being a general dental practitioner is the variety of procedures we provide. With the appropriate training and experience, we are not limited in our scope. This freedom includes the ability to exercise some control over the mix of procedures we perform. As with all of our decisions, it is the patient’s welfare that determines our choices.
If we enjoy a particular area of care, we can expand our education and training to allow a wider range of proficiency, or conversely, refer a segment of that area of treatment. Practitioners cannot allow financial pressures or third-party contracts to temper their judgment about when or what to refer. Nor can we rely upon our patients’ preferences regarding referral. We have all wrestled with, “Please, Doc, can’t you just do it?” General practitioners will often be held to the skill level of a specialist for procedures routinely referred. So the risks must be carefully weighed.
The following question was recently presented to the MDA: What does a dentist do with a patient referred to him or her who needs additional dental work that is outside that dentist’s specialty? Does he or she send the patient to the dentist down the road, or does he or she return the patient to the referring dentist? And what if the patient would rather see someone other than the referring dentist?
In one case, a dentist referred the patient to another office. After the consulting dentist had completed the patient’s treatment, it became apparent that further work would be needed.
Instead of contacting the referring dentist and returning the patient to that office, the consulting dentist sent the patient to yet another dental office, even though the additional care needed was something the original dentist was more than comfortable performing.
Was this a simple failure in communication, or could this be considered a breach of ethics? In the introduction to their article “General Guidelines for Referring Dental Patients”, the American Dental Association states, “In situations where two or more dentists are involved in the treatment of the patient, communication between all parties is essential.” The ADA article continues that “any care rendered by a consulting dentist should be coordinated with that of the referring dentist, and any other dentists involved in the treatment. Each dentist should have a clear understanding of the role each is playing in providing care to the patient.”
The consulting dentist is also required, in most cases, to return the patient to the original dentist, according to the ADA’s Principles of Ethics and Code of Professional Conduct. Citing Section 2.B.1 of the Code, the general guidelines article reports “the specialist or consulting dentist upon completion of their care shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist or if none, to the dentist of record for future care.” Without a clear request to not return to the referring dentist, the patient should always be directed back.
The specialist or consulting dentist is also in a unique position to mend fences if the referring doctor/ patient relationship has deteriorated or suffered some damage. Honest communication with the patient, supportive of the referring dentist, can often repair or improve such damage and further the referral relationship. A conversation between practitioners can also serve as a learning moment and help avoid future similar problems.
The patient, too, should be kept apprised of all procedures. According to Section 4.C.1 of the Code, “Patients are dependent on the expertise of dentists to know their oral health status. Therefore, when informing the patient of the status of his or her health, the dentist should exercise care that the comments made are truthful, informed, and justifiable. This may involve consultation with the previous treating dentist, in accordance with applicable law, to determine under what circumstances and conditions the treatment was performed. A difference of opinion as to preferred treatment should not be communicated to the patient in a manner which would unjustly imply mistreatment.”
Other aspects of patient referral are also covered in the ADA’s “General Guidelines for Referring Dental Patients” article, including:
• Possible referral situations or conditions
• The elements of dental patient referrals
• Communication from the referring dentist to the patient
• Communication from the specialist or consulting dentist to the patient
• Ways in which to facilitate and improve the referral process
• Legal and ethical issues that must be considered when a patient is referred
Both the “General Guidelines for Referring Dental Patients” and the ADA’S Principles of Ethics and Code of Professional Conduct can be found on the ADA’s website: www.ada.org
Since all practitioners share the care of patients to some degree, we need to be excellent at facilitating the referral process. We need to clearly define our treatment plans and future goals. Diagnostic quality radiographs and images should be included when appropriate and available.
We dentists choose to refer to someone in whom we have confidence. Share that confidence with your patient. Meet or communicate with the consulting practitioners to create parallel treatment goals. Help set the stage for a positive and more predictable patient experience.
Often overlooked is the follow-up responsibility in the referral process. We should set deadlines for patient compliance and remind those who delay of the reason for the referral and the possible risks if they do not pursue the recommended care. Such follow-up may include tickler files or reminder dates to ensure the referral is emphasized.
Our patients lead busy lives; don’t let them fall through the cracks. Many need reminders and encouragement to comply.
Let’s help our patients efficiently navigate the referral process.
*Dr. Kurkowski is Chair of the Minnesota Dental Association Committee on Ethics, Constitution and Bylaws. He is a general dentist in private practice in Saint Paul, Minnesota. Email is firstname.lastname@example.org