Inter-disciplinary dentistry persists as a challenge for rural dentists
Yvonne Hanley, DDS
Imagine yourself surrounded by beautiful mountains and fabulous fly-fishing streams. Imagine a practice filled with rural residents enjoying such a setting. Some of my close friends have such practices. If you will, imagine the place where I live in Otter Tail County, Minnesota, with 100 resorts on more than 1,000 lakes where fishing, boating, hunting, and cross-country skiing are some of the daily pastimes. Living and practicing where others choose to spend vacations, we are surrounded by nature’s beauty. In striving toward comprehensive treatment, dentists travel to continuing education centers - in my case, The Pankey Institute - advancing skills and becoming comfortable with promoting optimal care. What rural dentists still need is easier access to dental specialists who can help them work through interdisciplinary cases.
It wasn’t so long ago that I went to an upper-level Pankey Continuum course where a restorative dentist and his periodontist/implantologist were sharing with the class how they work together as a team, meeting in conference during the treatment-planning and sequencing phase. The restorative dentist is chair-side to the periodontist at the time of implant placement for impression and provisionals. Together, they coordinate well-communicated post-treatment follow-up. Their slides were beautiful, the process seamless and inspiring. Oh, by the way, their offices are in the same medical complex.
As my mind drifted back home, I remembered performing palliative access and debridement on an abscessed molar of a dear, long-term patient. The referral to the endodontist included a two-week wait for an appointment 60 miles away over the open wind-swept plains in the middle of January. Hmmm, I’m thinking, this is a long way from dentistry in downtown Atlanta.
Creating smooth working relationships with a team of specialists takes time and energy, regardless of the location. For instance, even within the same medical complex, referring a patient from your relationship-based, low-volume practice to an orthodontist who routinely sees 70 patients a day could easily result in a hurried-up experience that your patient questions. To achieve the intended results, you will need to pro-actively manage the interdisciplinary doctor-to-doctor communication as well as doctor-patient relationships.
The time to start relationships with specialists is not after a mishap occurs. By then, the tendency will be to find defensive excuses. Ideally, the time to start is before making referrals, and it should begin with an open, honest discussion with the specialist about your philosophy of practice. In my case, this includes the goal of optimal care, which I communicate from the initial conversation with my patient on through the comprehensive exam and consult with the patient to collaboratively build agreement on appropriate treatment and scheduling the chosen sequence of procedures. It also includes a careful treatment-planning process which is individualized for each patient’s particular oral condition, health history, personal concerns, and temperament. And, it includes my desire to have the specialist collaborate in treatment planning and treatment for optimal results. Overall, I hope that in communicating my philosophy I communicate my expectation for the specialist to continue this thoughtful level of care with my patient.
Conversations such as these with each specialist might evolve into the development of a joint position paper. A position paper is a written synopsis of how you desire to work together on cases and your agreed-upon preferred outcomes. There is commitment involved in actually having this information written down. Once written, the synopsis functions as a set of written goals. Once it is on paper, it just seems to happen. Remember - a goal is only a wish until it is written down. Additionally, this position paper serves as a wonderful resource to discuss your goals with the staff personnel in each office.
Some of my colleagues across the country have responded to the challenge of distance between their patients and specialists by developing their own expertise in one or more specialty areas. They have sought additional training and mentored experience to deliver “specialty care” such as endo, perio, ortho, implant placement, or other surgery in their communities.
You may be able to entice specialists to move closer to your location. By approaching dental school graduate programs about the opportunities available, a recent graduate might be attracted to your community. A recent graduate of a specialist program will be loyal to the principles and style espoused in his or her training program, and therefore may need to grow into an understanding of optimal care and the value of collaborating with the general dentist. With open dialogue, time, patience, and mutual respect, any tendency of the specialist to “know it all” can be overcome so an interdisciplinary team relationship can be formed.
Inviting specialists to participate with us in a study club or a CE offering is another way we can develop the relationship and improve communication. Seattle Study Clubs have proven their worth in raising the quality of interdisciplinary care in low-density population areas. By bringing general practitioners and specialists together, these study clubs have improved communication between referring dentists and specialists. The list of speakers available to the local organizations is second to none. Attending the same lectures right along with your team of specialists not only improves communication but also expands treatment options when planning a complex case. Seattle Study Club treatment-planning sessions have strengthened relationships and communication.
Three three-day courses in the Interdisciplinary Level of The Pankey Institute’s Continuum (C5A, C5B, and C6) are designed to facilitate the development of synergy between the general dentist and his or her accompanying specialists, including treatment planning and sequencing complex cases requiring ortho, implants, or orthognathic surgery. There are no prerequisites for specialists to attend these courses. While there, the participants spend time in groups treatment planning actual cases. This facilitates much valuable discussion that carries over to the cases you will be treating back home.
If one is faced with referrals that involve significant travel time, you need to be prepared to handle any postoperative support that is needed for the patient. You will get a call from the patient after a procedure at the specialist’s office, and before you have received the postop report. It is important this is handled as smoothly as possible. First, it is important to contact the specialist or his or her treatment coordinator to get all the information regarding the procedure completed. Then promptly follow up with the patient by phone or an office visit to assess the situation. It is not uncommon for us to see the postsurgical patient and affirm that healing is occurring as expected. The patient appreciates this, not only for the peace of mind it provides, but also for the many highway miles it saves when compared to a return trip to the specialist. It also demonstrates the close working relationship you have with the specialist. Yes, this takes a bit of your valuable time, but why risk losing the patient’s confidence, especially in a complex interdisciplinary case?
One last thought - the stock, padded referral forms provided by specialists to general practitioners are helpful; however, checking off boxes and circling tooth numbers on a form does not exemplify the level of referral many of us desire. A letter detailing all pertinent information, including the patient’s circumstances, objectives, and temperament, accompanied by quality radiographs, photos, and mounted models is the minimum requisite for differentiating you and your practice.
If all your efforts to find and communicate well with quality specialists fail, you have another option. You can move! But then, where will your patients find the level of care they have become accustomed to?
Dr. Hanley has been in private practice for 25 years in Fergus Falls, Minn., just 12 miles from the dairy and grain farm where she grew up. Working for her family dentist at the age of 15, she eventually bought the practice. She has been active in the Heartland Study Club for 12 years, and has served on the visiting faculty of The Pankey Institute since 1989. She chairs the Provost Committee, and served on its Board of Directors for more than 10 years. She leads a regional Pankey-affiliated learning group she organized in 2002. She may be reached at [email protected].
