Hi there.
You are listening to the Perio Hygienist Podcast, a podcast for my professional colleagues. My name is Dr. Ben Young, and I am a periodontist actively practicing in San Antonio, Texas. The title of today’s podcast is: “Interdisciplinary Treatment Planning.”
In the title for this entire podcast, I identify one group of professional colleagues specifically – dental hygienists – because they are my primary focus.
Why?
Because they most directly support the care of my patients and all the periodontists’ patients who return to continue care in the dental practices from whence they came.
But there is a second, very important group, and the one I will primarily focus on in this particular podcast and these are other dentists.
Why?
Because they interact with dental hygienists and periodontal patients and are central to all of the periodontal care patients receive both from specialists as well as within their own offices.
You see, the beauty of a podcast like this is the opportunity for different groups with different experiences to come together over certain things we all have in common professionally – and the most important thing the profession of dentistry shares, or should share, is the primary, critical, importance of the patient’s best interest. What is best for patients, whether it results in immediate gain for any particular healthcare provider, must guide each of us. The patient’s best interest is our common denominator – and this is therefore the common denominator to the topic for today I have entitled: Interdisciplinary Treatment Planning.
There is a third group I am aware this podcast reaches as well and I group them under the category: Anyone else who cares to listen.
This is important because the information I share here is not a secret. It may be technical in nature which obviously limits large audience interest. However, if you are a student thinking about dentistry as a possible career choice in the future or are in professional education at any level, this topic will be helpful to you as well.
When I graduated from dental school, I thought I knew what treatment planning was, but my understanding was limited – and for a very good reason. I had a limited view of dentistry at the time – which, looking back on it, makes perfect sense. Up to the time of graduation the patients I had treated had been selected for me – they had been screened – in order to make sure that I had the opportunity to accomplish very specific procedures that I needed to learn as part of the development of my basic skill set.
At the time, I thought little about the screening process because I had enough on my plate, but looking back on it, and now having had the opportunity to screen patients for students myself, I understand how important the process was to protect both the student and the patient.
Once I graduated, this screening process no longer existed. There was no longer a safety net, for me or the patient. Now, suddenly, I was confronted with a variety of people that could easily present with problems way past my comfort zone.
Certainly, over time and with experience, my comfort zone expanded, but this is not to say, even now, that I can’t still easily find myself flirting with unnecessary and unwise risks.
So now, for the next few minutes, permit me to give you my take on what interdisciplinary treatment planning is – and why it is critical for dentists, especially the newly graduated. It is my biggest tool to tackling complexity in dentistry and reducing risk.
As an aside, and those of you who have had formal residencies, let me first ask it as a question: What is the primary objective of every residency program?
My answer is that they help young dentists develop better Interdisciplinary Treatment Planning Skills. This is the logical next step once someone has mastered subjects at the individual tooth or unit level.
Think about it, we started with learning about the teeth individually. We learned how to accomplish root canals on individual teeth and restore individual teeth and to scale and root plan individual teeth. We learned to deliver individual crowns and possibly a few individual bridges, and a few individual dentures. What we were not yet ready for was to put all of this together in an organized manner – for every possible patient who would walk through our office door in the future. In other words, residencies help expand our organizational and communication skills in order to enable us to work within the context of a larger team of providers – they are not, as many may think at first, to make us more independent from colleagues but actually help us interact in healthier and even more efficient effective ways.
One of the things I do in support of organized dentistry, is work with the local dental society as the chair of the peer review committee. This gives me an opportunity to help both patients and dentists resolve problems before they become expensive and time consuming legal matters. If you had to guess, what would you say the most common problem all of these people are dealing with? I would tell you that most of the time, these problems are the result of breakdowns in communication – which, quite honestly, can happen to any and all of us, whether we are dentists or patients.
What I am telling you is that Interdisciplinary treatment planning is one of the greatest tools you can have in your bag as a dentist and can often help any of us avoid problems, especially with patients we may find difficult to communicate with.
Which brings up another method of attempting to manage difficult patients that in many ways can actually hinder the relationship when done poorly – and that is informed consent.
Done poorly, this is the idea that if we can get a patient to sign a document that explains the risks to the procedure up to, and including, death, that we are off the hook. It really doesn’t work this way.
What we really want in informed consent are patients who understand the nature and risks of procedures and are in agreement to proceed – which means they are on our side and support our efforts.
Do you get my point here?
It’s incredibly important for your own enjoyment in the practice of dentistry or dental hygiene. One of the big reasons to become really good at communication is that it reduces friction in the office. Friction between people on the team as well as friction with patients. But it’s an art. It is a learned procedure. And when we do this really well, a number of really good things begin to happen.
When informed consent follows good clear information, patients do understand and sign documents prior to treatment. But really, all a patient has to say, following any problematic event, is that they did not understand what they were signing. My point is that informed consent documents cannot replace conversations – and certainly, conversations can run long, which is why I am a big proponent in scripting narrative explanations about the problems and procedures we have to communicate every day. This is part of the purpose for my explanation about periodontal disease and what patients need to know about it that I have all my patients see on the front end. And because it is a published video, they can watch it at home or refer back to it anytime they wish to. Also, the fact that it is my personal explanation does not mean I am the only one in my office who can present the information. It becomes the background to all the activities of my office, especially patient communication.
Let me branch out a little here in a brief aside to say that when you work through your patient communication protocols or narratives, they then also populate your website – your marketing. What begins in the office speaking to one patient at a time can eventually morph into articles, podcasts, video, website content and even books. My The Joy of Flossing Book came out of the fact that I grew tired of repeating the same thing over and over – and yet, I find the information so important to patient care, that I could not give up on attempting to share it as often as I could. The book enabled me to come out from under the weight of a message that I believe is under-appreciated in society. How many preventive procedures cost less than a penny a day and yet can save untold thousands of dollars in dental bills over a patient’s lifetime? But, it has to start early, and it has to be embraced within families and taught when kids are impressionable. It’s a little late to be learning this when someone is referred to a periodontist, don’t you think?
But let’s take this back to the main point now that patient communication is critical and should be streamlined as much as possible. However, even with scripted explanations about problems and procedures, some patients are even more complicated still. This means that there will still be in our patient populations, people who will deviate from the routine patient encounter and so will need further explanations about problems.
This is where the beauty of interdisciplinary treatment planning shines.
Here is how I think of it.
I don’t look for the problems I can fix, I look for the problems the patient has and then I prioritize them.
You already know what this looks like.
We start with medical conditions. If the patient stops living, there is no dental treatment. The best management of medical emergencies is to avoid them if at all possible. Now, not every medical condition rises above the dental problem, but a few do, and need to be addressed first.
My best advice is to pick up the phone and call the physician whenever you have an important question. This cuts through so much red tape. I know we can fax things but paperwork gets lost. You are a doctor. Call the other doctor.
But what if it isn’t urgent? Then write email or fax copy and send them – but make sure you have a way of tracking them, just like you track lab cases. You need the information back – and if it isn’t coming back, then call and then write entries in your record that become your documentation.
Let me also stop her and talk a moment about documentation.
Think of it this way. If you are ever in a court of law or a peer review hearing, you can certainly plead your case and certainly your word has a lot of weight, but what either reinforces your words and undermines them is your written documentation and the quality of your other records – radiographs and models.
For example, it is one thing to say that you did this and this and this back then. It is quite another to present a document that is dated with the steps and procedures organized as they happened.
But there is something else you can have that supports your treatment and these are the documents you have obtained from specialists. In other words, when you get a complicated patient, rather than treatment planning them yourself, you can send a referral to a specialist and ask for their evaluation and recommendations. If you want to then accomplish the treatment, go right ahead. This is something many young dentists without residency experience do not understand. You don’t have to give up your patient to the specialist entirely. Just get the specialist to accomplish the work you do not wish to accomplish. If there are procedures you wish to perform or have performed in your office, simply let the specialist know this.
In fact, I will take it one step further. Let’s say you are interested in learning how to do a procedure. Then ask to watch the specialist perform one or two and then ask the specialist to support you on do then next one or two. Why would the specialist do this? It’s really very simple. The more you understand and appreciate the specialty you are interacting with the more you will refer, especially those that you know will slow your practice down.
It really is true that every dentist specializes – because we all have parts of dentistry we like and don’t like – or have had experience treating and not treating.
So let’s back up and let me give you an example of interdisciplinary treatment planning.
A patient presents with missing teeth and bone loss around teeth. We will make him male but he could easily be a she. He has not seen a dentist for a number of years. How you talk with him from the beginning will likely determine whether or not he will stay with you. Here is where ownership comes in. Regardless whether or not the patient sees other specialists, you are responsible for managing all of the patient’s dental care. You are his primary dental provider. This does not imply that you will be supervising the treatment of others per se, but you are managing care to make sure it is all accomplished and coordinated.
If you will be referring the patient, then your conversation with the patient will be different than if you are providing that particular specialty care in your office. You should be talking about how the care will be coordinated and why it is important that the patient sees the particular specialist or specialists you work with. If you do not have a preference between specialists then figure out which one might be closer to where the patient lives or works. In other words, the more involved you are in the specific referral the more the patient will believe that you are remaining involved.
Many dentists simply tell the patient he or she needs to see a specialist and then leaves it up to the patient or someone at the front desk to actually make the referral. This problem with this type of referral is that you are relinquishing control of the patient’s care. You are letting the patient simply go somewhere and come back when they are finished. Because it was not a strong referral, the patient may not see why it is necessary to return to your office, he or she can simply do the same thing again and that is look for another general dentist.
Now here is something that may seem to look like it works but really doesn’t – and that is setting up the appointment in your office for the specialist visit. I’m not talking about sending patient information to the specialty office with the request the patient be contacted. I’m talking about your front office scheduling a patient’s appointment while they are stand in front of them. Many of these patients will allow you to schedule an appointment but do not necessarily feel they have to keep this appointment. Certainly make a pitch for the patient to see the specialist you recommend, but if for any reason they decide to go somewhere else, request they let you know so you can discuss their care with that particular specialist. The most likely patient to follow through with keeping a specialty appointment is the one who makes this appointment for him or herself. Even wives making appointments for their husbands is usually a flag that this patient is not particularly committed. Certainly there are exceptions to this but when adults are not making their own appointments, it’s a flag. Even executives who delegate medical and dental appointments are going to be a bit of a compliance challenge should they actually enter treatment.
My point here – and it is a subtle one I know – is that whether or not you refer, the patient is still yours if you want them to be. If you don’t want them to be, then certainly you need to make referral recommendations and also state that it is unlikely you will be able to support their care going forward, but if you do wish to support their dental care, then communicate this both with the specialists you work with as well as with your patients.
Perhaps we can stop here. I would love to get your comments and questions.
So let me sum up this way.
Dental school taught us all to accomplish a great number of procedures. \
The world is filled with patients who need these procedures but who also present with other problems. Our safest approach at patient care is to establish relationships with all sorts of other healthcare providers, whether they be physicians or dentists and enable them to provide us with, at minimum, consultative services.
What I have found is that the contributions of others to my treatment plans invariably result in better care while protecting me from risks I may not even be aware I am taking.
Let me put it this way. When I encounter difficult patients, one of my greatest tools is to refer to others for consultations. In this way, I am spreading risk. It also means that others will be in the conversation, not just me. I have learned, as everyone eventually does if they stay in dentistry long enough, is that it isn’t always about the number of patients we treat. Sometimes it also includes those patients smart enough not to treat, or at least not treat alone. That’s it for today. This has been The Perio Hygienist Podcast and I am still Dr. Ben Young. Thanks for listening. Bye for now.
