Many years ago when I was new to my own practice I had a hard conversation with one of the periodontists with whom I was working. I told him that I was going to do all of the scaling and root planning procedures for our patients before I referred them to him. My rationale was very simple at the time. New practice, big debt, not many patients---I needed the money from any procedure I could keep in my office.
The thing was, I really thought my hygienist could do it as well as his hygienist; they had the same training right? Calculus is calculus and I had a great hygienist. I also believed that if I kept those procedures in the office that it would enhance the final outcome because it gave me a chance to deepen my relationship with my patients and to monitor their home care and how they were doing. I rationalized that they would be in my practice longer than the periodontists and it would be my responsibility to make sure they were doing ok.
Today, it becomes even more complicated to make this decision because of the wide range of local therapeutic agents that can be delivered in a site specific manner and that have shown to be efficacious in the appropriate situations. They are easy to administer, require little training and they seem to work, except when they don’t.
This short article is not about the right or wrong of keeping or referring cases. I have long believed that the person to treat the patient should be the one most able to deliver successful care and whom the patient has the best relationship. Rather, I want to talk about how we can make that decision responsibly and also to think about implications of the decisions we choose to make. I also believe that GPs should be doing any procedure they choose to do, as long as they can do it to the standard of care of the community in which they practice.
I think there are three questions every practitioner needs to consider when deciding to add a new procedure into the practice:
- Is this procedure in the long-term best interests of my patients? Does their welfare trump all other considerations?
- Can I do this procedure to the standard of care of the community?
- Does this procedure make economic sense to my practice?
My belief is that if the answer to any of these three questions is NO, then the patient should be referred to someone who can better do the procedure.
Let’s use my SRP example as a starting point. Not long after I made this pronouncement to my periodontist, he asked to meet with me at lunch. As we chatted he brought up a finding from recent resective surgeries he did for our mutual patients. He also brought some slides of cases we had done before and after I took over the SRPs in my office.
You know that the goal of SRP is to remove, biofilm, plaque, calculus and to create a smooth, hard root surface, free of those contaminants. He showed me cases where his hygienist had done the pre-surgical prep, SRP and ones where my hygienist had done them. The obvious difference was that his hygienist did a far better job of creating the smooth hard surface, thus making the surgeries faster and easier for the patient and with better healing and less post-operative discomfort because the flap was not open as long.
You might think his purpose was to get me to stop doing the SRPs in my office, which was not the case at all. He wanted to invite my hygienist to come to his office and work with his hygienist so she could do a better job of treating our patients. The end result was I got to keep the production in my office, our patients got much better care and our professional relationship improved.
I see similar controversies today over implants endo and orthodontic procedures. Ambitious GPs want to do more procedures in their offices for both the production as well as for professional growth and satisfaction.
Let’s think about the third question; does this make economic sense for my practice. If I am doing a procedure that may seem to be profitable, yet takes me three times longer than a specialist doing the same procedure, will that really benefit my practice financially down the road? Take implants for example: if I am only placing 15-20 implants a year I can never be as effective as someone who places 400. I will be slower, likely have a higher percentage of complications and my productivity per hour may be much lower than those procedures that I am very accomplished at completing. The 90 minutes I spend placing a single implant might be better spent making impressions and delivering three crowns on three implants placed by a specialist.
I also believe that making the decision to add procedures is important and we each should consider that option. If as a GP, I decide to do something that I have been referring to my specialists, it can threaten the relationship on both sides. My personal belief is that if I want to maintain that relationship, I should talk with my specialists and tell them what I’m thinking and ask for their support. I think that enlightened specialists want to help GPs as long as we respect the relationship and continue to refer. The only way to find out is to have the conversation in an open, honest fashion.
Finally, I think that having the conversation with specialists can be clarifying. For instance, part of the discussion should include, if and when I refer, when is the best time? What do you need to do your best work? What do you expect from me? Those questions can lead to more effective and better care on both sides and show a high level of respect on both sides.
We each need to make our choices and we need to do it in a way that always considers our patients.
Steve Ratcliff, D.D.S., M.S., Spear Faculty and Contributing Author