Specialty Care Exclusive Survey: Working together

The way you treat your patients is changing.

Gone are the days of simply fixing a cracked tooth and moving on to the next case. These days, you’re expected to look at your patients more comprehensively, to treat them as a whole rather than as components.

That shift in philosophy is just one of the reasons more general practitioners are branching out into specialty areas that enable them to treat their patients on a broader level, said Dr. Brian Gray, a GP who’s taken a special interest in orthodontics. Developments in technology have made it easier for GPs to take on cases they may have referred in the past, while more evidence-based science has given them the confidence they need to keep the work in-house. And the boost to the practice’s productivity and bottom line doesn’t hurt either.

The trend for GPs to offer specialty services really has taken off in the last five to eight years, said Penny Reed Limoli, owner of the Reed Limoli Group, and it is an interest that likely will continue to grow. Almost 80% of GPs think they need to offer some type of specialty care in their practice to stay competitive, according to DPR’s January 2010 Specialty Care Survey. And of the 9% who don’t already offer such services, 72% would like to.

“We are seeing fewer dentists refer out procedures,” Limoli said. “They’re saying ‘OK, I have this active patient base, and the patients very often don’t want to go anywhere else.’ The patient looks at the general dentist and says ‘Can’t you do the root canal?’ or ‘Can’t you extract this tooth?’ It’s such a relationship business.”

Whether it’s orthodontics, endodontics or implants you’d like to add to your list of offerings, GPs and specialists agree it’s not something you can just jump into. Before you place that first implant or try that first Invisalign case, you have to take the proper steps to prepare. But once you’re ready, focusing on a specialty you’re interested in can help renew your passion for dentistry and make your job all the more rewarding.

Getting started

Remember specialists spend extra time in school for a reason; there’s a lot to learn about the area they’re studying. So you can’t expect to take one CE course and be ready to go, said Dr. Olivia Palmer of the American Academy of Implant Dentistry, especially when it comes to implant work. If you want to reap the benefits that come with offering more specialty care in your practice, you have to put in the time. And many of our survey respondents listed implant work as a service they’d like to provide, with 52% indicating they already do.

Regardless of what area you’re interested in, there’s opportunity for learning. Start at association or manufacturer websites or check out institutions like the Dawson Academy and The Pankey Institute.

Researching the different technology options also is important, said Dr. Tony Soileau, a GP who has offered endodontic services to his patients since his practice first opened. Take courses that show you how to incorporate the technology and give you the hands-on experience necessary to make the right purchasing decisions.

“Technology can get really expensive if you’re not careful,” he said. “You need to know what you’re buying. Otherwise you’re going to spend a lot of money and not know what works best in your hands.”

And don’t feel like you have to buy everything at once, said Dr. Joyce Warwick, who recently earned a Fellowship from the International Congress of Oral Implantologists. The thought of making all those purchases at the same time can be overwhelming. Start slowly and bring on more tools as your skills advance.

“It’s definitely intimidating. I felt like I wasn’t sure I was going to be able to recoup my investment between education, time out of the office and the supplies I needed to buy,” Dr. Warwick said. “But if you do it slowly, it’s more manageable. And a lot of implant companies will work with you. They’ll give you the surgical kit if you buy a certain number of implants or work with you to discount your first purchase. Implant companies really want to get you started, and they will work with you to make the transition.”

Building relationships

Dentistry is based on relationships, whether it’s the relationship you have with your team, your patients or other practitioners. If you want your patients to benefit from the best treatment options and the best treatment plans, it is necessary to offer an array of specialty services. If you are not yet working with a specialist, you should develop a good relationship with someone in your area of interest. Find someone who’s willing to work with you and let you learn how to perform or-most importantly-correctly diagnose and treat a patient with several options. Many specialists are eager to teach and show off their work, and would enjoy spending the day with other dentists, orthodontist Dr. Jacqueline Fulop-Goodling (Dr. Jacquie) said.

“The most important thing for a GP in relation to orthodontics is to establish a good, comfortable relationship where they can approach an orthodontist in their area, whether it’s someone in their practice, down the block or someone they play golf or ski with,” she said.

Not sure of the best way to find a mentor? Dr. Soileau recommends taking a specialist to lunch. While most are willing to offer some guidance, there are others who would rather keep even the easiest cases for themselves. You’ll be able to tell in the first 15 minutes if the specialist you picked is someone you’d like to work with or if you’ll need to find someone else.

Study clubs, meetings and networking are other ways to find the right specialist. Some specialists, like Dr. Jacquie, even offer Webinars to help educate their GPs. Dentists usually e-mail patient photos and radiographs in advance, which are then uploaded into the Webinar presentation for discussion. Doctors can follow along from their offices or the comfort of their homes.

Give back

After you establish this relationship, you have to maintain it-meaning it can’t be one-sided. It’s important for you to refer your most difficult cases to the specialists who work closely with you, said Dr. John Shefferman, an orthodontist who works with Dr. Gray. If you don’t, that specialist is going to be less likely to help you navigate through the difficult cases you’d like to take on.

“It goes both ways. If you go to the orthodontists you refer to they know that you respect their abilities and you’re confident in their abilities to treat your patients,” Dr. Shefferman said. “If someone sends me a lot of patients I’m more than willing to sit down with that GP. They may not send me some of the really easy stuff, but I’d rather help them out than say sorry and then they don’t send me anything.”

Know your limits

When starting something new, it’s easy to get yourself in trouble. You may be excited to take on a case, but you have to think about the patient before you do, Dr. Gray said. It’s best to start off slow and build yourself up to the more difficult cases. The last thing you want to do is start a case and then realize halfway through that it’s way beyond your scope or that it’s going to take much longer than you originally thought.

“If you get to be four or five appointments in, you lose money, the patient loses confidence, everyone is frustrated, and no one is happy,” Dr. Soileau said. “Don’t start a case that’s going to take you a long time to do unless you’re comfortable talking to your patients about a higher fee.”

Talking it out with a specialist can help you determine if the case is something you should try or if it’s something you should pass on, Dr. Jacquie said. The education you’ve gained through your CE courses and your experience level factor in as well, but ultimately it comes down to what is best for the patient. If you don’t think your skill level is where it should be and patient care might suffer, you need to refer the case to a specialist.

The American Association of Endodontists offers a case difficulty assessment form designed to help GPs know what’s beyond their scope. Each case is different, but these guidelines help with the decision process, AAE President Dr. Gerald Glickman said. And according to the survey results, 84% of GPs offer some form of endodontic treatment in their practice.

“The patient deserves the best possible care. The rule is never do harm,” he said. “If you think you’re in trouble doing a root canal, you likely are in trouble and the patient will have to be referred to an endodontist. To avoid problems, it is important to evaluate the case from the radiograph before the root canal is initiated. Clinicians should recognize difficult cases in advance and send them to an endodontist. If a patient has to be referred mid-way through a root canal, the procedure becomes much more complicated for us to handle than those that were never started at all.”

When it comes to orthodontics, Dr. Shefferman said it’s a case-by-case situation. There are simple cases, like closing a space in the two font teeth or pushing back a molar to make space for an implant or a bridge. But if you have a patient with a lot of crowding and you need to decide between taking the teeth out or just lining them up, that becomes more difficult. Remember, moving teeth can change a patient’s profile, and you really have to know what you’re doing before you can make such decisions.

“It’s just education. Some dentists might think they can do the movement, but they don’t think about what else can happen. The best thing to do is find an orthodontist who’s willing to let you bring a case and ask, ‘Should I do this,’” Dr. Shefferman said. “There’s no easy way to know what you can do and what you can’t do. Sometimes closing space between two teeth is not a problem at all, other times, unintended problems come up.”

Take control

Typically, your patients don’t want to be referred. That means extra time for them, and going to a doctor and an office they’re not familiar with, Dr. Gray said. They’d rather have whatever procedure they need done right then and there, in your office.
Branching out in a specialty area gives you the opportunity to do this, Dr. Soileau said. As a GP who does a lot of endo, he has the ability to help get his patients out of pain immediately. Patients don’t schedule oral health problems, but when they come up they want them fixed. He’s able to do that, which makes his patients happy and boosts his practice’s productivity.

Knowing how to perform some of these procedures also puts the control back in your hands, Dr. Warwick said. Patients can find the referral process inconvenient or frightening, and the plan can become delayed or even lost in the process. By doing the implant surgery herself, she knows exactly what’s happening. She’s expedited the process and has control from start to finish.

Keeping more cases in-house is great, but don’t let fear of losing a patient take over when you’re looking at a difficult case you really should refer, Limoli said. Remember, keeping patients in your practice isn’t the only objective when it comes to specialty services.

“You have to provide the quality they would get elsewhere, or you’re not doing the patients any favors,” Limoli said. “There will always be some cases that need to be referred.”

Don’t keep it to yourself

You’ve taken the courses. You’ve established the relationships. You’re ready to go. Now all you have to do is let your patients know about it. And, according to our survey, only a little fewer than half of you are.

That’s where marketing comes in. The best place to start is internally, Limoli said. It doesn’t do any good to spend a lot of money on outside marketing if your staff members can’t answer questions about the new services you offer. You have to get your team excited and knowledgeable about what you have to offer and how it benefits the growth of the practice.

Once your staff is educated, begin marketing to your existing patient base first, said Tom Limoli, President of Limoli and Associates. Send something in your newsletter, put a poster about your new offerings in the waiting area and encourage patients to ask you questions. Talk to patients during their appointments and give them educational materials about services that may apply to them. Simply put, communicate.

Dr. Palmer also recommends marketing via your website, your local newspaper, through civic organizations and via good old fashioned word of mouth. Let current and potential patients know you’re equipped to offer your specialty of choice. Go out into the community and offer public seminars about the benefits of certain procedures. If you are passionate about what you’re doing, people will see that and turn to you for their dental care.

“Patients are wanting these (implant) services, and when they realize their GPs are qualified, well-trained and credentialed, they will want to talk to them about the benefits of implant dentistry,” Dr. Palmer said.

Reap the benefits

Once you put all the pieces together, there’s much to be gained from branching out into new areas. You’ll feel rejuvenated and more passionate about what you do, and you’ll save your patients the time and stress that can come with being referred.
And when you do have to refer, you’re referring to someone you’ve really come to know and trust through this process, someone who has become a mentor to you.

There’s no doubt the relationship between the GP and the specialist is changing, Tom Limoli said, and it’s changing in a way that benefits you and your patients.

You, the patient and the specialist all benefit from this relationship, Dr. Glickman said. And the bottom line is to ensure patients get quality care.

To that end, remember GPs can’t and don’t want to do every part of every specialty. If they did, they likely would have taken the extra schooling to become an endodontist or an orthodontist. There are specialists for a reason; now’s the time to work with them.

Renee Knight is a senior editor for Dental Products Report. She can be reached at rknight@advanstar.com.

About this survey
The January 2010 DPR Specialty Care Survey was sent via e-mail to 10,000 general practitioners in the United States. The link to the survey was also promoted on Facebook, where we currently have 3,688 followers. The survey was completed by 162 people.