The next time you’re on the phone making a new patient appointment with a general dentist’s office, ask the receptionist: “Does Dr. X refer a lot to specialists?” This is a question they rarely get and the answer will tell you a lot about the practice philosophy. Why?
Before I went back to school to become an orthodontist, I was a general practitioner (GP) for 20 years. When I was a GP, I believed that it was my job to become the best at what I did. I wanted to learn about how to do everything in dentistry. After all, I was trained in all fields of dentistry and my title was “general” dentist. I earned Fellowship in the Academy of General Dentistry which requires education in all areas of the profession. For the first 7-8 years of my career, I tried to do everything I could to save my patients a trip to the specialist and help them within my own office. I referred out the “tough” cases and saved my patients money and travel time to another office. Then something happened that changed my perspective on how I practiced.
Understanding what a specialist really does
As I performed more root canals, I realized that not only did I enjoy alleviating patients’ pain, but by any standard, my outcomes were pretty good. I had taken a lot of continuing education courses on endodontics (root canals) with some of the best names in the field and felt pretty confident in my ability. Then I went to lunch with an endodontist and saw his office. He had all of the journals that he read every month to stay on top of the latest research. He had microscopes in his operatories so that he could see things that my own dental magnifying loupes couldn’t. We went over his cases and he got spectacular outcomes on cases I wouldn’t have touched because of difficulty.
The more we talked, the more I realized that the endodontist was a true “master” of his profession and that no matter how much I learned, I would never know what he knew about treating every root canal case. If I needed a root canal, I would go to him, so why wasn’t I sending every patient who needed a root canal to him as well? He had a policy of getting my emergency patients into his office the same day they called, so I decided to send every root canal to him. My patients thanked me for the referral, he took great care of them and if there was any complication (which is inevitable when you deal with biology) he dealt with it. I enjoyed it so much that I found the best in every specialty and referred my patients there. He was an extension of my practice.
A paradigm shift
I then found the best oral surgeon and sent every extraction there. Though I was very well trained in implant placement, I only restored implants placed by my periodontist and oral surgeon. I had done a ton of Invisalign, but my orthodontist now handled every case that needed straightening. I focused my energy on becoming the best restorative dentist I could be and never looked back. My practice grew, I dealt with far less emergencies and somehow did better financially. Best of all, because I was working with the best specialists in town, my practice life was a breeze. At the same time, I had a ton of friends who rarely referred. Was the decision of referring to a specialist simply a personal decision for the general dentist and had nothing to do with who was better trained?
Some perspective on general dentistry
When my dad became a general dentist in the early 1960’s there were two materials from which he could make crowns: Gold and acrylic. Cosmetic dentistry hadn’t been elevated yet and implants weren’t an option for patients. Bonding didn’t exist and the high speed drill hadn’t been invented. In short, you COULD learn everything about general dentistry and be an expert in everything. If you could take out teeth well and perform root canals well, you were a rock solid clinician. Fast forward to 2016.
The body of knowledge in dentistry is expanding rapidly. There are more dental journals than I can list, each with numerous studies every single month related to a new technique or material useful in some sort of specialty procedure. As Malcolm Gladwell mentioned in his book “Outliers”, it takes 10,000 hours to master something. That means if I do nothing but orthodontics for 40 hrs a week , it’ll take me roughly 5 years (including residency) to be a “master” at it. So, how does a dentist who does orthodontics for an hour or 2 a week become a master? Fair question, right? Are we to believe that a general contractor can make cabinets as well as a cabinet maker who only does that? Or that your internal medicine physician should deal with your heart issues instead of a cardiologist? I hope not.
There are a ton of general dentists who truly care about their patients, do great work and refer just the “hard” cases to specialists. Any specialist will tell you that there’s really no such thing as an “easy” case. Some are easier than others, but every case requires attention to detail, thorough diagnosis and proper treatment. There’s value in what my mentors told me when I became an orthodontic resident. He said that my job was now about learning “more and more about less and less”. So true.
So, when should one see a specialist?
I am not saying that dentists should just do crowns and fillings. However, when braces, root canals, implants or other treatment is necessary, general dentists should properly educate patients about the option of seeing a specialist. There are obvious benefits (mastery of the procedure) and perceived downsides (travel to another office, slightly higher cost, new relationship) of seeing a specialist. Patients should be given the opportunity to say “yes, I do want to see a specialist” instead of being greeted by a treatment coordinator who says “Dr. X would like to place those two implants for you. How does next Tuesday sound?”
There are numerous discussions about referral/non referral on dental websites. Nobody will ever be able to prove which is correct. Many general dentists believe that they can treat the “easy” cases as well as specialists can and others (like myself when I was a GP) want to focus their practice on restorative dentistry alone. What I can tell you is that for the vast majority of dentists that I know who do not refer much, when their kids, spouses or staff need wisdom teeth out, they usually see a specialist. The same can be said when they need braces.
The patient should decide
My friends who are GPs generally believe that they are doing their patients a favor by not referring many of the cases to a specialist. I’m not saying that general dentists shouldn’t do specialty procedures. I never want to tell someone else what they should and should’t do. What I am saying is that if I went to my internist and he simply decided to deal with my heart issue instead of at least bringing up the pros and cons of sending me to a heart specialist, I’d be really angry. There should be thorough education to every patient regarding the benefits of seeing a dental specialist and it should be the patient’s choice of who they see, not the dentist’s.
As always, please feel free to contact me with any questions or comments at doc@Kriegerorthodontics.com .
All the best,
Glenn
The Dental Sherpa 
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