"Training matters. Competence certainly matters. But I’d argue that what matters even more is your integrity. It’s what drives you to be better, to do the right thing and treat people well."
Dr. Joe Vaughn
WSDA News Editorial Advisory Board
I recently received a newsletter from a specialist that featured a shocking front page “Case-Gone-Wrong.” Treatment had been started by a general dentist, but then just short of disaster, this specialist stepped in to correct it.
There were two messages on the front page of that newsletter. The explicit one, “Look at the great result we achieved in spite of the difficult situation we inherited.” And then the one between the lines, “GPs shouldn’t be doing this work. See the terrible things that can happen when you don’t refer?”
I get that.
I can appreciate how tough it must be as a specialist fixing someone else’s mistakes, having those really tough patient conversations, and knowing the result won’t be as good as it would have been if you were the original provider.
I also know that this tends to be a pretty touchy subject for our entire profession, but it’s so important for us to have this discussion. Heavier debt loads, unfair benefit plans, and improving technology are driving more GPs to consider performing specialty procedures.
And while I did agree with the newsletter that day, the underlying message didn’t feel so good. It was taking a very complex issue, with many variables at play, and instead simplified it to:
“Refer. Because we can do it better.”
Many times, I’m nodding my head to the “we have more training” and “we’re better at handling complications” arguments. They’re rock solid… most of the time.
But I believe that “who can do it better?” is actually the wrong question.
“Who can do it better?” takes us through a complicated flow chart where at the end, I’m no longer a general dentist. I’m just a professional referralist, because that’s all the chart says I’m “best” at. Making matters worse, we can’t decide which specialist “does it better,” so I’m really not that good at referring either.
We could go on talking about training, clinical hours, and cases. When are you competent? When are you capable? Why isn’t there a standard, an exam, or any guideline at all? And this is when the conversation gets really, really uncomfortable.
The fact is, it’s a grey area. And at the center of the grey, I think there’s something that matters much more than “who does it better?”
Last year, my sister had a terrible toothache on #14. As a law student, she qualified for California Medicaid, which covers posterior root canals. I was thrilled to hear that she had an appointment with an endodontist, but her call after the appointment was very disappointing.
“Twenty-three minutes!” she proclaimed. “It only took 23 minutes from the time they put on that rubber dam thing until they finished. I timed them!”
Ten months later, I got another call. The toothache had returned, even worse than before. A few stressful days and several phone calls later, my sister had an endo retreat with an MB2 canal found by a different endodontist. This time though, payment was completely out of pocket.
Training matters. Competence certainly matters. But I’d argue that what matters even more is your integrity. It’s what drives you to be better, to do the right thing and treat people well.
Visiting Japan last year, I had dinner with my friend Hiroki who I met through a dental school exchange program. It was fascinating to hear him describe the dental landscape there. Everyone has universal dental coverage, and many dentists take big pay cuts when treating under that plan. This sometimes leads to poor, unethical work, and there isn’t a reliable quality assurance system to monitor and restrict that.
When I asked why some dentists in Japan do great work and others don’t, Hiroki just raised his finger and tapped his chest.
“It’s what’s in here.”
On Instagram, I see specialists attempting brand new techniques and GPs experimenting with new products. We all take new courses and try new things. Dental school is definitely not the last time we do something for the first time.
So it’s a delicate balance. And at the end of the day, the only way it can work is if we all meet in a space where everyone’s heart is in the right place. Where GPs can ask specialists about a case they want to take on and there’s no fear of judgement or ill-will. There’s no more need for shocking newsletters, because cases that should be referred actually get referred. It’s a space where everyone is held accountable, and where who does the treatment matters much less than the quality of the treatment.
I hope you’ll meet me there.
This editorial originally appeared in the Fall 2020 Issue of WSDA News.
The views expressed in all WSDA publications are those of the individual authors and do not necessarily reflect the official positions or policies of the WSDA.