Collaborative interdisciplinary agreements
A new paradigm in laboratory and specialist communication and patient care
Mark T. Murphy, DDS
The restoration of a patient’s oral health is in some ways comparable to the building of a house, as it often involves and requires a team. For restorative dentistry, this team can include specialists, the restorative dentist and the dental laboratory technician working in collaboration with clearly defined goals and open communication. It also is important to note that the patient is an integral part of the team and that, like the homeowner, the patient is ultimately in charge and makes the final decisions.
Like the builder, the restorative dentist must work in a coordinated fashion with all of the subcontractors (specialists and laboratory technician) to perform each task well and in the correct time-sensitive order for successful results to occur. This means the team must confer regarding, plan, give feedback regarding and share in the common goal for the initiative to yield the best results for all. For dentistry, this can be referred to as an "interdisciplinary collaboration."
To clearly define the expectations of each member within this interdisciplinary collaboration, one should consider the concept of developing an agreement (in business referred to as "position papers" or "white papers"). Without clear agreement on the expectations and the outcomes of treatment, mistakes can and do occur easily—mistakes that compromise the quality, and can affect the amount, of treatment.
In the world of construction, lack of collaboration and misunderstanding of documents have added hundreds of thousands of dollars to building costs. A single hyphen omitted from a government construction order for a nuclear installation may hold the record. A manager ordered rods of radioactive material cut into "10 foot lengths." He received 10 one-foot-long pieces instead of the 10-foot lengths required. The loss was so great that the information was classified by the government.1 Similarly, lack of collaboration and resulting misunderstandings can have a substantial negative impact on a patient’s dental care.
Gone are the days of simply sending a patient out for a consultation and hoping that the specialist can guess the treatment plan the dentist has designed or will design on the basis of the specialist’s findings. It behooves all involved to create a carefully communicated understanding of what each contributor is expected to do before the patient is sent to the specialist. If all professionals involved have an intentional plan for how they will diagnose, plan treatment for, communicate with and treat a patient, then there is an increased likelihood that the patient’s best interests will be served in the long term. Similarly, it is essential to have intentional plans for communicating and working with the laboratory technician, as clinical decision making and treatment often require his or her input.
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MULTIDISCIPLINARY VERSUS INTERDISCIPLINARY INTERACTION
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If input from specialists and the laboratory technician is sought in a linear fashion (Figure 1
) merely through repeated referrals from the restorative dentist (in other words, in only a multidisciplinary fashion), the opportunity for coordination of optimal care can be lost. In this approach, after receiving treatment from the specialist, the patient returns to the referring dentist for the next phase of care, which may or may not be either appropriate or in the appropriate sequence for the patient. By looking at the case as an interdisciplinary team in which collaborative interaction occurs, expectations and an optimal treatment sequence can be laid out by all contributors before treatment begins.
Spear2 noted the characteristics of an interdisciplinary team: commitment, self-confidence and competence. This article will describe a methodology for implementing this strategy successfully. It will provide a framework for having the appropriate discussions with the laboratory and specialists to open the door to success. The interdisciplinary approach is multidisciplinary, with the addition of clear collaboration on a multitude of factors that create the optimal treatment environment for the patient (Figure 2).
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POSITION PAPERS, OR DEVELOPING COLLABORATIVE RELATIONSHIPS
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The use of white or position papers is the norm across most businesses and even for the American Dental Association,3 the American Dental Education Association4 and the American Academy of Periodontics.5 The use of this concept is a collaborative agreement, not a one-directional proclamation, and thus is preferred today. According to Chris Sager, executive director of The Pankey Institute, "These ‘position papers’ are not meant to supplant the interactive communication amongst the professional team, but rather to support the development of additional areas of concurrence between independent operating entities."6
Rather than a top-down statement that describes the initiator’s beliefs and positions on a plethora of topics, the concept is one of an open dialogue about what each participant needs so that he or she can do his or her best on behalf of the patient. Topics such as referral protocol and the records that should be sent enhance the patient’s experience and the caregivers’ professional competence. Even such seemingly mundane items as financial arrangements should be discussed in advance among the members of the interdisciplinary team.
The development of these is so important in comprehensive care practices that the Pankey Institute Continuum series of continuing education courses includes an exercise of authorship of collaborative agreements. In this exercise, dentists and specialists are instructed in communicating and documenting how they want to work with each other and their dental laboratories to maximize the opportunity to diagnose, plan treatment for and treat each patient optimally and collaboratively. Below, I list several topics for inclusion.
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ASK, DON’T TELL
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In my own journey toward interdisciplinary communication, I initially told my specialists and laboratory what I needed and expected from them. Fortunately, they used this opportunity to begin a dialogue about optimal care. What followed was much more a group effort than simply my stating a position I had taken.
For example, with the periodontist to whom I refer patients, I explored what he needed me to do to prepare the patient for his care. Items such as which radiographs to send, the tentative treatment plan, treatment philosophies about when to maintain a pocket depth and when to perform surgery (and why) all are examples of topics that we needed to clarify early in the relationship. We also decided to alternate continuing care visits between our offices in difficult postsurgical cases instead of one or the other of us carrying out all of the follow-up. We even discovered we needed to understand what a pocket depth or attachment level loss meant to each other and therefore sought calibration between our practices.
As our collaboration discussions continued, we even invited some patients to participate in some fact-finding tests. All of our hygienists participated with us, and our comparisons and the discussion of what the results we obtained meant for patient care led to a deeper and clearer communication of our mutual goals and objectives.
The easiest path to this level of understanding is to ask, not tell. By asking specialists and laboratory technicians what they need to do their best for the shared patients, they not only are likely to tell the restorative dentist but also ask the same question in return. The focus should be less on what the restorative dentist wants from the other members of the team and more on what each member of the team can do to help create optimal oral health for the patient.
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TOPICS FOR DISCUSSION
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An open "position" discussion will not be completed in one brief lunch meeting. Experience indicates that the process can be framed by an agenda that includes discussing the reasons for the process (optimal patient care and relations, optimal professional relations, efficiency, increased referrals) and how each can help the other concerning a long list of issues. This list includes the following:
- – hospitality toward patients;
- – philosophy of care;
- – referral slips or letter inclusions;
- – the role of occlusion;
- – patient records and appropriate imaging;
- – specific therapy issues;
- – financial arrangements and patient preparation;
- – periodic calibration;
- – dentists’ preferences regarding restorative materials;
- – how and when to communicate with each other.
This list of topics can serve as a guideline for beginning a dialogue with specialists and laboratory technicians. Do not think of it as the endpoint, but rather as the start of a collaboration that will yield significant returns for you, your new team members and your patients. This win-win-win style of intellectual and knowledge investment return is the currency of the future. By revisiting and updating these agreements over time, you will find that your relationships with colleagues will grow.
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FOOTNOTES
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Dr. Murphy is the director of marketing and professional relations, Pankey Institute, One Crandon Blvd., Key Biscayne, Fla. 33149, e-mail "mmurphy{at}pankey.org". Address reprint requests to Dr. Murphy.
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REFERENCES
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- Blundell WE. Confused, overstuffed corporate writing often costs firms much time—and money. Wall Street J 1980 August: 20, 21.
- Spear F. Forming an interdisciplinary team. JADA 2005;136:1463–4.[Free Full Text]
- Berthold M. ADA white paper targets care for the underserved. Available at: "www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1143". Accessed July 11, 2006.
- Position papers (as approved by the 2003 House of Delegates [of the American Dental Education Association]): Exhibit 9—statement on peer review. J Dent Educ 2004;68(7): 752–8.[Free Full Text]
- Clinical/scientific papers: AAP position papers. Available at "www.perio.org/resources-products/posppr3-3.html". Accessed June 30, 2006.
- Sager CB. Director’s message. Pankey-Gram 1993 Spring:1.
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MULTIDISCIPLINARY VERSUS...
POSITION PAPERS, OR DEVELOPING...
