Dr. Jesse Watkins is a soft-spoken, personable man. Though few dentists fail to quickly notice his intelligence and technical skills, it is his humility that is most impressive. His patients recommended him warmly for his skill but especially for his gentleness and compassion. He graduated several years ago from the state university’s graduate periodontics program. It was a gutsy choice on his part to enter the program; he gave up a solid, five-year-old middle-class general dentistry practice in his old family neighborhood and knew he would be dependent as a periodontist on referrals from general dentists of many different backgrounds. But in addition to his desire to meet the intellectual and technical challenges of specialized practice, this was also his way of partly repaying his personal debt to those who had given him the opportunity to receive an education when many of the talented youth with his background did not get one.
He located his specialty practice in a near suburb of the state’s largest city, close enough to the city’s middle-class minority neighborhoods that he might get referrals from the little group of minority general dentists who served them. But he also knew he needed referrals from the majority of dentists in both the city and the suburbs if his practice was to survive.
During the first lean years, he and his wife made ends meet with her position as an account executive at a local television station. Dr. Watkins spent a lot of time visiting general dentists throughout the area and teaching continuing education classes on periodontics for general dentists through the local dental society so that he would become known. Now, in its fifth year, Dr. Watkins’s periodontics practice is solidly established, with a lengthening list of faithful patients and a large number of referring dentists from many ethnic backgrounds.
At present, two patients sit in Dr. Watkins’s operatories. Alonso Nelson was referred by Dr. Jack Chong, whose practice serves patients from a dental program for the city’s transit workers union. Many general dentists would not refer Mr. Nelson, preferring to trust their own skills and keep Mr. Nelson from having to bear costs, travel inconvenience, and additional time spent traveling to a specialist. Dr. Chong is not overly cautious about treating the more common forms of periodontal diseases, but he has found his past collaborations with Dr. Watkins to be very constructive. So Dr. Chong is confident that Dr. Watkins will not only do a good job for his patients but will contact him if anything about his own work needs attention before talking with his patients about it and that Dr. Watkins will encourage his patients to continue working with Dr. Chong as their general dentist. Dr. Watkins has given Dr. Chong useful information and helpful advice about a few patients in the past, and Dr. Watkins, in turn, has always taken Dr. Chong’s comments and insights seriously. So, rather than performing a procedure for Mr. Nelson that Dr. Chong has done only a couple dozen times since dental school and that he would need to reschedule for a later date in any case, he prefers to send Mr. Nelson to a specialist who does these procedures twenty or thirty times a week.
Mr. Nelson enters Dr. Watkins’s operatory well informed about his periodontal condition and the procedures that Dr. Watkins will likely discuss with him. Mr. Nelson suffers from diabetes mellitus and self-administers a daily regimen of insulin injections. In spite of a daily oral hygiene routine carefully developed by Dr. Chong and his dental hygienist, Mr. Nelson’s diabetes is obviously beginning to take a toll on his gums.
After reviewing Mr. Nelson’s medical and dental history and examining his mouth, Dr. Watkins notes several indications for possible full-mouth periodontal surgery. But he is also concerned, taking everything into account, that full-mouth surgery for Mr. Nelson at this time might do more harm than good. He thinks it may still be possible to buy Mr. Nelson more time before that step would be needed. If this second path is followed, Mr. Nelson will need to work even more closely with Dr. Chong and his dental hygienist and also make regular visits to Dr. Watkins’s office to assure things don’t quickly get out of hand. But putting off the risks of full-mouth surgery, even for one year, are worth the effort in Dr. Watkins’s judgment.
Before discussing these thoughts with Mr. Nelson, Dr. Watkins calls Dr. Chong’s office. Dr. Chong is finishing up with a patient at that moment, so Dr. Watkins asks Mr. Nelson if he can wait a few more minutes until Dr. Chong is free. When Dr. Chong comes to the phone, Dr. Watkins explains his thoughts and asks Dr. Chong if there is anything he may have missed. When Dr. Watkins determines that he and Dr. Chong are in agreement and that Dr. Chong’s hygienist will also be on board, Dr. Watkins and Mr. Nelson speak via speakerphone with Dr. Chong and his hygienist, and the four of them go through the treatment plan in detail. Mr. Nelson agrees with every step and is grateful to have the surgery postponed for a time.
Meanwhile, Kathleen O’Gara is in Dr. Watkins’s other operatory. She recently moved to the area from the town where she was born and now works at the same television station as Watkins’s wife. Kathleen began noticing some pain when chewing, and because of the distance, she does not think it reasonable to go to the dentist who had treated her since she was a teenager, Dr. Herbert Schmidt, whom she liked a lot. So she has gone to a local clinic where she has been informed that she has severe periodontal disease and periodontal surgery is advised. She can’t believe it; Dr. Schmidt never mentioned such a thing. So, having heard from someone that Sarah Watkins’s husband is a periodontist, she found him in the telephone book and made an appointment.
On examination, Dr. Watkins confirms that Ms. O’Gara has an advanced form of periodontal disease. Ms. O’Gara gets very angry when she hears this and tells Dr. Watkins she expected the husband of a friend to say something less frightening. (Dr. Watkins has never heard his wife mention Ms. O’Gara, and his wife later confirms that she barely knows her.) Dr. Watkins gently acknowledges the emotional response, bypasses the familiarity comments, and simply asks Ms. O’Gara if Dr. Schmidt had ever spoken with her about gum disease.
“He would look at my teeth and then clean them with that little rubber thing on the drill,” she answers. “The last couple of visits, he said he found some deposits or something and that he would scrape it off. But it made my gums bleed. I really didn’t like it. Once in a while he would have to do a filling. But he said my teeth were very strong. He said that every year, twice a year, since I was fifteen. That’s seventeen years of strong teeth. Now I move away and I’m told my teeth are in wretched shape. I want to know what’s going on.”
“I’m a specialist, Ms. O’Gara, but I did practice as a general dentist for five years before going into periodontics, so I think Dr. Schmidt was quite justified in saying you have strong enamel and a good bite. I don’t see any signs of active decay and only a few small fillings. All of these are signs of excellent teeth. That’s why I asked if Dr. Schmidt ever specifically talked about the health of your gums. Strong teeth need healthy gums to do their work. The scraping on your last two visits might well have been aimed at treating a periodontal condition, especially if Dr. Schmidt was going down below the gum line.”
“He’s a very good man. I can’t imagine that he would have forgotten to tell me anything important about my teeth. He’s the only dentist I ever went to who was kind and considerate. The dentists my parents took me to when I was little were like dictators—they had no compassion. I used to cry and scream every time I had to go, until I went to Dr. Schmidt. My girlfriend’s mother recommended him when I was in high school. I went to him and never went anywhere else after that. He certainly would have told me if something was wrong with my gums. Couldn’t all of this have happened since I last saw him?”
“How recently was that?” asks Dr. Watkins.
“I moved here eight months ago. I had a checkup and cleaning about six months before that. I was due for another when I left there, but I figured I would wait until I found a new dentist here. Then I never got around to it. I guess I was nervous about starting with a new dentist, since I had so many bad experiences before Dr. Schmidt.”
“There are exceptions, but it’s rare for a periodontal condition like yours to sneak up on a person,” says Dr. Watkins gently. “May I ask if Dr. Schmidt took X-rays of your teeth at your regular checkups, especially after he started that scraping? X-rays can help show if a periodontal condition exists—even if it’s not obvious just by looking in the mouth.”
“I don’t like X-rays, doctor, and Dr. Schmidt and I had an understanding about that,” says Ms. O’Gara. “He used to take them when I was younger, but once I heard of the risks, I told him I was opposed to them. He wasn’t happy about that, and the more he explained the more I felt like I was being pushed into something I didn’t want. I told him so and he stopped.”
“Have you noticed bleeding around your gums?”
“Yes, but that’s what happened when Dr. Schmidt did the scraping, and I didn’t like it.”
“Has that been going on for a while?” asks Dr. Watkins.
“Did you ever discuss that with Dr. Schmidt?”
“It didn’t happen very often until recently, maybe last spring. Before that it was just now and then. I don’t remember being worried about it, but I suppose I might have mentioned it to him. Like I said, his scraping made my gums bleed, so I might have mentioned it then. Are you saying he should have been paying more attention to my gums?” asks Ms. O’Gara.
“Your periodontal disease has undoubtedly progressed since you last saw Dr. Schmidt, if that was fourteen months ago,” says Dr. Watkins. “But it’s unlikely there were no signs then. Dr. Schmidt probably thought the scraping plus your regular oral hygiene would be enough to keep it under control. He probably didn’t want to alarm you unnecessarily. Perhaps he figured keeping a close eye on the condition—because you were so regular with your checkups—was enough. Did he show you how to brush and floss as part of your daily care?”
“No, he never mentioned using dental floss or I would have gotten some. You are saying he would have found something fourteen months ago if he had looked, aren’t you?” asks Ms. O’Gara.
“Well, I wasn’t there, obviously, and I haven’t spoken to him or seen his records. I can certainly say that for someone of your age and history the disease in your mouth is far enough advanced that it would be unusual for the more common kinds of periodontal disease to go from being unnoticeable to this point in only fourteen months.”
“Then what are you going to tell me to do?” asks Ms. O’Gara, clearly upset.
“You obviously had a very positive relationship with Dr. Schmidt,” says Dr. Watkins, “and that is something to build on now. Dr. Schmidt did a fine job with the small fillings you needed. If you wouldn’t mind, I want to contact him to see what he noted about your periodontal condition back then and whether he had any plans in mind regarding it. I can offer better care when I’m able to work closely with a patient’s regular dentist. Dr. Schmidt cared for you the longest and was the most consistent with you until now. But since he’s quite a distance away, I would still recommend you contact a general dentist in this area. Hopefully we can help you establish a good long-term relationship like the one you had with Dr. Schmidt.
“As for your periodontal disease itself,” continues Dr. Watkins, “I understand how disappointed you must feel, learning about all of this so suddenly. But there is plenty that can be done. It’s also not so far advanced as to be a serious threat if you begin to take action now. I would be happy to develop a treatment plan for you if you would like. It will involve medications and other periodontal treatments, including some surgery, and also working closely with my dental hygienist. We will need to help you develop a pattern of self-care to prevent the condition from worsening now or recurring later. I would also work closely with your general dentist here when you get one.”
Ms. O’Gara silently studies Dr. Watkins’s face for a few seconds, then stands up from the chair, takes her purse from the counter, and heads for the door. “I don’t think I can ever trust any dentist again,” she says, and she is out of the office before Dr. Watkins can say another word.
Ms. O’Gara never returns to Dr. Watkins’s office and declines to speak with his receptionist when she calls to ask how Ms. O’Gara is doing and if she has additional concerns or questions. Several weeks later, though they barely know each other, Ms. O’Gara goes out of her way to tell Sarah Watkins, “I have nothing to say to you.” Hearing of this strange incident from his wife, Dr. Watkins becomes more concerned about Ms. O’Gara’s final words as she left his office. Though Ms. O’Gara did not give him clear permission to contact her previous dentist, her expressed lack of trust in all dentists and her history of dental fear prompt Dr. Watkins to carefully consider the next step. Ms. O’Gara still needs proper follow-up, whether from the clinic that referred her to his office or another local dentist or periodontist or perhaps a special counselor for her dental phobia.
Having little else to go on, Dr. Watkins makes a call to Dr. Schmidt. He tells him that Ms. O’Gara has visited his office and about her severe periodontal disease. Dr. Watkins explains that she left suddenly and without treatment, although its importance was explained to her. He wants Dr. Schmidt to be aware of this in case he hears from Ms. O’Gara or perhaps wants to take the initiative of calling her about getting treatment.
Dr. Schmidt tells Dr. Watkins that he remembers Ms. O’Gara very well and that he had been treating her for a periodontal condition when she was his patient. “It was completely under control at that time,” he explains. “As usual, a little scaling and regular use of the toothbrush was all that was needed. I sometimes wonder how you periodontal specialists stay in business.”
Dr. Watkins wishes Dr. Schmidt well and politely ends the conversation without saying anything more or trying to answer his question.
Many strands of American culture, and many aspects of dental training as well, conspire to inculcate a picture of dental practice—and of human life in general—as something that is principally accomplished alone. Many important and undeniable facts about dental practice give the lie to this picture. Besides the obvious contributions of the members of their office staff and, for most dentists, a chairside assistant, all dentists continually depend on the work of dental and biomedical researchers, and all researchers, in turn, depend on dentists and others in practice to share their experiences and data. Together they can better articulate the needs of patients and how their research efforts and treatment recommendations affect patients’ oral health needs. General dentists are also unavoidably dependent on specialists for cases they can’t or do not want to handle; specialists, in turn, depend equally on general dentists to refer patients to them and for maintaining the continuity of patient care. The specialist’s work, like that of the generalist’s, is carried out within the context of patients’ lives, basic home care routines, and the possibility of other complex medical and oral conditions. All dentists also depend in a number of ways, then, on the educational and therapeutic initiatives of public health dentists; public health dentists, in turn, depend on the educational and preventive activities of dentists in office-based practices.
Every dentist’s success in practice, in other words, depends on collaborating effectively with many individuals and institutions, as well as on working together through formal dental organizations and informal groups of many sorts. Nevertheless, these facts can fade in significance under the influence of our cultural perception of dentists as single-handedly confronting the challenges to patients’ dental health—the picture of dentists that most often dominates both the profession’s and the public’s imagination.
Because of this perception, the most underdeveloped of the nine categories of professional norms described in chapter 3—not only for dentistry but for all our society’s professions—is the category of Ideal Relationships Between Co-professionals and Others Assisting in Care. Many readers may even be surprised that the authors consider this a category of professional norms for dental practice; guidelines for conduct in this area may well seem more like rules of etiquette among dentists than norms of ethical professional conduct. But some guidelines for conduct of relationships between co-professionals do clearly state that these are matters of professional obligation for dentists, and there are important reasons for seeing a general ethical commitment to effective collaboration as part of dentistry’s ethics.
First, some of the more familiar categories of professional norms that have already been mentioned have clear implications about the relationships of dentists with their co-professionals. For example, the norm of Competence obviously requires that dentists not practice beyond their expertise; hence, referring patients whom they cannot adequately care for in their practices to other professionals who can care for them is a form of professional competence. The Central Practice Value of Autonomy and the Ideal Relationship between dentist and patient both require that this referral not undermine the patient’s relationship with his or her general dentist. In addition, if dentists believed that how they viewed and treated one another made no professional difference, then this and many of dentists’ other obligations to their patients would be almost impossible to fulfill.
Suppose that both the general dentist and the specialist viewed themselves as “lone rangers,” responding to patients’ dental needs without acknowledging their dependence on collaborators. Each would work to strengthen his or her own relationship with the patient and connect with the other practitioner only grudgingly when the limits of his or her expertise had been reached rather than trying to bring the patient the greater benefit of two heads and two lives of rich professional experience working together. The authors submit that this is only one of many aspects of dental practice in which the relationships of co-professionals are not matters of professional indifference. The picture of the dentist as a “Lone Ranger” is a myth. The provision of appropriate care for patients is dependent on dentists working together and, as chapter 15 will stress, a dentist’s ability to grow in professionalism also depends on his or her development of positive, collegial relationships with other dentists.
Because this component of the professional-ethical practice of dentistry has been so little examined, this chapter will survey a number of areas of dental practice in which, in the authors’ judgment, a self-conscious commitment to effective collaboration can make an important difference.
The most obvious example of professionally required collaboration is the one emphasized in the introductory case and in the examples used so far—namely, collaboration between the general dentist and the specialist. On the other hand, general dentists might send their patients to specialists only after they have realized, through experience, that they have practiced beyond their ability, and specialists might simply treat the patients and send them back to the generalist without a spirit of collaboration. But where collaboration is highly valued and where working with another dentist is viewed as a positive component of good patient care, the general practitioner’s temptation to practice up to or even beyond the limits of his or her current expertise is lessened. Thus, fewer errors occur as the result of a dentist practicing at or beyond the capabilities of his or her technical skills and knowledge, and patients are likely to receive better overall care. General dentists are also not afraid that the specialist will fail to support, or may even undermine, the general dentist’s relationship with and work for the patient. For when the care of the patient is viewed collaboratively, then the specialist has a clear obligation to support and strengthen the patient’s relationship with the general dentist. Nor will the specialist begrudge “returning” the patient to the general dentist. For in the specialist’s view, if care of the patient is genuinely collaborative, the patient has never “left” the generalist’s care. At its best, in fact, collaborative care of a patient is team care. The generalist and specialist view themselves as caring for the patient with combined knowledge and combined skills, each respecting the contributions of the other and each working to integrate his or her own contribution with the positive contribution of the other (rather than working to have the patient view his or her own contribution as the one that is the most important).
This picture of collaborative practice is, admittedly, somewhat idealized because of the often competitive nature of dental practice in today’s society and because of the demands of daily practice on each dentist’s time and energy and also because of the social and economic history of American dentistry as a profession which was previously practiced almost exclusively solo. A dentist can say to the larger community, “Our society has created pressures that draw us into competition and conflict. Therefore, that is how I shall live and practice.” But this is not necessary, and it is certainly not the best way for dentistry to serve its patients, individually or collectively. Instead, dental care can be viewed as being inherently collaborative, and dentists can affirm this reality about their profession in their actions and in their education of the larger community about dental care.