What constitutes a referral, and when should I refer?

The principles of ethical dental practice set out a number of obligations toward patients.¹ The primary responsibility of dentists is the health, welfare and safety of their patients. Furthermore, dentists should perform treatment only within areas of their competence and if appropriate, referral for advice or treatment to other colleagues should be arranged. This issue of referral between dental practitioners is the subject of this article.

The experience of Guild Insurance in assisting dental practitioners is that there appears to be some misunderstanding as to what constitutes a referral. So what is a referral?

Appropriate referrals are part of complete quality dental care and referrals are an essential part of managing the patient's dental care needs. Dentists are expected to recognise the extent of their patients' treatment needs and when referrals are necessary.

A primary dental practitioner ought to consider referral to another practitioner whenever the welfare of the patient will be safeguarded or advanced by utilising those who have special skills, knowledge and experience. Patients may need to be referred for several reasons. Any one or any combination of the following situations or conditions may provide the dentist with appropriate rationale for referring a patient:

• Level of training and experience of the dentist.
• Dentist's areas of interest.
• Extensiveness of the problem.
• Complexity of the treatment.
• Medical complications.
• Geographic proximity of specialist.
• Patient load.
• Availability of special equipment and instruments.
• Staff capabilities and training.
• Patient desires.
• Behavioural concerns.
• Developmentally disabled or handicapped patients.
• Desire to share responsibility for patient care.

In the event that a dental practitioner forms the clinical view that referral to a particular dental specialty is warranted it is crucial that the referring practitioner explain to the patient what it is that the specialist practitioner does. We have dealt with a number of matters where a patient has been referred to another practitioner and turns up completely ignorant about why they are there, causing embarrassment and confusion for all involved.

To avoid this situation arising it would be prudent that the referring practitioner ensure that the following matters are considered:

• An assessment of the patient's ability to understand and follow instructions.
• Explanation of the problem to parent or guardian, if the patient is a minor.
• Indication of which area of dentistry or specialty is chosen and why.
• A specific appointment made while the patient is in the general dentist's office.
• If known and requested by the patient, information about the specialist fee for the initial consultation or examination.
• Instructions that will assist the patient's introduction to the specialist ie directions to the specialist's office.

Communication between the specialist and the referring dentist is critical. The patient should receive clear and consistent information about their dental problems and treatment from all dental professionals. Mixed messages can confuse and frustrate patients and can undermine their confidence in the care provided.

It is the role of the primary treating dentist to manage the overall dental health care of the patient. With that in mind, in treating a referred patient the specialist shall: ³

• keep the referring practitioner informed of progress
• not make additional referral without the consent of the referring practitioner
• not perform services which are outside his/her speciality without the consent of the referring practitioner, and
• after completion of treatment direct the patient back to the referring practitioner.

What a referral is not

From the above it is suggested that a referral is a formal process which involves a letter of referral and arranging an appointment with the specialist practitioner if necessary. We sometimes hear dentists say that they "referred" a patient when in fact all they have done is discussed with the patient the option of treatment with a specialist practitioner.

Whilst the primary dentist might put a treatment option to the patient of having the work done by a specialist practitioner, this is not a referral. The provision of such an option is in the context of a discussion about treatment options and is very different to a referral being made to a specific practitioner.

Take for instance the example of nerve injury following tooth extraction. A generalist practitioner may discuss the option of referral to an oral surgeon to assess the injury. That is not referral. To have had the discussion is a starting point but in order to have satisfactorily referred the patient, somewhat more is involved. That is, arrangements are made for the patient to see a particular specialist, say an oral surgeon in this case, and a letter of referral is completed and provided to the patient and to the specialist to whom the patient is being referred. Whilst on this point, it would be our strong suggestion that whenever a letter of referral is completed, a copy be maintained on the patient file, the original given to the patient and a further copy sent to the practitioner to whom the patient is being referred.

It is important to recognise that at law a patient will not be considered to have been referred to another practitioner unless and until arrangements have been made with a particular practitioner, the patient is made aware of the details of the referral and a letter of referral has been provided to the patient.

KEY LEARNINGS :

• Dentists should perform treatment only within areas of their competence and if appropriate, referral for advice or treatment to other colleagues should be arranged.
• A primary dental practitioner ought to consider referral to another practitioner whenever the welfare of the patient will be safeguarded or advanced by utilising those who have special skills, knowledge and experience.
• Whilst the primary dentist might put a treatment option to the patient of having the work done by a specialist practitioner, this is not a referral.
• In the event that a dental practitioner forms the clinical view that referral to a particular dental specialty is warranted it is crucial that the referring practitioner explain to the patient what it is that the specialist practitioner does.
• A patient will not be considered to have been referred to another practitioner unless and until arrangements have been made with a particular practitioner, the patient is made aware of the details of the referral and a letter of referral has been provided to the patient.

1. Australian Dental Association Inc - Policy Statement 5.4
2. American Dental Association - Principles of Ethics and Code of Professional Conduct
3. Australian Dental Association Inc - Policy Statement 2.4

Don Grant, Senior Associate, Meridian Lawyers, on behalf of Guild Insurance