By Marc Ackerman, DMD, MBA

I practice orthodontics full-time in a hospital setting. My patient population is about as diverse as they come. Kids with chronic disease. Kids post-transplant. Kids with intellectual disabilities. Kids with syndromes. Kids who are termed well-children. There isn’t a day that goes by where I don’t see something so unusual that I might not see it again in my practice lifetime. I am often asked by friends, colleagues, and parents of prospective patients how I am I able to treat such cases. The answer is simple: I treat each patient the best I can in light of their limitations, my limitations, and in some instances, I elect not to treat them at all!

I have no magic wand, no miracle drug, and definitely no special appliance system.  It’s remarkable though how many general dentists, pediatric dentists, and orthodontists think that I do. My favorite referral that comes in is usually from an outside orthodontist who has examined a patient, brought them back for records (fee charged), and then dismissed them from the practice on the basis that the patient is too difficult to treat. The last line of the referral letter is usually something like this, “You should consider general anesthesia and/or sedation to treat this patient.”  So let me get this straight, I should take the patient to the operating room to place the braces, use some form of conscious sedation for all routine visits, take them back to the operating room if things break, and then take them back to the operating room one last time to take the braces off and take impressions for retainers.  Really?

When I examine an extraordinary patient, I remind myself of these things:

  • Be honest with yourself and the patient’s parent in that first meeting
  • I don’t know everything and I can’t do everything asked of me
  • There is nothing wrong with saying that you do not have the skill or experience to treat the patient, as long as that’s how you truly feel
  • If in your opinion the patient cannot be treated for a particular reason, tell the parent why and stand by it
  • Don’t take records if you know beforehand that you won’t treat the patient
  • If you are unsure about anything, let the parent know and offer a second opinion referral if you believe someone else may realistically be able to treat the patient
  • Will I do any harm if I try to treat the patient
  • Imagine that you are that parent

I think that we all could learn some beautiful life lessons from this type of referral, I sure have.  Really!

8 thoughts on “Really?

  1. so true…..I know my colleagues strengths and if I feel that patient can get a better result there…I have referred there in the past… When you are hammer, everything is a nail…..need to step back once in a while. Cant treat the world

    1. Sheldon:
      Totally agree. The ABO exam should test you on why you wouldn’t treat a case!

  2. This spoke to me. Truly. I’ve had a poor mentality regarding this type of stuff in the past but since I put on my big boy pants and been forthright with my opinion and more bold with my action I’ve been surprised with how well-received my treatment and treatment recommendations itself have been. Thanks Dr. A!

    1. Cole:
      You are really kind to say that. It is amazing how when you shift your mindset even slightly, practice becomes easier and much more fulfilling.
      I learned many lessons from your MKS talk! Everyone should hear you explain how to handle the tough conversation with the staff member that just isn’t working out!
      #IWISHIWASCOOLLIKECOLE

  3. This is fantastic advice that we should tell ourselves everyday with every patient, not just the special ones. Thanks for the reminder. I was taught the greatest of lessons one day when I was trying to figure out a way to tell a parent that I may not be able to achieve 100% correction. He looked at me and said “Doctor the initials after your name say DDS not GOD” I am forever grateful for that lesson years ago and have never forgotten it. Thanks again.

    1. Greg:
      Isn’t it amazing the first time we are all humbled by a parent or patient? I remember when I was trying to convince the parent of an extraordinary young man with autism that jaw surgery was essential for an ideal result. Dad looked me in the eye and said, “We don’t do perfection in this family!”
      I am really touched that you feel the same way as I. Thanks.

  4. A truly great post. If you are honest with yourself, you are automatically honest with your patients and their parents, as “night follows day.” Thank you for sharing your thoughts with all of us. For 40 years, I treated my patients in the same way…….

  5. Robert: 40 years, that is amazing! I hope that we all can be blessed with a long and fulfilling career. Thanks for the note.

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