We spoke in detail about transfer patients from out of town on Sunday and based on the response I wanted to discuss transfer cases from other orthodontists in the same town. In town transfers are probably an even more emotionally charged subject than out of town transfers and the strength of the feelings and opinions belies the importance of this topic.

  • “I won’t take in town transfers”
  • “I send them back to their orthodontist”
  • “They probably are behind on their payments”
  • “I don’t want a trouble maker in my practice”

The above are but a few of the derogatory statements I hear from orthodontists when discussing patients who want to move to them from another orthodontist in town. If you look at these comments you can detect several assumptions made by these statements individually and as a group.

  1. The patient is obviously the problem
  2. The orthodontist is not at fault
  3. I don’t want to meddle in another orthodontist’s case, not because I care about the other orthodontist, but because I would be offended if they meddled in my case
  4. Patients who question the orthodontist are bad
  5. It can’t be the orthodontist who is at fault (yes, this is repetitive but so is the thinking behind it!)

There are a multitude of problems caused by our prejudicial mindset and this mindset is shared by the vast majority of orthodontists. These assumptions go unquestioned and orthodontists almost universally agree that the patients are the problem. It’s always a good idea to question anything orthodontists all agree upon. Based on my experience, let me share a few common threads and recurring issues I’ve seen when it comes to in town transfer patients:

  1. Sometimes the patient is behind on payments or noncompliant. This happens probably ¼ of the time so it is always a good idea to talk to the orthodontist who is treating the patient and find out the scoop. Most orthodontists assume delinquency is the case 100% of the time but that’s not realistic or logical, though it is convenient for our egos.
  2. Sometimes people just don’t get along. The patient can be doing their job and the orthodontist can be doing theirs but it still may not work out. This seems to be the case in about ¼ of the in town transfer cases. In these cases, the patients and the orthodontists both need an outlet and a change. You can help them both!
  3. Sometimes the orthodontist is unreasonable and/or takes a dislike to a given patient or parent for no good reason. This happens about ¼ of the time. I’m always shocked when it happens but, when present, this situation becomes readily apparent when you call the original orthodontist if you let them do the talking.
  4. Sometimes the patient or parent is unreasonable and places unrealistic demands on the orthodontist in terms of treatment, time, convenience, attention, etc. I know we would like to think this happens more often but it’s the cause of an in town transfer about ¼ of the time just like the rest of the major issues.
  5. I’ve also seen countless variations of all these causes combined with hygiene issues, attitude problems, family issues or tragedies, and/or freak occurrences on both both sides of the orthodontist/patient equation.
  6. I’ve been party to each and every one of these issues and had patients leave my practice because of every single one of them. I am as human as anyone and can lose sight of the big picture just as everyone can.

The point is that assuming the patient is in the wrong and the orthodontist is in the right whenever you see an in town transfer is wrongheaded, egotistical groupthink that has been perpetuated in orthodontics for generations. This mindset is bad for us and bad for patients.

So What Can We Do About It?

Each and every one of us can practice in the way we see fit. That’s the beauty of what we do. However, if I may be so bold, I would like to suggest a few things to help us handle in town transfer cases more effectively.

  1. Agree to see each and every patient who calls your office wanting to transfer or wanting a second opinion. Even if they are from another orthodontist in town. Encourage the other orthodontists in your area to do the same. It is far better to get resolution with the assistance of a peer than to force a patient to call the state board or a lawyer because they have no other option. If you don’t know the orthodontists in your area make a point to meet them.
  2. Take a full set of records before you see the patient or call anyone.
  3. Before you call the original orthodontist, meet with the patient and ask open ended but neutral questions questions like, “What can I do for you today?” or “What can I help you with?” Don’t start off with things like “What are you worried about?” or “Why are you unhappy?”. The patient will tell you what is on their mind. Don’t put your prejudices into their heads.
  4. Do what you can to get the patient to talk and do your best to let them do most of the talking while you listen and take notes.
  5. Ask the patient for permission to call the treating orthodontist to discuss the case with them. Patients/parents almost always will give permission. If they don’t then that is a cause for concern for me and if they persist in that position, I’ll probably send them on their way and refuse treatment.
  6. With the full set or records and your notes in front of you, call the treating orthodontist and start off by saying something like, “I’ve got ______________ here and they are concerned about ___________. I told them that you are a solid person and orthodontists and that I knew you would want to hear about this and find resolution. This kind of thing happens to all of us from time to time so I’m hoping I can help you with this case because I’m sure I’ll need your help next week or next month…” And then be quiet and let the treating orthodontist talk. Use open ended statements/questions like “Tell me more” and “I understand” and “How do you think we should proceed?” and allow the treating orthodontist to do most of the talking while you take notes.
  7. Based on what you hear, decide what you think the issue is (reference the reasons for in town transfers above or create your own list). Unless it is obvious what you want to do, I would tell the original orthodontist that you will call them back at the end of the day to discuss options. This can be an emotional situation for orthodontists so time is your friend.
  8. If it is apparent that the patient is being non-compliant, unreasonable or not paying their bill then you can discuss what you want to do with the original orthodontist – sending them back or taking over the case or whatever. You will want up-front payment for your work if it’s a payment issue without good reason. You may opt not to treat the patient. You may refer them back to the original orthodontist. OR, you might consider removing the braces at no charge and taking final records for the original orthodontist if this is something that’s been going on for some time. Resolution in these cases is a blessing for all involved. I do this often and it seems to make most people happy though I’ve had a few orthodontists get upset and say “You shouldn’t take the braces off. I won’t take the braces off until they pay what they owe me…” **I hope that those of you reading here recognize that this is an unacceptable position for an orthodontist to take. Holding people hostage for payment is unethical at best.**
  9. If you decide the orthodontist is being unreasonable or that the patient and the orthodontist are doing their best but just can’t get along then it’s probably best if you take over the case. You can certainly charge for doing so but I would suggest a different tactic. In cases like this I will often finish the case for free and tell the original orthodontist that I’m happy to do so and that they should keep the money they were paid and cancel the patient’s account. I make it clear that it’s my pleasure to treat the case and that I’ll send final records to the original orthodontist when I’m done. I repeat something like, “This kind of thing happens to us all from time to time so I’m happy to help out because I know I’ll need help in the future.”

Yes, yes, you are correct. Some orthodontists don’t get it and will not return the favor when one of your patients seeks them out. Yes, some orthodontists will get indignant and upset when you agree to see their patient. Yes, some other orthodontists will badmouth you when your patient goes to see them. The problem is that you can’t control any of that. All you can control is you and the way you act. Someone has to be first. Someone has to set the example. Someone has to be brave enough to put the patient first. Why not you?

We desperately need to change the way we orthodontists interact with one another and with our patients when it comes to transfers – in town or out. To do otherwise is folly. As it stands now, pride, ego and machismo rule the day when it comes to transfers of any sort and that is not good for the profession or patients. Do you have the guts to be different? Are you willing to put the needs of patients above your ego? I hope so. I hope we all, or at least most of us, are willing to do so. Otherwise, what’s the point?


8 thoughts on “In Town Transfer Patients

  1. Love how you make me think outside of my paradigms Ben. Thanks for your insights. Lou

  2. Glad you like the post Lou. Have a great week!

  3. Ben, you always make sense.
    I already align with a similar approach but thanks for softening my stance and perception.
    Only real difference is that we ask the patient to pay a “skin-in-the-game fee” ($20-100/month based on appliance cost until the case is finished).
    I think the patient gains by not becoming a “charity” case and it encourages them to be compliant and finish quicker.

  4. Ben, I enjoyed this post, and it is a topic that is very timely today. I do have a few thoughts I would like to share, and I am not going to write a long missive as you have covered the issue quite well. As we know, orthodontics has become quite competitive, and sometimes ethical standards tend to lapse in those situations. When I was still teaching, I would periodically, at least once a year, relate to the residence my philosophies on in-town second opinions, or any second opinion for that matter. Upfront, I would say that I believe that second opinions are a professional obligation, and should be treated as such. One time, in my in-office course, a doctor noted that I had several cases are presented that had come in on second opinions and asked if any of them came from in town. I replied that some had, and asking why asked the question. He stated that he personally does not see those cases because he wants to “maintain the collegiality of the orthodontic community within his town”. I responded to him with the following scenario: suppose your child has been diagnosed by a physician as having juvenile diabetes. You and your spouse decide that you would like a second opinion, and you do your homework and hear great things about another doctor. If you went to that doctor and he refused to see you, and everyone else in town behaved the same and you had to drive two hours to Atlanta to get an opinion, wouldn’t you feel rather upset towards that profession? I summarized by saying that I believe a second opinion is a patient right, and as a professional, I don’t think I have a right to turn them down summarily. After interviewing the patient, I may make that choice to not accept the patient for treatment. So this is the sequence in my office:
    1. First, my treatment coordinators know that if the patient announces on the front and that they are seeking opinions, to please inform the patient that I approach second opinions as a professional obligation, and would like to treat it as such. In other words I do not want to know what you are told by the other orthodontist, or costs. In that way the patient knows that they are getting an honest opinion, and if they ask for a monetary quote, I am not trying to “beat out the other guy”. It is the truth, and it also puts our office in the most professional light (which by the way is often the most attractive feature to the patient).
    2. Speak as though the other orthodontist were sitting there listening to you-I treat it almost like a seminar in school. In other words, treat it a bit like a debate that we have in study clubs or in school, arguing both sides. So if after I have my say, the patient is free to tell me what the other opinion was. Rather than bash the other opinion, I will explain the philosophy behind that particular approach, and the rationale for that treatment option, and why I personally might disagree.
    3. If the patient is in the middle of treatment and is unhappy, I agree with you, Ben, that it is appropriate to initially ask the patient what is making them unhappy. In that way I can gauge the nature of the patient and their “maintenance” factors. I find that often they just don’t like the way the staff operates or the relative professionalism of the office and that causes them to lose confidence. As Ben comments, sometimes people simply don’t match and it is a personality difference.
    4. I don’t call the other orthodontist unless requested to do so by the patient. First, the patient generally does not want the treating orthodontist to know they have been anywhere, because they may be honestly seeking a second opinion and don’t want to return to a hostile office. Second, it is easily taken by the other doctor as gloating. I have a doctor near me who used to call me every time he saw one of my patients, and he would go on and on about how professionally he was and that he did everything he could to get them to return, and was very complementary of my treatment. I told him he did not have to call me every time you saw a second opinion from my office, because I feel that when a patient leaves your office for another office, it is either because they don’t like me, or they don’t like my office, or whatever. In any event, the likelihood of them returning to my office are extremely remote, so no reason to gloat, please!
    Just some thoughts to share.

  5. Thanks so much for your insight Dr Sarver. It’s always timely and appreciated.

  6. I learned the “skin in the game” lesson years ago. Have treated many cases for $5 to $50 per month, but have not treated a charity case since. And they do not want to be considered “charity.” They have pride.

  7. Fair enough but whenever I give anything away I talk about it being an Orthodontic Scholarship. Scholarships are earned and not charity. Do whatever works for you and your patients best!

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