Consultation
by Zale Smilack, DDS

DEFINITION:

A type of service provided by a physician/dentist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician / dentist.  So says the American Medical Association in its Current Procedural Terminology manual.  It is a communication between two parties, the requesting practitioner and the consultant. Basically, consultation, then, is a type of communication among members of a treatment team on behalf of a patient.  If good communication enhances good patient care, then proper consultation is essential to provide the best care for our patients.

DISCLAIMER:

This discussion is not to be taken as any official or legal opinion and is not meant to state any legal standard of care.

There are at least two types of consultation that may be initiated or sought by a patient's attending dentist an opinion sought from a physician, and one sought from another dentist.  Generally, a consultation can be considered as a means by which a dentist can obtain an answer to a question about providing care for a particular patient, for example:

"I've obtained Mr. Jones' medical history, and I know he has cardiovascular disease. Type 2 diabetes and asthma. He's on Verapamil, Accupril, Glyburide, Atenol, Sinvastatin and  Theophylline. How safe is it for me to provide the dental care he needs? Do I need to modify my care plan to reduce the risk to the patient, and what  modifications would be helpful?"

"My patient, Ms. Smith, says she thinks she has a heart murmur, and reports some palpitations during the period of her husband's serious illness about eight  months ago. Does she require antibiotic prophylaxis for SBE?"

"Eric, an 8 year old new patient in my practice, is a bleeder according to his mother. Can I do his prophylaxis, do I need some sort of hematology evaluation or care before I do anything else?"

"Mrs. Rogers has been a patient of mine for several years, but hasn't been as regular as she should about visits. Today, she came because of a tooth she chipped. I noticed  a small ulcer on the side of her tongue. Does she need it biopsied?"

"Sherman Herman is a 45 year old man I'm seeing in my oral surgery office today. He tells me he saw his dentist because of occasional toothaches in the upper right area last month.  He has no pain or other symptoms today.  He says his dentist sent him to me to remove tooth number four, but he lost his written request.  My exam shows both maxillary right first and second premolars with mild-moderate chronic periodontitis and some recurrent caries at class II restorations of both teeth.  Neither tooth is sensitive to hot or cold or percussion. Neither tooth has  a periapical lesion evident on x-ray.  Which premolar first or second, does his dentist want removed?"

The dentists of all five of these patients need to obtain consultations.  These are questions requiring other professionals' opinions to provide answers.  The answers to these questions are required before the best care can be given these patients. Mr. Jones' dentist should consult the patient's physician as should Ms. Smith's dentist.  If Ms. Smith has no physician, she should be referred to a physician/cardiologist for evaluation and consultation.  If appropriate follow-up medical history questions to Eric's mother yield answers indicating possible hemophilia, for example, consultation with a hematologist is mandatory.  Mrs. Rogers should be referred to an oral and maxillofacial surgeon for an answer to the biopsy question.  Finally, Mr. Herman's oral surgeon should consult the patient's dentist and not assume one or the other premolar was the tooth that the dentist requested be removed.

Consultations can be obtained in person, by telephone. or in writing by letter, fax or e-mail.  Where a consultation is obtained in person or by phone, proper written documentation of the question from the dentist and the opinion given by the consultant should be done.  One way is for the dentist to make a sufficiently detailed written entry into the patient's treatment record or chart.  Another perhaps even better way is for the dentist to send a follow-up confirmation of the consultation communication by fax to the consultant.  For example, "Dear Dr. Blank, Thank you for sharing your time and expertise today in regard to our mutual patient, Donald Jones.  As we discussed, his dental problems are A, B, and C and his medical problems are X, Y and Z. As we agreed, we shall proceed with his dental treatment as follows per your recommendations.  State the particular agreed plans for treatment.  Again, Dr. Blank, thank you very much."  File this confirmation together with the verification of fax transmission in your patient's record.  Now, even if the consultant didn't record the conversation or recommendations, you have evidence of the details of the consultation and that it was received in writing.

All this may seem like a lot of effort, but in practice, it's not burdensome at all.  Consultations and proper documentation of consultations can be a significant, even vital, element of good patient care.  That makes life better for both the patient and the dentist.
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