Time for Rapprochement
The amount of orthodontics being done by GPs is most frequently mentioned by orthodontists as a cause for lack of growth or decline in specialty practices. This belief is creating a schism between orthodontists and GPs that is both unseemly and unwise. Orthodontists generally believe that the increased amount of orthodontics by GPs has been accompanied by a virtual disappearance of GP referrals to orthodontists. Some misconceptions die hard, and this is certainly one of those. It has been shown time and again that GPs are still the most important source of referrals to orthodontic practices.
Apart from the question of the viability of GP referrals, more is to be gained by cooperating with GPs than by antagonizing them. The University of Nebraska has produced some timely additional data on this important subject, published in this issue of JCO.
It seems clear from that study that it is unwise to lump all GPs together--to generalize about generalists--or to question the motives of GPs as a class. It would be better to assume that GPs, including those doing orthodontics, have a genuine interest in their patients' welfare.
According to the Nebraska study, approximately 33% of their graduates who are in general practice are doing more than a little orthodontics and expect the amount to increase. Two-thirds of the general practitioners are doing little or no orthodontics and do not expect to increase that activity in the future. Almost half of the GPs, presumably from the latter group, thought that general practitioners doing orthodontics were beyond their level of expertise. Two-thirds of the general practitioners thought that teaching more orthodontics in the undergraduate and postgraduate programs would result in more referrals to specialists. It would be interesting to know whether these two-thirds are the two-thirds who reported little or no interest in doing orthodontics.
Almost 100% of the orthodontists were of the opinion that GPs doing orthodontics are beyond their level of expertise. Fewer than 40% of the orthodontists believed that more undergraduate and postgraduate orthodontic training would increase referrals to specialists.
It seems to me that universities should beef up their undergraduate orthodontic training--not in how to bend a wire or design a functional appliance, but in growth and development and diagnosis. With the possible exception of space maintainer construction, undergraduate technique courses are a tease, stimulating interest in orthodontics without providing competence. Education in the fundamentals would provide a greater service to students by increasing their understanding of growth and development. Those with a special interest in orthodontics could be encouraged to pursue that interest in a full graduate program immediately upon graduation. Postponing orthodontic education most often makes it inconvenient or impossible to seek graduate training, and encourages the taking of numerous short courses instead.
JCO has always maintained that a full two-year graduate orthodontic course or its equivalent is prerequisite to orthodontic competency. Anyone with such training--specialist or GP--can be considered to have the minimal educational basis to practice orthodontics. The problem with attempting to do orthodontics with less training is that successful treatment depends not only on ability to move teeth, but even more--especially when treating children--on knowledge of growth and development and on diagnosis that takes into account the entire craniofacial complex.
Orthodontics is a demanding discipline, even with adequate training. The fact that some results achieved by trained orthodontists can be less than perfect should be a warning that orthodontics is a difficult undertaking and that patients' welfare is not served by underestimating that difficulty.
It is important for orthodontists to realize that a majority of GPs are already aware of that. If schism there be between orthodontists and GPs, it does not exist with all GPs. It is with something less than 33%--perhaps only 25%. A good relationship between orthodontists and even that group is not inconceivable. There is much to be gained from a positive approach on the part of the universities, the specialty, and individual orthodontists. It would be good for patients, good for dentistry, and certainly in orthodontists' self-interest.