A number of years ago there was an orthodontist named Donovan who conceived a plan in which, for a fee, he would assist numerous general dentists with diagnosis of orthodontic cases and supervise their treatment by periodic progress evaluation. Many dentists faced with a reduction of their usual income sources, largely due to fluoridation, were attracted to the idea. For Donovan it was a means of expanding his patient base at a time when dental practice acts severely limited delegation of operatory tasks to auxiliaries, thus limiting the number of patients any one orthodontist could treat. In those days, delegation in the operatory rarely got much beyond an assistant handing the doctor ligatures. The brilliance of Donovan's idea was that he could get around the dental practice acts by delegating treatment to licensed dentists. Since the GPs conducted their own practices, he could increase his income without increasing his own case load or his overhead for the additional orthodontic patients he supervised.
For a number of reasons, including the question of fee-splitting, Donovan was discouraged from carrying out this scheme. In any event, Donovan's dream was made moot when dental practice acts were opened up to allow almost unlimited delegation to non-dentist, in house-trained office staff. The effect of this delegation, however, is the same as in Donovan's plan--extending the number of patients who can be treated by one orthodontist. Before and after Donovan, many orthodontists have sought to increase their referrals from general dentists by assisting them in treatment of orthodontic cases. This has generally involved consultation on diagnosis and treatment planning, or bailing out cases that went astray. There is no consultation fee. The quid pro quo is in the expectation that the general dentist will treat only the simplest cases and reciprocate with referrals of the more complex cases, or will eventually tire of the orthodontic treatment and refer all the cases to the mentor. In practice, the results have been mixed. Many of these general dentists ended up referring only the most difficult or mutilated cases.
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There have also been efforts to replicate Donovan's original idea with GPs. Those who do this need to be careful about fee-splitting and may accept a certain amount of malpractice jeopardy because of the shared-patient relationship. The orthodontist necessarily places a good deal of faith in the knowledge and skill of the GPs with whom he or she is associated. If a GP is deficient in either one, problems may arise that cannot be resolved by an orthodontist attempting to provide a colleague with an orthodontic education. There are also other difficulties associated with remote control that cannot always be anticipated or easily coped with. The advantages of in-house delegation include close and continued training of assistants and immediate visualization of the cases under treatment.
Before an orthodontist enters into any relationship that involves mentoring general dentists in their diagnosis and treatment of orthodontic cases, one overriding question needs to be addressed: For the three participants--GP, orthodontist, and patient--is this a win-win-win situation? For the GP, it is obviously a win. He or she treats more patients and derives more income. For the orthodontist, it may be a win. Under the Donovan concept, there would be a consulting fee; in a non-Donovan mode, orthodontic patient referrals may be forthcoming. For the patient, it is only a win if the treatment outcome is satisfactory. But if the remote-control arrangement could result in less-than-adequate care for the patient, for any reason, it should not even be contemplated. Our first responsibility is always to the patient.
ELG