The Father of Interdisciplinary Dentistry

Ralph O'Connor, DDS: When I transitioned my practice from focusing on efficient practice management production to exceptional comprehensive patient care, I began to look at and listen to the whole person. I listened to their wants and needs in a 20- to 30-minute, oral, two-way conversation that I called "the interview." Knowing what the patient wanted gave me a context in which to share what they needed and offer them treatment awareness, options, choices, and ultimately, control.

When I began treating patients comprehensively, not just treating what they felt that they needed or what I thought they would financially accept, I realized that I needed help because in order to truly rehabilitate mouths biologically, structurally, functionally, and esthetically, I needed skills that I did not have. This was in late 1970s. Like at all dental practices, our patients presented with periodontal disease, crooked teeth and jaws, endodontic abscesses, unusual lesions, and other issues. So I started working with specialists without any kind of a base, common practice, or treatment vision. The only problem was that we had no trained specialists in Tacoma, Washington, except for an orthodontist.

West: So what happened next? It seems like you had a problem with no solution.

O'Connor: One of the first things that happened goes way back to Vincent Kokich, DDS, MSD. I was fed up with my orthodontist, and you encouraged me to meet with Vince. At that time, Vince thought I was all about practice management. But Vince, I later learned, always had an open mind and was a very good listener. I had become fed up with my orthodontist and the area's periodontist because I would get a case back, and I would ask, "What am I going to do with this?" I did not get any input about what teeth needed to be extracted or anything else. The patient just had "gum surgery" and that was it. They sent the patient back kind of like magic. The only problem is there was no magic. They did their thing, and then I was supposed to do mine without any direction, coordination, sequencing, or a consolidation of the patient's treatment plan. This approach was better termed multidisciplinary versus interdisciplinary. Each specialty's dentists do what they do and then the patient is dumped back into your care with a "good luck" note attached to the treatment report.

I remember one time when the orthodontist said he had finished a patient's case. I looked in the patient's mouth and then looked at the patient, and I said, "Look, this has to be totally redone." She said, "You mean the whole 2 years?" And I said, "Yes, at least 2 years." We were both deeply frustrated at that point in time.

So, I met with Kokich, and I said, "I want a setup on every case, and you are going to do it." He said, "No problem." And I said, "In addition, I want the patient referred back to me 3 months before you take the bands off." He said, "No problem." Then I said, "I will tell you what teeth to move and what teeth not to move so that our efforts are coordinated." And again he said, "No problem." It turned out that he was one of the first specialists that I worked with before the NNDE, and from there on, it was a matter of trying to find additional people like you, David Steiner, DDS, and David Mathews, DDS.

In the early days, I had referred a patient to Mathews, and without my knowledge, he had referred the patient to another dentist. So, I went over to his office, and I said, "Let's get something straight. You're going to be my periodontist because you are the only one in the area who has been trained. What is it going to take for you to become the periodontist for my practice?" He replied, "Well, I want to see five or six of your cases." And I said, "Fine, I will show you five or six cases, but then, I expect you to do something. If I pass your test, and you pass my test, call me first before you assume that I cannot treat my patient." He saw the five or six cases, and he said, "Well, I guess you know what you are doing." I said, "What made you think that I didn't?" And he replied, "Because you are a practice management expert, and anybody knows that practice management experts are not good dentists." It was all a wonderful outcome.

When I first started the NNDE, it was out of need-a need for comprehensive and predictable treatment that was satisfying for the dentist and successful for the patient. If the treatment was done right, I knew the patient's investment for a healthy and attractive smile would be one of the most successful long-term investments that he or she would ever make for his or her oral health and overall well-being. Everyone wants to look successful, feel successful, be healthy, and have a great smile. And some yearned for this.

I began my journey by meeting everyone on my specialty team individually. I was meeting multiple times about patient cases, sometimes at 5:30 AM, and it got to the point where the meetings became impractical for me. So, I invited the entire group, including oral surgeon Robert Dunley, DDS, MSD, restorative wonder Frank Spear, DDS, MSD, and pediatric dentist Daniel Cook, DDS, MS, to the Sheraton hotel in Tacoma. I said to them, "This is my plan. I want to bring all of you together once a month, present cases, and see how the other members of the group see them. I will provide the case at first and then we can expand on this, but that is what we are going to do." They said, "Well then, you need a projector and patient radiographs, models, and clinical images, and we need a format, food, and this and that." Others were later invited, and we expanded our base with temporomandibular joint cases and removable prosthetics. I had to learn a lot too, so the specialists wouldn't call me a dumb dentist. This actually became a rather affectionate term, and later, I began calling the specialists "Limiteds" because their knowledge was limited to a specific area, but they all thought that they knew everything about dentistry. That is one of the big problems when setting up an interdisciplinary group. I was often the facilitator of a case and would purposely ask a dumb question (being a dumb dentist) in order to see what their reaction was and get them started discussing the diagnosis and interdisciplinary treatment options.

It was and still is important to find people who are willing to change, and that is probably more important than anything else because these individuals are able to learn what other people see, and what others see is often quite different from our own perspectives. So, for example, in endodontics, one overarching question is whether an endodontically diseased tooth should be treated or extracted and replaced with an implant. That argument still goes on today, and it should go on because there is no definitive answer. In a presentation, Frank Spear once demonstrated that an implant only lasts for 10 years. What most people and many dentists think is that a new implant is going to last forever, and it likely will not.

In the beginning, there was kind of a free-for-all that would happen in the monthly NNDE meetings. They would start with the case and show the background of the patient, what the patient wanted, and so on. We did, in fact, expose the group to what was communicated during the interview process, and from there, they would start picking it apart. I would go around the room and say, "Tell me what you see here," and surprisingly enough, participants were shocked that the other clinicians would see a great deal more or something different than they saw. Many couldn't believe it, but that's where the real work was done.

West: How hard is it to find specialists who are going to respect each other and are willing to learn from one another?

O'Connor: We were very fortunate, and the people involved were all very secure-that's really the key. You've got to feel secure when you expose yourself. You had to leave your ego outside because that way, there was a chance to see what the other clinicians were thinking and be challenged. Most of the time, what the others saw was different. Then, they would get into an argument while we went around the room, having each specialty weigh in on the diagnosis and treatment plan. They were very good about giving up what they saw, and then, we would open it up to the floor and people would get into the discussion. For the large majority of those cases, many participants were never expecting the result to be what is was. The result would end up being something totally different than what anyone thought when they walked into their office or walked into the meetings. Without needing to be right or defend my position to the end, this was the proof that the old style of collaboration was not in the best interest of the patient.

West: How were the NNDE meetings structured in order to maximize the collaborative aspect of the learning process?

O'Connor: Well, first of all, we always looked forward to the NNDE meetings, and later, the members became masters in their fields and were sought after globally. After we had acquired a few more members, there was usually at least one member of each specialty present at each meeting. Regarding the structure of the meetings, first, there would be an hour-long formal presentation. The periodontist, orthodontist, restorative dentist, oral surgeon, and the pediatric dentist would present a subject that involved as many of the different disciplines as possible. Then, there was a literature review (or several), which also related to as many specialties as possible followed by a long-term or otherwise interesting case report. Then came everyone's favorite part of the meeting, the "What do you do with this?" segment. Each clinician would bring an interdisciplinary diagnosis and treatment plan that they were currently undertaking with a restorative dentist. That's when we really had wonderful discussions. We would make a consensus diagnosis and treatment plan options, evaluating their pros and cons. Each presenter would then return to his or her dental team outside the NNDE, and they would discuss the options presented, often choosing one in consultation with the patient. All of us followed up by coming back and sharing the results of these patients, sometimes for as many as 25 to 30 years later. It was always fun to ask if we would do it the same way again, modify what we did, or do something entirely different, given the availability of new technologies, products, and techniques. We were often surprised by the fact that we would, now knowing the long-term result, treat the patient in exactly the same way.

West: Can you say more about why the NNDE group was so educationally rich for its members and how its members became a global influence in their own right? Also, what allowed the NNDE to set itself apart as the most sustainable interdisciplinary study club model?

O'Connor: Two or three study clubs in each community had tried to create their own networks and stalled or failed because they invited friends. It's not about friendship. First, it is about finding the best dentists that you can in the area. Second, they need to feel secure about what they want. Third, they need to be open to new ideas and to new concepts rather than closed-minded. Last, there can't be one person who controls the whole thing. All of our members entered into the deal saying, "I do not know what the result should be, but I am going to do my best to sell my argument the best way I can."

And that's what makes it happen-the boiling down of the process, of different things, and of different thoughts from one specialist to the next. Many network type study groups are, in fact, composed mainly of specialists, and they actually want to exclude the general dentist. This is a mistake in my opinion because the general dentist is the person who is best qualified to referee the conversation, and the next best is probably the periodontist. Those two should be vitally important. We were fortunate in that we happened to have a bunch of guys who wanted this educational relationship with other people, and it was the process that brought them in. The University of Washington sent down someone who was in charge of their postgraduate education, and he was totally impressed. But what he was most impressed with was how everyone spoke to each other because they communicated in a no-holds-barred kind of discussion.

They didn't feel like they had to protect anybody or themselves. They just spoke about what they thought about the topic and that was really the key. This was a group; there was no individual expert. There was no one person who knew it all. When someone had an idea in mind, it wasn't withheld for any reason.

West: So, the "What do you do with this?" part of the monthly NNDE meeting was the most educational?

O'Connor: Yes. Assessing these problems was really the teaching and learning solution because that was where we learned what other clinicians were thinking, and that was invaluable. What do we do with a smaller version of a larger issue that another clinician saw? We always started with what the patient wanted and needed. We first arrived at a consensus diagnosis and then developed one or more treatment plans, depending on all the variable determinants of each unique patient situation.

West: So, if everyone is equal, who runs the show?

O'Connor: You need somebody to act as the moderator. Part of that moderation involves making the participants feel totally secure. You can't care whether you sound like an idiot or you sound like you have the right advice. There is no right advice, and there is no wrong idea. Everyone enters into it, and from that, you boil it down. After the discussion, the moderator would summarize what he or she heard (sometimes writing it down to provide clarity about preferred treatment timing and sequencing), and then facilitate a group consensus. Members would defend a position, but they were still willing to see it differently. That was such a huge thing. They argued strictly from their point of view but were accepting of the combined idea. We did not meet to get referrals. We met to get an education. We would work through these cases as both dentists and patient advocates to arrive at the best possible treatment choices for them.

West: What held the NNDE together through everyone's careers and beyond?

O'Connor: Well, I think the number one quality for our long-term monthly collaboration and education was security. You had to be secure enough that you could be challenged about an issue or your opinion because, sometimes, the debates were really hot. However, that exchange was really essential. Ego had to be left outside the room. The second essential characteristic of interdisciplinary study club success was and is a willingness to understand that members of each specialty can see things differently. Members often realized that they hadn't even considered some of the perspectives that were shared or conclusions that were reached. The NNDE began to understand that our monthly meeting provided some of the best education available anywhere in the world, and the interdisciplinary study club was helping each of us tremendously. Many of the NNDE members ended up teaching throughout the country and the world. Because we expanded our thinking, which became a sort of security in and of itself, members were able to engage in open-ended discussion and maximize the potential treatment for their patients.

West: This all sounds good, Ralph, but what about new dentists who are deeply in debt and afraid to tell the patient what is possible? Don't they just want the patient to say yes because they are fearful that he or she will find cheaper dentistry somewhere else?

O'Connor: Let me tell you a short story that should answer your question. I did some consulting work for a new dentist who was having trouble with patient presentations. The guy who sold him the practice had asked me to come in and do some coaching. When I told the new dentist that I wanted to see his charts, he responded, "Well, which patients do you want to see first? Do you want to see the patients who have rejected treatment or the ones who have accepted treatment?" I said, "Show me the patients who are not going to proceed with treatment." Eventually, I got him to do an experiment with the next patient he believed was not interested in taking care of his or her mouth. I said to him, "When the next patient who needs full mouth reconstruction comes in, present the treatment option under the pretense that you do not care at all whether he or she accepts it." If you do not appear to care whether the patient proceeds with the treatment, it changes it from something that the doctor needs and wants to something that the patient needs and wants. You are not trying to sell or push patients; you are only educating them, and it is all based on the interview, their values, and what you see biologically, structurally, functionally, and esthetically. When the next patient who came in was a man who happened to need a full-mouth construction, the young dentist used my suggested approach. He called me and said, "I cannot believe it. I just cannot believe it. I gave the patient the whole shot (his word), and it was for a lot of money, and he replied, ‘How do you want me to pay for it? In cash or whatever?'"

West: If you could tell new dentists to do one thing that would help them make it, what would it be?

O'Connor: Well, first of all, you have to realize that the debt they are coming out of dental school with is between $350,000 and $500,000. They need the patient to say yes, which really puts pressure on both the dentists and their patients. It's a hard nut to crack. The natural thing is for the new dentist to just go out and do what they see. That is a very limited way of thinking, however, because they cannot see much (ie, basically just restorative concerns) initially, but that is fine. They try to do endodontics, and you see the results of that. They try everything. Many new dentists get in over their heads because they haven't done a thorough examination, they haven't done a good interview, and they really don't know where they are going. It has been said that if you don't know where you are going, any road will get you there. Sometimes, they develop fear that they will not be able to do what they cannot see or that they will fail to see what they don't know how to do.

Regarding advice for these new dentists, maybe it isn't a bad idea to start by practicing in a clinic for a couple of years, honing their skills and speed, and achieve an understanding that there is more to be done than what they are initially instructed to do for their patients. Then, from the corporate model, I advise new dentists to go into an associateship with a more experienced dentist who can mentor them. But it has to be the right associateship. I used to teach a class for dentists who were in their first 5 years of practice, and one associate I taught was frequently abused by the owner while in his associateship-not physically but mentally and intellectually. It seemed like the owner would do anything that he could do to destroy the new associate. With that, it was time to move on because there are excellent dentists out there who do want to teach and pass on their skills and knowledge.

Ultimately, new dentists will learn to conduct the patient interview, present the treatment plan that is needed without pressure, and let the patient make the decision. My daughter, Beth, is a dentist. She understands the process of winning patients over and how this translates into winning for the dentist. Asking the patient what he or she wants to do takes the responsibility off of the dentist and places it on the patient.

West: Are you saying that the interview should take the pressure off of the new dentist completely?

O'Connor: Exactly. Competing with low-cost dentists is one of the main things that young dentists get panicky about. For example, in the city of Lakewood, Washington, there are probably three or four dentists in one area, and they are all competing against each other because they have blinders on and only see what they think the patient will pay for. This belief system is killing them, the joy and satisfaction that they receive from practicing, and their profit. That pressure is unbelievable, and they cannot keep on going like that for very long. If one dentist is assigned to ten chairs, the consequence is that he or she cannot do very much for any of the ten patients during their appointed time. A lot of clinics are set up in a way that they are effectively paying dentists not to do treatment because they are told that they will only be paid so much a day and that they are going to be given multiple patients.

West: So, let's say I am a young dentist, and I have made it past this first phase of "dental initiation," or I am sick of the process and ready to move on and up or get out of dentistry. Am I ready to start a solo practice? What should I do?

O'Connor: First, find the very best people you can. Remember, attitude trumps experience every time. Find individuals with great attitudes who you can teach and who want you to teach them. An experienced person sometimes acts like he or she already knows everything and is unwilling to grow with a changing practice or accept new guidelines. Second, join or begin an interdisciplinary study club. I would not limit the participants by their practice age. Although new dentists of a similar age to yours may feel more comfortable, they have got to be tolerant of the other participants. When you take a younger person and put them with an older person, the older person can think that they are an authority, and the younger person can assume that the older person is blind to new thinking and techniques. Both of these positions are incorrect for the optimization of learning. Regardless of their age, you need to be able to judge that people that are secure. Study club members need to be at the highest skill level and yet accepting of the fact that they are all going to be learning together. No matter who they are, they will learn. Whatever they have been doing at their practices, members are going to find out if it is the correct or best thing.

West: If readers wanted some coaching from you, would you be willing to talk to them on the phone, or guide them through a problem, situation, or something else that they are struggling with? Are you available to be a committed coach if there are agreed upon ground rules and expectations?

O'Connor: Well, yes. I would certainly consider that.

West: Could you summarize the critical factors that new dentists need to consider in order to increase treatment acceptance, achieve the best outcomes for patients, and become successful in their careers?

O'Connor: Let me think about that one. If you are asking me for takeaway principles that call for action, they would include the following:

• Master the Patient Interview. It is rarely done. Find out what patients want and need and don't pressure them about treatment decisions. This is the cornerstone of gaining acceptance for any treatment that could take several years to complete. Many average dentists consider this a waste of time. Unfortunately, I think that these dentists are just too excited to get to the chair to see what they can get the patient to do.

• Be Open Minded During the Exam. Usually, during the patient exam, the dentist is looking to see what he or she can do. If dentists are "crown-odontists," then they will see the need for crowns. I usually allotted 20 minutes to do an interview in the private office. I told the staff that I was not to be disturbed, even in the case of a fire. When I started doing full clinical exams, it became very clear that I could not do all of the things that my patients needed or wanted. That's how I got started referring to specialists. I soon discovered that if I referred to more than one specialist at a time, the patient became overwhelmed. I also discovered that not all specialists were equipped to do what I expected and wanted. I think that was about the time that the idea for the NNDE was formed.

• Plan for the Future. Dentists must decide fairly early on in their careers what road they are going to travel. They are either going to be a "patients' felt needs" dentist, treating one tooth at a time, or they will be someone who is willing to travel a road that may be a long haul and start conducting patient interviews. Because the new dentist is hit with the reality of paying back student loans as well as his or her living expenses, we cannot expect this to happen overnight. They can set their sights on the future with the help of postgraduate courses, and if they allow time for their practices to mature, they will see them grow into practices that truly represent them, their values, and their beliefs.