The Definitive Guide To

Writing Referral Letters

By

@DentistGoneBadd

Basic Referral Writing

Let’s start with the essentials. Referral letters should contain the basics; name, sex (if any – I don’t like to ask really), date of birth and reason for returning….oh sorry, that’s sending a parcel back to Amazon. Long gone are the days of “Please see and treat,” so try and give the specialist you are referring to, a bit of a clue as to the reason for your referral. Throw in a couple of vague differential diagnoses if you can, just to demonstrate you aren’t completely gormless, with proper medical terms like ‘epidermolysis bullosa’ or ‘squishy lump.’ It’s probably best not to refer a patient just because you don’t like the look of them, tempting though it is.

Choice of Specialist

If you are worried about a lump, it’s best to send to a consultant lumpologist. But beware, some specialisms do cross over and consultants can get a bit elbowy and will fight over interesting lesions. I once witnessed a near fist-fight between an oral medic and an oral surgery registrar – both convinced they could write a paper about it. Every time, make sure you are referring to the most appropriate department. One department will treat a lesion with a spray and ineffective mouthwash, while another will cut it out and put an implant in its place.

Oral Surgery Referrals

Oral surgery referrals are probably the most common type made. It’s not quite clear why this should be. Fewer dentists get into trouble over oral surgery than perio neglect or root-treatments. I think that oral surgery is probably all a bit too gooey for a lot of dentals and the anticipation of complications is overthought. Because oral surgery departments are absolutely swamped, you have to make a convincing case. Warfarin patients are no longer a bar to treatment in practice, so throw in ‘difficult access’ and ‘a history of difficult extractions’ for good measure. ‘Proximity to the antrum’ doesn’t often wash. Since many oral surgery departments insist on you supplying a supporting radiograph, they can justifiably throw out the referral and tell you where to stick your jpeg when they realise it’s a lower molar you are talking about.

Orthodontic Referrals

These are probably a little more clear-cut, if you completely ignore IOTN, which I did. I doubt very much if it’s done now, but the acronym ‘FLK’ (Funny Looking Kid) in the margins of the old paper files, acted as a reminder to refer to the orthodontist once the overcrowding started to hurt your aesthetic sensibilities. I find FLK’s generally DO get orthodontic treatment, so providing they are reasonably competent with toothbrushing, and generally look as if they’re using the hairy end, send that referral. Again, don’t just ask to ‘see and treat’. Throw in ‘well-motivated,’ ‘optimal oral hygiene’ and ‘very stroppy mother’ to emphasise the need for action. Chuck in a couple of measurements if you can, and try and crowbar in a stab at a ‘division’ to show to the orthodontist you’ve given it some careful consideration.

Periodontal Referrals

This type of referral is usually done in panic five minutes after you have just unexpectedly lost a BPE probe down a previously scoring ‘1,’ so do try and keep the panic out of your letter. Make it sound like you’ve been closely monitoring things for a considerable period of time and really emphasise that when you first saw the patient, most of the damage was already done. ‘Despite my oral hygiene instruction’ also shows that you have been caring, but don’t get too down about having to refer and being condemned by the periodontist. The specialist will probably only see the patient for twenty minutes max anyway, and will never see them again, immediately throwing the patient into the ‘Pit of Hygienists.’

Endodontic Referrals

Endodontic referrals are becoming incredibly popular and you are highly unlikely to get one rejected, since they are often made to private specialists. Don’t bother trying to refer to your local dental hospital. The sun will have died well before your patient gets to the top of the list. Besides, dental hospital endodontists are exceptionally picky about what they treat. My local dental hospital won’t treat any tooth beyond a first molar. They aren’t that clear why, though I suspect it’s because trying to get to a seven is a bit ‘too fiddly.’ Failure in endodontics is a growing area of litigation and if you are an NHS dentist in particular, don’t risk ANY root-treatment – refer. You can throw a lot of information into your referral letter – sclerosis, unusual anatomy or “There’s a prominent squiddly-do on my radiograph” – but it doesn’t matter. These are endodontists. They have to pay for swanky microscopes and German Sportwagen. They’ll accept anything.

Implant Referrals

See Endodontic Referrals. Patients think they are the same thing anyway.

Prosthetics Referrals

Tricky. Prosthetics specialists are a dying species. Their natural habitat in the 60’s and 70’s was gummy, but since forestation with teeth, the need for them has diminished. The few prosthetists left, tend to pack together at dental schools, desperately attempting to procure close relationships with implantologists, borne out of their innate instinct to survive. Having said all that, I have had more referrals rejected by prosthetics specialists than any other type. To be absolutely honest with you, whatever you say in your referral to a denture specialist, they’ll write back with “We would recommend extending the flanges and see no reason why this cannot be carried out in practice. Now leave me alone. I need to bury my nuts for the winter.” Good luck.

Community Clinic/Paediatric Referrals

This is where you send all of your ‘challenging’ patients, or those that take an hour to do an enamel-only incisal edge composite on. Terms you should include in your letter are ‘wriggly,’ ‘anxious,’ ‘fearful,’ ‘phobic’ and ‘gagger,’ though be careful you don’t end up making it sound like a Facebook advert for happy hour at the local S&M Club. Make it absolutely clear that this patient needs sedation. Forget about suggesting GA. The clinicians at these emporia don’t stop talking about the risk of death from the time the patient enters the place having found it after previously mistakenly walking into the adjacent STD Clinic. If your local clinics have their own referral forms and it gives you the option to have the patient back if they refuse sedation, tick ‘NO!!!’

Restorative Specialist Referrals

Quite a few restorative specialists lurk in dental schools, but despite this, they try not to have anything to do with teeth. There is only one important, indeed, CRITICAL sentence you need to include in your referral letter, and that is: “I am ALREADY monitoring the diet and wear.”

Oral Medicine Department Referrals

You will normally refer to the oral medicine specialists as a means of backing up your diagnosis, which is almost certainly, atypical facial pain/burning mouth syndrome. Often, you would save a lot of time by giving a nightguard or benzydamine hydrochloride rather than wasting your time on a referral letter.

Say hello to your friendly chatbot

In the news today is a story about Facebook planning or already on the way to creating a single underlying service, that integrates the Messenger, WhatsApp and Instagram message services that so many of us use.

It will mean that a Messenger user will be able to send messages to an Insta user or Whatsapp user, of whom they don’t have other personal or contact details.

This integration, whilst retaining the apps of each separate branded platform, may be the source of some friction during 2018, when the Instagram founders, Mike Krieger and Kevin Systrom unexpectedly left Facebook. They were followed by the Whatsapp founders, Brian Acton and Jan Koum, all for largely unspecified reason, like “playing more Frisbee”.

There will be other advantages for users, as well as the reasons I give below, and one will be the addition of end to end encryption of messages as standard. This will mean neither Facebook itself, nor others, can read what is being sent. Some feel the integration will be a further reason to move away from these services, as they doubt the altruism of Facebook in all of this. Whatsapp users don’t give away too much of their personal data to use that messaging service. However, Facebook users have given an ongoing dump of their personal data to the company in exchange for the service for many years. I think there will be a long debate on what people are willing to share across the platforms. One thing is for sure, billions of people will be more wary of what they share with the data giants.

There is one another basic motivation. Whatsapp has about 1.5 billion active users each month, yet it generates very little revenue for Facebook. Instagram has 1 billion monthly users, this business has very valuable advertising revenue. There must be an undisclosed masterplan behind this move, which must raise revenues.

Here are two possible [speculative] reasons this might all be going on:

Firstly, business would like to message people using these systems. Messenger presently allows automation of some interactions of business with their customers. Invoices and receipts can be sent this way, and some organisations have chatbots working successfully already.

Here is an example from my personal phone – an airport car park chatbot.

It’s not too hard to see that message could be sent by email, or to Whatsapp, but the improvement is the interaction with the chatbot – ask it for directions, or the confirmation, and the result is instant. Humans might chat and smile, but the chatbot simply responds with the answer you want, instantly.

This sort of interaction will allow companies to compete to provide super efficient customer services we cannot yet imagine. Of course the reach can therefore be worldwide, and would not bar the present users of the other services.

Whatsapp already has a platform to allow for customer services direct, BBC news uses Whatsapp for news images and remote crowd sourced news gathering, the uses of these services is gathering momentum daily.

Secondly, email is failing for personal communications. Randomised spam emails are a nuisance, as well as needing to be filtered daily. People use email for business use, but so much personal comms traffic is now via the various messaging apps, on our smartphones.

Putting it very simply, people read these massages when their phones buzzes or vibrates, somehow emails are easier to ignore, or delete later. This is a further factor which will drive businesses to communicate and provide services in this way.

On the other hand, we can expect spammers will find a way through these systems, but no doubt there will be privacy settings in place, and instant long term blocking. Apparently, the email marketing industry is already turning over more than $100 billion.

Any company, individual or spammer can guess, buy or steal your email address, then send you those unsolicited messages. But if these three services I have described above are integrated, the ecosystem created, with verified contacts, the resulting service could take over from email, possibly consigning email to the dustbin of technology history.

The rules must be that users would opt in to receiving messages from business, so we would only receive messages from the people and business that we know, interact with, and possibly have an account with already.

Life without spam email? You never know. . .