Collaborating with Dentists and Other Professionals

	Dentist - Psychologist Collaboration: The Case of the Anxious Patient/Bruce Peltier and Paul Glassman
	Dentist - Psychologist Collaboration: A Big Kid in a Candy Store/Bruce Peltier
	Establishing Collaborative Multidisciplinary Teams in the Treatment of Children and Adolescents/David B.Goldstein

		Bruce Peltier, Ph.D., M.B.A.			Dentist - Psychologist Collaboration: A Big Kid in a Candy Store It became clear early on that I did not possess the temperament optimal for private psychotherapy practice. I simply could not sit still and listen to people all day long, day after day, so I found other ways to practice my profession. A partner and I started a DUI program and ran it for a decade before we sold it. I taught at local universities. I got a supervisor and relearned psychological testing so that I could conduct assessments. I joined colleagues to run a training institute and provide continuing education in hypnosis. I ran leadership training for an equal opportunity program at community colleges. I was spread all over the place and mostly loving it. But one consulting job turned in a direction I didn’t anticipate, and it led to a full-time position. I’ll use this essay to describe how I came to be a full-time faculty member at a school of dentistry, I will describe the things that I do there, and I will offer observations about the importance of the role of psychology in this kind of setting. Dental school. About ten years ago I helped assess and train faculty advisors at a local dental school. It is an enlightened place, and the dean who brought me in was a Ph.D. - Educational Psychologist. The administration and faculty have valued a “humanistic” approach to dental education for the past twenty years or so—well before I got there. By way of background, dental education has a long history of all-male, regimented, and often humiliating approaches to the teaching and learning process. The University of the Pacific’s approach is progressive, humane, and, as such, it has been unique and a pioneer. The addition of psychological services to the mix was a natural. The dental school followed this consulting assignment by asking me to provide on-site consultations with students on an “as requested” basis. I drove across town to meet with dental students during lunch breaks and other periods when it was convenient for them. The role was essentially to serve as a one person, mini student counseling center. (To their credit, dental faculty were well aware that they did not possess the requisite skills to perform this service themselves.) Since my post-doctoral internship and first three years of work were in university counseling centers, the fit was good. Over the next two years the number of students who sought counseling grew. Faculty encouraged and supported this trend and saw it as positive. They were encouraged on the occasions when I was able to right a tilting ship and get a student back onto a successful path. Sometimes this was pretty easy to do: I listened and reflected and helped students sort things out. I helped them diagnose their own problems, taught study skills, helped with relationship difficulties, self-esteem, and self-doubt. Sometimes, of course, the help was more difficult to provide, and at others, the problems were simply insurmountable. But at least the dental school had a more or less valid way to tell the difference. If they thought the problem was insurmountable and the psychologist agreed, they could feel more comfortable when they took the necessary action. Occasionally it even seemed like I “saved” a student or a career, and this made my presence seem all the more valuable. On average about 15% of the members of each class now uses my services (in individual sessions). At the beginning I was paid on an hourly basis. I provided services when they were requested by students and then simply billed the school for services rendered. We had agreed upon a rate which was lower than my usual fee in exchange for the regular opportunity. At some point, however, the fees became substantial, and the administration sought a way to do two things at once: 1) to cap their expenditure; and 2) increase the extent to which their psychologist was integrated into the dental school community. I joined the faculty as a part-timer, something that many dentists do at local dental schools. Dental education depends upon part-timers to a much greater extent than does psychology programs, and the structure for a two-day-a week-faculty member was already in place. As time went on I found other ways to contribute, and will describe those below. As I became more and more involved, I added more and more time to my contract until I eventually found myself in the position of a four-day-a-week associate professor at a dental school. I’m happy here, and there are several interesting reasons why this is so. First of all, the administration, faculty, and staff possess integrity. They have created a healthy (if workaholic) culture. You can count on what people say, and people legitimately care about each other here. Second, dentists understand their limitations and are respectful of my “skill set.” They don’t try to do what I do and they don’t tell me how to do it. I did not expect this when I began here, and, based upon my experiences with physicians, would not anticipate it at a medical school. This puts pressure on me to “get it right.” They accept what I say as the opinion of a professional, thus, I am careful about opinions that I render. Third, there are so many interesting ways that virtually any psychologist could make a significant contribution! It’s like a big, professional candy store for a psychologist. (And I don’t mean that everybody’s crazy...). Here are some of the things that I do: Advising and counseling. This amounts to the practice of mainstream counseling psychology in an academic setting. Students are generally quite healthy in the important ways, but they are under enormous stress. I help them with stress management, relationships, study skills, time management, conflict management, mood management, anxiety, and occasionally depression. Communications skills. I teach a mandatory course on basic listening skills, speaking skills, and therapeutic empathy and rapport. Dentists and students are well aware that doctor patient communication in dentistry is a daunting task. Ethics. Five years ago I was asked to create and teach a basic bioethics course to all students. The dental school was kind enough to send me to several lengthy and comprehensive training programs to prepare for this assignment (at Georgetown and Loyola of Chicago). Wellness. When the need arose, the obvious choice for a chair of the Wellness Committee was the psychologist. We address the issue of the overall wellness of the school and offer regular brown bag presentations on breast cancer, prostate screening, substance abuse, and alternative or complimentary medicine. Human Resources. The HR director consults with me on a regular, as-needed basis when she is confronted with difficult personnel situations. Facial pain. The Facial Pain Clinic asks me to work with them from time to time on cases which would benefit from psychological input. These cases are inevitably complex and interesting. Contact Point. The dental school publishes a glossy alumni magazine and I author a regular “Psychology and Ethics” column which solicits reader reaction. Hypnosis. From time to time I offer an informal hypnosis study group for students and faculty. Admissions Committee. The director of admissions asks me to interview applicants when the committee cannot determine whether a good fit exists between candidate and dental school. Substance abuse training. I offer lectures to students and coordinate outside presentations to faculty and students which are designed to help dentists work with patients and to monitor their own potential problems. The involvement of a psychologist at a dental school represents a true win-win situation. As far as I know, several other dental schools in the United States use a regular psychologist, however, the majority do not. Before I discuss the obvious opportunities along with some ideas about how to take advantage of them, it must be said that there are difficulties associated with dental school-psychologist collaboration. Challenges. First of all, confidentiality is tricky, if not problematic. I cannot offer students a truly confidential relationship, and I tell them that. I inform them that I will do my best to protect what they tell me, but staff, faculty, and other students can see who waits outside my office door. Administrators have made it quite clear that they are willing to honor any confidentiality constraints that I require, and they have been consistently supportive (over a decade) of the privacy of my relationship with students. I serve on no committees wherein a student’s fate is determined (academic promotion committees, ethics committees), and although students are sometimes mandated to spend time with me, administrators never ask for content information. It seems important, however, to inform students up front, about the limited nature of the confidential relationship. Second, work in this collaborative setting requires the clinician to be tolerant of and facile with dual relationships. The most obviously tricky situation occurs when I must teach (and thus grade) a student I have seen or am seeing in consultation. Luckily, I teach a course which counts for just a small number of credits and is graded on a pass-fail basis, so there have never been conflicts about evaluation. I do, however, have to hold onto the occasional “secret” and then later come into regular contact with those students who have told me their secrets. There is clear potential for discomfort. I must be careful about how I speak to students on elevators, less students feel uncomfortable. I have completely abandoned the idea that I could consult with faculty members about personal issues. As a policy I refer them to someone in private practice. I also refer students out when it seems appropriate, as well. Arrangements related to confidentiality, expectations about information, and dual relationship must be negotiated early on in order for collaboration to succeed. On the positive side of these difficult equations, it is my impression that the addition of the psychologist’s sensitivity to confidentiality and dual relationship have had a positive impact on the dental school. When I began to teach ethics there was really no awareness or discussion of the nuances of dual relationship in student-teacher or dentist-patient dynamics. And dentistry seems poised to take confidentiality more seriously as it becomes clear that all dentists treat gay patients and substance abusers and patients who have HIV and hepatitis B and C. It must be said, too, that the dental school where I work is unique. It is small and private and housed in San Francisco. We are not part of a large hospital-medical center or a larger university campus (the main campus is ninety miles away), and our leadership is autonomous and progressive. We are able to make decisions without many layers of bureaucracy, and are committed to a “healthy family” atmosphere. When someone in the family has troubles, we try hard to help. Not all dental schools are like this. Some are less warm and more bureaucratic, but this seems to be changing. There is certainly room for change. Opportunities. It is my impression that clear and worthwhile opportunities exist for psychologists to make a contribution in the “physical” health-care arenas. It seems to me that we are extraordinarily underutilized. Much of doctoring involves teaching and encouraging people about how to fix and take care of themselves. All doctoring involves a doctor-patient relationship, which is the specialty of the psychologist. In the academic arena there is a clear trend toward recognition that professional students (medical, dental+&Mac178;and law students) sometimes have learning disorders and skill deficits which can be discerned with proper testing and can be effectively accommodated. It seems to have been previously been assumed that acceptance into professional school precluded the possibility of a learning disorder. There are roadblocks to collaboration, as well. Dental schools, like most institutions of higher education, are under funded, and they must make do with limited resources. Also, curricula are already crowded, and it is difficult to add more subject matter to the mix of biochemistry, pathology, histology, and removable prosthodontics. But dental education evolves like everything else, and there is a trend toward behavioral subjects (ethics, patient relations, law, esthetics, leadership, practice development and management). Dentists have done a good job of keeping the managed care wolf from the door, and most dentists prefer to practice independently in every sense of the word. Many dentists are exquisitely aware of the relevance of good relationships with their patients. Some pay “practice management.” consultant-experts large sums of money to help them develop and sustain their independent practices. These consultants spend much of their time teaching the very subjects and skills that psychologists already know: empathy, reflective listening, effective reinforcement, and teamwork. How-to. Dentists, dental professional organizations, and dental schools are always looking for speakers and presenters for workshops and conventions. Dentists must take 50 hours of continuing education during each two-year period. If you have an interest in developing collaborative work relationships with dentists or dental schools, contact your state dental association with an offer to present continuing education. If you can find the right person, they will tell what topics interest them. Contact the local dental school and offer to make a presentation about how your specialty can help them. Offer to help with students who are struggling. Offer to teach a course on study skills. Offer to assess students for learning disabilities at a reduced fee. Lead a workshop on listening skills or substance abuse or defense mechanisms or EMDR, if you have a skill in that area. Dentists posses a wide ranging curiosity about other health care matters. New ways to manage stress or to work with staff members are always matters of interest to dentists. The key is to stumble onto the right person in the organization, the one with the enlightened point of view or the one assigned to find new talent. If your local dental school already houses a psychologist or behavior science specialist, meet with them to offer your services on a referral basis. Opportunities truly exist, and for the right kind of psychologist, can result in a lovely win-win circumstance. Dr. Peltier is Associate Professor of psychology at the University of Pacific School of Dentistry in San Francisco. He is a licensed clinical psychologist and marriage and family therapist. His E-mail address is: bpeltier@uop.edu.
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