It’s (almost) always about money

I want you to think about the worst patient problem in your practice. When you peel back the layers, it’s almost certainly about money.

If you think I’m wrong, let’s do a thought exercise. Think of the patient problem that’s been occupying your mind the most lately. It may be lack of case acceptance (the obvious one) or patient dissatisfaction (bad Yelp review anyone?). Hold that problem in your mind. Concentrate on it. Feel it.its-almost-always-about

Now…how does that problem become different if the treatment proposed to the patient was free? How might that problem resolve? What could you do in your practice to take away that objection?

I’m not offering any specific solutions here. Obviously there are a million ways to skin the financial arrangements cat. But it’s worth remembering that patients may love us, our office and our team. But no one is sitting at home hoping that they’ll be able to cut us a check using money that they’d rather spend on the new iPhone.

I know what you’re thinking. What about anxiety? That’s a big patient objection, too. I agree. But I’d say we’re talking 10% or less of patient objections are primarily due to anxiety. Also, how many anxious patients are in your office letting you know that they’re really freaked out about dental care, but clearly are happy to pay you whatever? If anxiety is their biggest hang up, money can (and probably will) still be an issue.

We’re not great at getting past this objection in my practice. The practices who can really identify and move past money as an objection definitely do better financially and probably are more satisfying to the dentist.

So next time you struggle with treatment acceptance it might be worth asking the patient, “is there anything besides the cost that would keep you from doing this treatment?” You’ll probably learn a lot.




Doing reps

Let’s say you need a procedure. Perhaps a filling or a crown. You have a choice between two dentists to do the procedure for you. You can choose yourself at this moment or you can choose yourself 10 years ago. Or 5 years ago. Or 20 years ago. The point being you are choosing yourself at a time when you had significantly less experience than you do right this second.

Who would you choose? I’d wager that you would choose yourself at this moment. Why is that? It could be that you’ve started using a new instrument or learned a new technique. It could be because the technology has come a long way since you were the other you. But most likely it’s the reps you’ve put in.

I look back on some of the work that I did 15+ years ago. Some of it I’m kind of proud of, but more often I cringe a little. I see underprepared crowns. I see overprepared direct restorations. Mostly I see things that were done to the very best of my ability at that time. Which is good. But much of it I would do quite differently today.

When I was a newly licensed dentist I planned to take the world by storm. I thought I knew a lot. And let’s face it, I did. I knew how to pass tests. National boards, clinical boards, microbiology exams, operative practicals. I knew how to play within the rules that were set by others that proved I was qualified to be a part of the profession.

What I didn’t know a lot about was how to be a dentist. I had done a bare minimum of clinical work on patients. I sometimes complain about how little clinical training I had, but let’s be honest. How much would have been enough? If I had done 5 more crowns in a setting where I had to check in with an instructor at every step would that have made me “experienced?” Probably not.

I’ve become the clinican that I am through reps. I’ve diagnosed real disease on real patients and then treated them. And make no mistake, I’ve learned how to treat patients by treating patients. It isn’t that I’m asking patients to be guinea pigs. But to some extent I ask them to believe in my abilities and experience up to that day.

Your patients trust your judgement and ability even though they really can’t know much about either. A poorly done restoration can be done painlessly. I’m not trying to make newcomers to the profession feel bad. You can’t get experience without doing the reps. But understand that most of us learn best by doing. I was never any good at reading the directions and then doing exactly as the directions said and having success. Those directions were written by someone with experience but were being read by me: someone with much less or different experience. For me, dentistry is a “learn by doing” profession. The only way I learn is by being open minded enough to see that there are different ways to get the job done and being patient enough to try something new.

The profession continues to evolve and as clinicians we evolve as well. I believe that most of us really do the best that we can at any given moment. But make no mistake, we get better by doing reps. This isn’t an excuse to be cavalier about treatment but a call to humility. Do your best, but be committed to being better next time.

letter from a grumpy dentist

Dear Patient that Didn’t Show Up for their 7am Hour and a Half Appointment,

I hope this letter finds you well. I wanted to take a moment to fill you in on how you affected my life today.

To you I’m probably just a service provider. Like the drive through at the bank or the guy who cuts your hair. Someone you see on occasion to take care of a small part of your life. And I’m fine with that.

On top of being a service provider I’m also a business owner. Which is to say that it costs me money to keep my doors open. As soon as I have employees on the clock, my overhead is growing. I pay employees, my rent, utilities and the rest from the proceeds that I’m paid to be that service provider. I understand that dental care is more expensive than a trip to the barber. I understand that paying for the services I provide can put a person out. I take my appointments with you seriously. I set aside appointment times for you and only you. My team and I are ready and waiting at the appointed time to take care of your needs. In this particular case, that meant getting up really early in the morning. So when you didn’t show up, my overhead didn’t get paid by the procedures we had planned and my business loses money.

More importantly than my role as service provider and business owner, I’m also a human and a dad. I don’t mind getting up early and I do it quite often. But given a choice, I might sleep another hour. I might delay the time that my office opens knowing that I’m not going to be seeing patients until later. I definitely would have preferred to see my children when they woke up and put my oldest on the bus than to drink coffee in my office.

So, what’s the solution? I could be a jerk and charge you a no-show fee. But that’s guaranteed to make me look like a bad guy. Furthermore, any reasonable fee couldn’t make up for the overhead that’s been burned. I could ask you to pre-pay for your appointments, but that’s never been part of the culture of our office. That would just make you feel singled out and resentful. Kind of how I’m feeling right now. I could just always double book appointments so that in case if one patient doesn’t show up I’ve always got another one in the next room. But that makes it so I’m not giving each patient my undivided attention and that’s something I pride myself on.

The solution is to make you another appointment. Because I want you to be my patient and I want to take care of your dental health. We’ll probably give you extra reminders to make sure that you remember.

And to write this letter. Because it does make me feel better. Slightly.



A Grumpy Dentist

License to Floss

I saw “Skyfall” this afternoon. It was a dream come true, really. I was there alone, so I could gorge on popcorn and Sour Patch Kids in the dark while watching the suave Englishman create cinematic carnage. Good stuff, all the way around.

The highlight of the movie was the bad guy, as it often is. Javier Bardem makes a really nasty villain and I think he should get another Oscar for his portrayal of a rogue MI6 agent wreaking havoc on Bond, “M” and the rest.

I suffered some wounds, too. The basketball sized bucket of popcorn that I ate caused gingival trauma on a blockbuster level. It happens every time I eat movie popcorn. And I do it every time I see a movie. You’d think I might learn, but I don’t. By the time I made it to the car I had discovered no less than 4 separate popcorn husks burrowing into my gums like the henchmen of a Bond villain.

Instead of pulling out a Walther PPK (customized to my palm print, no less) I whipped out my mint flavored waxed floss. I flushed out the bad guys in a matter of seconds. They never had a chance. You see, I have a very particular set of skills. And with the right tools, I’m very dangerous.

I’m like James Bond that way. James Bond with floss.

developing habits

In 2009 I picked up a habit. It was a habit that I had all through dental school. When I was in dental school we were all positive that we’d quit, and probably most of us did. I mean, I dabbled in it between 1997 and 2009, but it didn’t really stick. Now, I’m finding that it’s a really tough habit to break.

No, I don’t smoke. I’m talking about the rubber dam. Actually, not the “rubber” dam, but the “nonlatex” dam. It’s just that the name I know it by is rubber dam. Old habits die hard. And new ones are kind of the opposite.

Ever since I started reading and posting on DentalTown I realized that the dentists that I aspired to be like used the dam. And they used it effectively. Most importantly, they took pictures. It was like rubber dam porn. They showed these amazingly clean endo accesses, bone dry restorative fields and perfect isolation for seating crowns and onlays. I wanted that. But it was my habit to isolate with cotton rolls and high volume evacuation. I could think of many reasons NOT to change my habit.

  • It would take too long
  • Patients don’t like it
  • Rubber dam retainers (clamps, for those that like to scare their patients) pinched the gingiva and hurt
  • My assistant wouldn’t like the change

But in 2009, I finally decided to suck it up and give it a try. I don’t exactly remember how it worked. I think we (my assistant and I) decided we’d try it on every composite case that came through the door for a month. If we didn’t love it, we could always go back. But we didn’t.

I couldn’t have developed this habit without Shelly’s help. I think at first she didn’t really like it. It was different and kind of uncomfortable. Patients didn’t know what to think about it, because it was different from what we used to do. But we kind of slogged through. At first, I felt defensive about changing up the routine. After awhile, we developed a team technique for placement. We can essentially place a dam relatively comfortably and  quickly within a minute or less. I have a pdl syringe in every set up and can use a dam painlessly. I give palatals routinely to allow for retainer placement on the upper.

How do patients react to it? Half the patients love it and ask for it. Most of the other half tolerates it without a lot of questions with a very small percentage of patients that can’t tolerate it. But dentistry is SO much more fun with the dam on and I work so much faster once it’s placed. Shelly and I often wonder out loud how we worked without it!

The rubber dam is a great habit that I’ve developed. Your mileage may vary, but if you’re wondering…you ought to try it.

What’s the next habit I’m looking to acquire? I’ve taken a few classes from David Clark and he advocates using Aluminum Trihydroxide powder blaster to remove all traces of biofilm once you isolate your field. I love the concept. But it’s another habit I’m going to have to work to acquire the habit. It’s messy as heck and to use it efficiently I’m going to have to add an air line to my operatory set up. I’m sure I’ll get there, but it’s a process.

What habits do you have? Are they habits that you’re proud of, or do you need to work to eliminate them? I’d be interested to hear!

The “loving headlock”

I’ve got dentist friends who have chuckled about having to do fillings on their kids. They’re proud of how well their little cherub handled anesthesia and glad to know they can get the job done. Good for them, I guess.

I live in fear of the day I might have to restore one of my kids teeth. I have two active, healthy boys. Sean, my oldest is somewhere on the autism spectrum, which actually doesn’t mean much to me. I just know him as Sean. He has little quirks, but in all he’s a pretty regular kid. Jake is a solidly built 2 year old who wants to do everything by himself, including brushing his teeth. The upside is that he wants to brush. All. The. Time.

Not kidding. I got up with him at about five minutes after 6am this morning. His first request was to brush his teeth. Which is fine, but he’s not much on spitting, so I mostly skip the fluoride toothpaste. He’s got an obsessing brushing habit, but he’s not really reaping the benefits of it yet.

Here’s the deal. I don’t want to do fillings on my kids. I LOVE children, but not as dental patients. I handle the really easy pediatric patients, but I can’t hold it together for most of them. I have great specialists that I can refer to. Mostly I do. My pediatric dental goal: “don’t be the experience that this person is telling his/her dentist about in 30 years.” It’s a simple goal. Usually achieved with a referral pad and a smile.

But what about my own kids? Would I actually pay someone else to take care of their teeth? Hell yes. In a second.  Don’t even kid yourself. I’m sure I’ve already given my children years worth of therapy topics and I’m not willing to give them any more when I can avoid it.

My plan to keep them out of the dentist’s chair? I call it “the loving headlock.” I brush their teeth first. Then, if they want to brush their own teeth, I let them. But I get the brush on each surface so I can see it with my own eyes. Buccal, lingual. All of it. How do you do this on two vital, healthy and squirming boys you ask? Let me explain…

I stand behind them and to their right (I’m right handed). I have them stand on a step stool. I take my left arm and wrap it VERY firmly around their chin. I take my left index finger and middle finger (recently washed) and prop their little jaws open. Then I brush. I brush so I can see the toothbrush clean each surface. If I can’t see it, I’m not sure I’ve cleaned it. So I make sure I can see it. It probably takes me about 45 seconds to do all of it. I know you’re supposed to do it for two minutes. But that’s voluntary brushing.

Sean handles this exercise like a champ. I’ve been doing it with him for the better part of three years, so he’s used to it. I give him props, because he’s really strong and could probably wiggle away more than he tries. Jake is still learning. But he’ll get there.

“How long are you going to do this?” you may ask.

I figure I’ll do it until they’re big enough to push me off. Maybe college?

So far, the results are excellent. We’re O.K about avoiding sweets. We avoid sugary snacks as much as possible and we try to eat at meal times and only designated snack times. The kids drink no pop, but they’re fond of juice which is just as bad. But so far, so good.


Quick! Dental peeps, are you overdue for a preventive hygiene visit (aka…a cleaning?)

If you’re like most dentists I know, you probably are. So what does that say about us? What about a dentist with really nasty looking teeth? If you aren’t taking care of your teeth at least as well as your patients you’re kind of a hypocrite, right?

You would think that dental people have lower risk factors for dental problems. We’re supposed to know how to brush and floss and I’m sure our patients assume that we’re olympians in dental hygiene. (As an aside, did you know that I won gold in tongue scraping back in 1996? True story.)

The question I would ask of dentists and dental people in general…do you walk the walk? Do you have have a dentist that treats you? Do you go for regular visits? Would you do the treatment that you recommend for your patients?

One other thing. If you don’t have a dentist because you don’t think you’d trust your dental care to anyone but your awesome self it doesn’t make you superior. It makes you a douchebag. Get a dentist and show up. At the very least we ought to remember what it feels like to lean back in a dental chair at least a couple times a year.

By the way, I’m due for hygiene on 7/24/2012 and I was inspired to write this post because I think I broke a tooth.



40 minutes. One way.

I have a commute to work. I live west of Midland, Michigan and my office is in Saginaw Township, Michigan. I’ve been driving roughly the same route for 14+ years. 80 minutes per day. 4 times per week. When you do the math, it’s kind of depressing. I’ve been commuting close to 150 days straight.

I often hear about colleagues who have a two minute drive to the office. “Yeah, it’s two or three minutes. It just depends on whether I catch the light.” Or better yet, “It only takes me five minutes to walk to the office, so I usually go home for lunch.”

Then there’s the guy in New York City who lives upstairs from the office. That’s way too close, in my opinion. Or at least don’t let your patients know it. I’d feel a lot more comfortable calling on a Saturday if I knew it was only a walk down the stairs for you. Just sayin’.

There are obvious advantages to a short commute. I think of all the wasted time that I could be spending with my family. I have two little boys, so they’re not in a lot of activities yet, but I know that’s going to be complicated. I’m not sure how it’s going to work. Perhaps I’ll squish a four day week into three days some of the time. I’ll cross that bridge when I get to it. A shorter commute would allow me to sleep in a little longer, too. I feed 12 horses, two dogs and a miniature donkey most mornings. So I get up pretty early. Shaving a half hour off of my commute would mean another half hour of shut-eye. I’ve always been one to go to bed early, but that gives me even more of an excuse.

I generally like to know what’s on the schedule for tomorrow and even for the week. So I usually go online to check the schedule if I didn’t take a look the day before. Occasionally you’ll see that one patient on the schedule. You know the one. She’s the one that makes you contemplate injuring yourself while mowing the lawn, just so you can miss tomorrow. Or the guy with the removable case that gets worse. Every. Time. You. Touch. It.

I’m here to tell you. 40 minutes is a long time to think about those patients. 40 minutes gives me time to contemplate each and every way that appointment can go horribly wrong. By the time I get to work, I’ve already lived those tragedies in my mind several times. The upside is that they never go as badly as I’ve imagined them. There’s almost always less swearing and often less bleeding.

The upside of a 40 minute commute is that there’s some time to unwind from work. I listen to audiobooks and podcasts almost constantly. 80 minutes a day gives me some time to enjoy these. I also use the Spotify premium app to listen to whatever kind of music I’m feeling like. My time in the car allows me a chance to think of ideas to blog about. Some of my best ideas for have come in my morning commute. This very blog post was inspired by the ride in this morning. I’m less creative in the afternoon, since I’ve usually spent the day working on patients so I generally just unwind. But I think my family gets a better, more relaxed version of me because I’ve got decompression time.

Anyone else have a commute? I’m interested to hear about it. Thanks for reading!