Ode to the Dental Assistant

Tomorrow is my free dental day. “Dentistry with our Hearts” is a day we open our doors and treat as many patients as we can for free. I put a dentist in every room (eight) and we go as fast as we can. It is a crazy day. It is first come, first served; last year people got here before I left work on Thursday. We cut the line off at 130 people and that was at 6:30.

A lot of the stuff is donated: supplies, anesthetic, food for the volunteers (about 40). There is even a DJ and a grill master outside feeding the masses. T-shirts are donated. It is awesome. I may have a chance to write blog tomorrow, but if not, I will talk to you next Wednesday.

I was just thinking about my yesterday while I was getting ready for work. I had a very busy day and I was reflecting on it. And you know what? I started to think about how hard my assistants worked.

Yeah, the same assistants I talk bad about most of the time. Well not bad, but not great. I have two assistants mostly. Mine, who I met at one of my associateships 16 years ago, has worked with me for 16 years and in this office for 15 years. The other assistant is my father’s #1 assistant and has been with this practice for 34 years. That alone will tell you a little bit about them.

My assistant Chris is pretty special. In my lecture I have a list of the top ten things you must have to do awesome fillings. Chris is one of the top ten. Now, I know she can't be duplicated, but you have to have someone like her.

Our relationship is so unique. I always say she is my office wife. I literally sit 3 feet from her 8 hours a day. First, I have to like her and she has to like me. I can understand "a working relationship.” But Chris and I are friends. Her family is friends with my family. I love her husband. She gets invited to all Gammichia parties (her family even came over for Thanksgiving last year).



I know most of you are not that friendly with your assistant. We have a weird relationship. I think it works because she is a little older than me (13 years). But let’s put personal stuff to the side. She is a great assistant. She is responsible. I think in the 15 years she has worked here, she has missed about 3 days of work. She is on time EVERY DAY.

She believes in me, almost to a fault. Or rather, she believes in the kind of dentistry I do. If I don't think I can save a tooth with a filling and think it is going to need a crown, she will pipe up, "Oh, sure you can. I have seen you do bigger fillings." Then I have to explain to her and the patient why she will no longer be working here anymore.

She is awesome with the patients. God forbid she go on vacation. All I hear is "Where is Chris?" There are a couple of reasons for this. When people are getting work done, we are chatting. It makes their appointment not suck so bad. I am relaxed and can do my thing.

She knows me. If I move my head, she knows what to do. If I am quiet, she knows that I am into some serious tooth issues and she won't talk. If I change things in the middle of the procedure, BAM!, she changes gears without a lot of huffing and puffing.

Her and I like the same things. We talk politics and religion. We talk kids. And in all these subjects, she thinks she knows it all (did I tell you that she is 13 years older?).

You and I both know when people have been in a practice for that long, they can have a tendency to cop an attitude. And they can mark their territory in an office. A telling sign is how they work with new people. Chris is great with new assistants. I know you dentists see your assistants running the new girl ragged. You see them abusing her emotionally and physically, saying that if she can survive this abuse, she can make it here. I know what you dentists do and allow. And if you don't think it is going on then you are turning a blind eye to it.

But Chris will show them the ropes and ease them into it. She keeps them away from me until she thinks they are ready. This is not for them; it is for me. She knows I am getting crotchety in my old age and doesn't want me to be upset and doesn't want them to be put in a position to fail. She is not concerned about a new assistant taking over her job.

She is the queen bee around here and I let her be. I let her because I know she always considering me. Simple as that. She might show her teeth to other people in the office, but I am okay with it because she has earned it. But she is also approachable. I can talk to her about what I like and how I want things (and she will at least make it look like she is listening). I can also tell her when she is not playing well with others.

She is the assistant that can talk to me. People say I am intimidating, but certainly Chris doesn’t think so. She will tell me when my hair looks like crap and she will tell me when it is time to trim my eyebrows. She tells me when I have a wild hair growing out of the side of my ear. I mean, men are stupid, really. We need someone to take care of us. You have all seen the guy with nose hairs hanging out like crazy. You think, "Someone needs to tell that guy." Well, if I miss something at home, Chris is the one that is going to tell me.

In my first 18 months of practice, I went through 7 assistants. No lie. I know how hard it is to find that person. But I also know what it is like to love to come to work. Partly because I love dentistry and partly because I like Chris (and the others). I think I am a better dentist because of her. She lets me be me and doesn't judge. I couldn't do it without her.

I hope you all have someone like her in your office. Maybe I don't tell her enough. If that is the case, I hope she reads this.

Have a great Thursday.

john

All You Care About is Money

I know, I know. I told you I wasn't going to talk about money again for awhile. Has it been awhile?

Lately, I feel like I am getting some flak for "being expensive" or because "all I think about is money." But I feel like I am a fair, conservative dentist. I try to be the guy that saves people money.

Sure, my exam is thorough and when we are done taking a full mouth series and a Panoramic (which I don't charge for), the exam can be in the $225 range. But I think I am doing a pretty good exam. Perio charting (which most 50-year-olds have never had done), oral cancer screening, looking around, looking at their bite and teeth and joints. We have a sit-down conversation in a consultation room. Patients get my time. Isn't that what patients want? To feel like they are being cared for and not rushed? Or do they just want the $55 x-ray and exam done by the big teeth corporations? I think they want the former.

After I do a thorough exam and find some cavities, I tell them that they have some restorations that are broken (I show them the big broken filling with the intraoral camera; I am not making things up here). And I think that I can do a filling and restore that tooth to good again. No, I don't think you need a crown (which most dentists would do at 500% the cost of a filling).

My fillings are expensive. But are they really? I do a better job than the schmoe down the street (if you are a dentist down the street from me, I like you; I am just being creative with my words). I use the BEST products. The filling I do is superior. So I am $20 more than another dentist. Maybe it is $50. Didn't I just tell you that most dentists would put an $800-$1,100 crown on this?

So when I hear from my staff (I never it hear it from the patient. They tell my assistant the person answering the phone) that all I care about is money. WHAT?! Are you fricking serious? I go to the best continuing education. It costs money to have a nice facility and good staff members. And all this costs about $20 more per filling.

Look, I get that money is a big issue. I get that dentistry is expensive. I know. But I feel like some people are killing the messenger. I am who I am. I am the dentist that does really nice work and hopefully the dentist that people go when they want to like their dentist and feel cared for. I am not a regular dentist, and it will cost a bit more. But for patients to come here and say that all I care about is money? Well, that hurts.

I am going to stretch here and tell you I am like the Hilton. The Hilton is a beautiful hotel. They have awesome beds, great sheets and pillows. They have great staff that say, "It is my pleasure." They have things in place to make you feel so good. And after a stay there, you feel special. Then you check out and say, "Man, that was a little bit more than I meant to spend."

Then the next time you try the Holiday Inn. You didn't have a very good night’s sleep. You are just a number there. You get the bill and don't think anything of it. But you start to think, "Remember that Hilton? Yeah that was really was nice."

You can't blame the Hilton for being more than you wanted to spend. We as dentists feel like we are being thorough and find stuff. Then the patient always thinks we are trying to find stuff that doesn't exist (you aren't doing that, are you?).

I might be a bad time for them, I know. But if you look at me through a microscope, you are going to find warts. And maybe I used to just brush it off. Maybe now I am a bit more sensitive to criticism. I don't know.

I am trying to make this place worth the $225 exam and the extra $20 filling. It would be easy to just lower the price and work faster and make people feel a little less special, but I don't want to do that. I want people to say, "Remember Dr. Gammichia? Yeah, he really was nice." Or even better, "I love my dentist and I will stay there forever."

I am not bitter. Just sensitive, I guess. I will keep at it.

Have a great weekend.

Beer me,
john

Product Review

Hope things are going well for you and that you guys are busier than me. It has been such a grind lately. I think this lecture thing better take off soon because I might need that to pay the rent.

My father read my blog last Friday about old guys selling their over-priced stuff to the young guys who can't afford it (because the banks won't lend them the money). Even though it wasn't about him and me, it prompted him to come to me. We have agreed on the price and to the terms. Now I have to draw up a business model and go to the banks to see who will give me the best deal. It all sounds easy, but I know this is going to be a long process. I am getting tight just thinking about being the only owner of this sinking ship.

I’m making it sound worse than it is. I love this practice and the people that come here and the people in it. It is a great practice, but buying a practice that has decreased in production for the last 4 years is scary.

I want to talk about some filling products that I have tried recently. I have used the sectional matrix and BiTine ring for a long time. In the last 5 years, I changed my ring the Triodent V3 ring. This ring is so sweet. I kept using the sectional matrix.

But I bought a sample of Triodent’s SuperCurve matrix. Have you tried these? Wow! The sectional matrix is about 25% of a circle and the SuperCurve is about 50% of a circle. It wraps around the tooth. You might not think it would make that much of a difference, but it does. The gingival 1/3 of this matrix bends in to form the CEJ. It is pretty cool.

I usually work with Patterson. They have this deal where, during the year, you build up reward points. Turns out, at the end of the year, I had 1,200 points (each point being a dollar). I had to use $900 before the end of the year or I would lose it. Instead of buying things I really needed, I bought the SonicFill system from Kerr. Have you seen this?

Now, I struggle with using something that might not be as good as the stuff I am presently using. So I did my research and everyone really likes it. Reality and CR are all giving it great props. I used it today for the first time. Let me tell you that it turned out really nice. A lot of my stuff is not really material-dependent, but if it is less expensive and it reduces my steps, then I might try it.

While I was buying the SuperCurve matrix, I bought some 360° Cervical Matrix. This is basically a form guide you put on a facial filling after the composite and before the curing. It is clear; you put it on the filling and cure right through it. Wow, is this thing nice. I have always worried about whether or not the filling is tight in my facial box and about it pulling away at the margins. This thing takes care of both, and then afterwards the margins are like a baby's butt.

One last thing. I’ve started sealing my margins after a posterior composite. Burgess says that the occlusal wear is reduced by 15% if you use a sealer. That sold me. I bought Bisco’s BisCover LV. Not only do I feel better using it because I know it is going to make my fillings last longer, but it makes them look so good.

I know it is good to hear about it, but the proof is in the pudding. Here is a case I did this morning.

30-MO

 

I told you.  Really nice filling.  And this took me about 15 minutes.  No joke.  Adding the photos to the appointment made it 35 minutes.

Have you used these products before? What do you think? Do you have any products that I should know about? Have you checked out the AGD’s Product Review Directory? Let me know.

Hope your week is going well.

john

Why Not?

Greetings,

I hope everyone is healthy and happy as we start out 2012. After a long discussion with my family and some close friends, I’ve decided to email the owner of the Miami Dolphins and express my desire to be considered for the head coaching job.

Hopefully by the time this blog goes out, they will still be interviewing (which will increase my chances). If I get hired, I will probably have to give up the AGD blog because I will be spending a lot of time going over game film and interviewing my potential staff. I will miss writing to you all and I will miss dentistry to some extent. Maybe I can work a month in the off season? We’ll see.

The way I see it, I have a good shot now that virtually every big name has turned the job down. As a matter of fact, I have a few things going for me:

1) Miami is my hometown, and who wouldn’t want a hometown boy?

2) I’ve been watching the Dolphins play for the last 45 years, so I have an intimate knowledge of the team and what they need.

3) I couldn’t care less if Jeff Ireland stays on as the general manager. Shoot, why not have someone else do all the work?

4) They wouldn’t have to hire a team dentist (I may want a slight bit more cash in the agreement to cover both jobs).

5) I can give a locker room speech after each game. Granted, I am only 5’6”, but if I had something to stand on, I could tell the men how proud I am of them and maybe give out a game ball.

6) I can talk to the media because I know all the coach lines. For instance, “They made more plays than we did”, or, “The refs made some bad calls out there.”

7) I wouldn’t demand a large salary. I would take half of what they were going to pay Jeff Fisher! That will save the owner over 20 million dollars over 5 years. Maybe we can use that to get a quarterback. Who knows?

I do have some good friends with football minds. I might be able to talk Dr. John Gammichia into being my offensive coordinator. I mean, he has only called some peewee league plays, but there can’t be that much of a difference. I went to dental school with a couple of football players that might be able to work with my defensive and offensive lines. There is so much to think about right now that it’s a little overwhelming. I am going to be up long hours trying to figure out how to keep Tom Brady off the field.

There is also the small snag in my partnership contract saying that I can’t leave for more than a few months. I am still working on that one. If it all works out, I can get the Dolphins back on top in just one contract period. After that, I could go right back into dentistry, or maybe travel for a couple months. I would love to be able to travel in Europe. Other teams might want me once they see my results at Miami, but relocating out of Florida is something I may not want to do. Time will tell.

I wouldn’t forget about all of you out there either. Being the head coach, I could probably score a few tickets to some games. Just shoot me an email and let me know how many you need. I can have a Dental Block! (Total pun intended.)

Of course, if Mr. Ross hires someone before he gets my email, then I guess I will have another blog here in a couple weeks. It also means that I will have to see Mrs. Smith next month for that 16th denture adjustment. My plans for traveling in Europe will be shot down, too. The sad part is, we will have to all suffer through another bad season for the Dolphins.

Talk to you all in a couple of weeks (maybe).

Scott

What Would You Do?

F-R-I-D-A-Y! Oh yeah!!! Hope all of you are having a good week. Pretty good here.

I saw Hangover II last week and I didn't think it was that good. I am in the middle of Super 8. I have to say that I haven't had much time for movie or books, and nothing I have read or seen has been that good. Let me know if you have seen anything good lately. My queue is kind of flat.

I liked Wednesday's blog and that "what would you do?" kind of thing, so I am going to do another one.

Before I forget: I have been asked to be the guest speaker at a study club in Miami (or as my kids would say, “Your-ami”). You know the study clubs where the meeting is in a restaurant and there is a speaker at the front while everyone is eating? I am going to be that guy. I am kind of nervous, but I got myself into this so I might as well jump in with both feet. It is on a Thursday night. I will finish work at 1pm, get in the car, and be there a little early. I’ll eat, speak for 2 hours, sleep, get up and come home.

I think it is a great way for me to practice and get my name out there. Triodent is putting it on, so there is a little pressure for me to perform. They will have their rep there and she will tell corporate if I stinks or not. It is in three weeks and I am freaking out.

Anyway, I have this patient. He is a 70 year old man and a really good patient. I took this x-ray the other day.


Knowing what we talked about the other day, take a look at the distal of #30. Man, this is a tough one. There is a little spot, straight distal. But I know that to do this little thing, I have to blow through the marginal ridge and do a DO. If I wait, there is a chance it would be humungous the next time I take an x-ray. You can see on this x-ray that he isn't very cavity-prone. On this x-ray, all he has is a facial filling on #5. Would you do it? Would you wait? Tell him to up his home care?

Okay, next one. This patient is 7 years old with decay on distal of #F.


On paper, there is no question: do the filling. But looking at the x-ray, the permanent molars are getting close. Her 9-year-old sister is in the other chair getting her teeth cleaned and she has already lost her upper first baby molars. Is that cavity going to be an issue in two years if not done? If it becomes an issue, what is the big deal? Just take it out. We know the permanent tooth is going to be really close. But to do the filling is so easy. Just 0 minutes and she’ll never have to worry about it. But I don't want them to have to pay for something that might not ever be a deal.

Anyone have an opinion? Oh, let me rephrase that (I know you have lots of opinion; I have read all the comments). What do you guys think?

I hope you have a great weekend.

john

Cervical Burnout

Oh my gosh. Are the weeks flying by, or is it just me? It seems like we spoke on Friday and bam! Here it is Wednesday. I hate that my life seems to be going so fast.

I got to play golf this weekend with some buddies. I love golf, but I never get to play. How does this sound? "Honey, I am so glad it is Saturday. I had such a hard week. So, it is 8am now and I have a tee time at 9. I am going to leave now and hit some balls before my round. The round should take about 4 and a half hours, and then afterwards we are going to sit around and have some beers. Expect me around 4pm. And yes, I know you have been with the four kids all week, but I need an avenue to relax."

I don't know about you, but this stuff doesn't fly at the Gammichia house. If I said the above, all my stuff would be on the front lawn when I got home. But I digress. I went on a church retreat and part of it was golf. The weather here is so nice and the golf course was beautiful. I love stuff like that. It is really not about the score but being outside and having a beer and a cigar. Awesome. That is why I want that Shelby Cobra. Then me AND my wife can jump in the car (lock up the kids in the pantry) and enjoy each other and the beautiful weather that central Florida gives us.

Today I want to talk to you about Cervical Burnout. I realize that most of my posts have been about money, and I want to try to get away from that. I realize that most people are dealing with money issues one way or another, and I wanted to talk about things that are current and on the minds of dentists. But too much of one thing can be bad. This is a non-money issue.

I assume most of you that read blogs are more on the high-tech side, which leads me to believe that most of you probably have digital x-rays. Five years ago, when I got digital x-rays, I had to make a decision about which product to go with. We are big Patterson people here and we were already using EagleSoft, so it was kind of natural that we would go with EagleSoft and Schick.

Anyway, that is not what I want to talk about. What I want to talk about is that I find there is a lot of cervical burnout showing up on digital x-rays. One of the issues with digital x-rays is not with seeing a dark spot but deciding what that dark spot is. Most of the time, what I am seeing is virgin teeth next to crowns. If there is a crown, the adjacent tooth has a lot of radiopacities on it. Sometimes I go in there and try to feel something and the contact could be too tight. Now I have this supposed lesion on a tooth that I can't feel. What do I do? It looks like decay, it smells like decay, it is in a prime spot for decay. Is it decay? Most of the time, it is.

Check out #15 MO.


I want to say that I am really good at reading x-rays. I thought this was decay. I appointed him and I got into it, and I didn't see decay. It is tough because sometimes I go into the interproximal and it is two steps. I cut a box and nothing. Then I go deeper than I think and there it is. Or I think the decay is on the straight mesial and it turns out to be on the ML ling angle. So I cut into this thing and I didn't see anything. I went deeper and there wasn't much there. I went a little wider and I started to see what was going on here. IT WASN'T THERE. So I did the best damn filling I could and hoped that I actually took out some decay while drilling this tooth.

Anyone dealing with a lot of cervical burnout on their digital x-rays? Ever go into anything that wasn't there? (For the record, I did this once or twice with film as well.)

And before I forget, the next thing on my list is to get Kodak sensors. I know there are going to be some bridges and it is going to cost a bunch, but I think it is the best image and my patients should have the best.

Thoughts?

john

Deadly Combination

Happy Friday to you. I have been talking to a lot of younger guys lately and it seems like all of them have the same story. Guy/gal has been a dentist for a very long time, has built up his/her practice for a long time, has worked hard, but doesn't really save a lot of. Life, school, cars, college, weddings all get in the way of saving money. But don't worry; his/her retirement is going to be selling the practice and either leasing or selling his/her building to the new dentist.

Have you heard this story before? See, practices used to be worth a lot. There used to be lots of buyers with money. Properties used to be worth a lot. Words you should key on are “used to.”

It’s very different now. All the dentists that are ready to retire have seen a drop in production and have seen their practices decrease in value big time over the last 3-4 years. And the rent money they were counting on? It is now about half.

So the guy/gal getting ready to retire is in a bit of a pickle. The associate dentist or new dentist coming out of school might be a couple of things:

1. He/she could be very wise to the way things are going and realize that the practice he/she was going to buy is now worth less. The awesome, money-making practice that he/she was going to buy is now barely paying the bills.

Or...

2. He/she might be just getting out of school and have tons of debt and have no credit to go to the bank to borrow money.

Do you see what is going on here? These are deadly combinations.

Now the story I keep hearing is "This guy is crazy!" Dentists my age are getting ready to buy the retiring dentists’ practices and it seems like the sellers still think their practices are worth what they were four years ago. And the same with the rent. I can tell you from experience that my rent is too high. And it has been too high for a long time. But going to MY landlord is pretty tough.

I have a friend who is in an all-out brawl with the guy who owns his building. The guy is on the moon with the prices. His lease is up in September, but my friend knows that moving his practice would cost him an arm and a leg. Getting a new place, architectural drawings, the build-out, equipment. Then there is the simple fact that moving the practice is a pain in the butt. And patients don't like it. Plus, he likes it there. He wants to stay. Staying is good for the practice, but paying ridiculous prices is cost prohibited. Then lawyers are going to have to get involved, and nothing good can come of that.

Now in many cases, including mine, the deal was done on a handshake. This is very,very bad. People forget things, especially those who have been sucking on amalgam dust for the past 15-40 years. At the time when the agreement was made it seemed fair. But now it isn't or someone forgot a detail. Or one of the situations is different and one person can't live up to their end of the bargain and the deal had no clause for that.

I have to tell you that I am moving in the direction of practice transition specialists. I used to think they were so expensive. “Why do we need them? We are both reasonable people." NOT.

If people would just spend $5,000-$10,000 for a transition specialist, all of this would have been drawn out and we could just sit back and relax. Saving of $5,000 five years ago might now cost my friend $50,000-$100,000 in leasing and building out another building.

Are you guys hearing this story? Anybody the seller? Are you being pinched by the present downturn in the dental biz? Anyone about to buy an office?

Have a great weekend. I have to go, I have my transition consultant on the other line.

john