Man it is slow

Hey all,

I hope everyone is having a good week, after all it is FRIDAY.

I told you that I was thinking about lecturing again.
Turns out that this year at the ADA's annual meeting, they are having something called The New Speaker Stage.
I read in one of their gagillion mail outs that they were taking applications for one hour presentations. You submit your application and if you are selected, "this will be a great opportunity for individuals looking to expand their professional speaking opportunities!"
(Now I don't know if this is new for the ADA but I know that the AGD has been doing this for a long time. In fact I did this for the AGD about 6 years ago in San Diego.)

I decided to jump in with both feet.
Officially, I have sent my application. No thanks to all of you I thought of a title for it.
I am calling it (don't tell me if it sucks) Drill'em, Fill'em, and Bill'em....how to make money doing exquisite fillings.
I had to think of something. I couldn't just call it, "How to do a nice filling" or what one commenter suggested, "How to make a filling that will need a root canal in 3 months".

So I am officially in lecture mode. I am doing some research on the stuff I don't know. And as it turns out, it is a lot.
I have opened a dialogue with my old biomaterials professors who is dying to talk to someone about biomaterials. It seems that it is not everyday that someone calls who cares about the properties of a nanohybrid.

I have started reading again.
Let me know if you come up with something that would help me.
I am researching 2007 PowerPoint. I am talking templates and slide design.
I am talking slide transitions.
Oh, you think lecturing is that easy, huh?

I will keep you posted. They are suppose to let me know by July 31st.


Topic....

I have to tell you that it has been very slow at the office.
I mean scary slow. I don't know what else to do.
I don't know who to call. I don't know what ad to take out.
I don't how to improve my customer service.
I have exhausted all my resources to getting people in the chair.
I just is what it is.
I know I have to hunker down and do the best I can.
I mean yesterday there wasn't much on the books but some emergencies saved the day.
Today is like a ghost town in here....wait look a tumbleweed.
And I know I am not the only one slow because when my friends are slow I notice a lot more forwarded emails with jokes and pictures of drunk people in precarious positions.

Now I even have time to open every piece of mail. And I am opening all of the junk mail looking for that golden bullet.
Well what do you know, nothing yet, no golden bullet.
But one thing I did get from some junk email is that I was intrigued about.

It was something called my3zips. Have you gotten this one?
Well what they promise is traffic to your website.
This is what they claim....
You give them your name,
you give them your website,
And you give them 3 zip codes and they take it from there.

Let me back track a second. I have had a website for a couple of years and it has generated about 7000 hits. I know this not because I am checking it all the time or all into this but it has a little counter down at the bottom.
I don't know if this is good or not. But I do know that people have abandoned the yellow pages and just go to their computer for information.

The way I do business now is almost exclusively internet. If I need something my first move is always GOOGLE.
So I have a website. I don't know if I am getting any real business from it but it is at least out there.
My office is called A Soft Touch in Family Dental Care and it is Apopka, Florida.
So I bought two domain names. Asofttouchdental.com and apopkadentist.com

Okay so back to the numbers, I have had 7000 hits in two years. They are claiming that they will generate a ton of hits to the site (claiming they have had up to 50,000, yes I said FIFTY THOUSAND hits in one month).
And they are giving a three month trial for FREE.
I know that this is total bullsh@!t.

But I say to myself that I have nothing to lose.
So I do it.
I sent in the 3 requirements yesterday. I have already had 2 confirmation emails sent to me.
Apparently it is all set up and the magic is going to happen anytime now.
They have sent me a link to monitor the magic (hits).

I know, I know a shot in the dark. I know it is not going to work. I know we are going to get a bunch of hits but it is not going to mean anything.
But maybe just maybe something will happen.
Like I said I have nothing to lose.

I still feel like treating people right and making them happy is the place to start.
Then they tell their friends.
Now the problem with this is it takes a while. You might be good and people really like you but all those people that like you and think you are the cats meow, yeah their income has be reduced to levels that they have to make decisions.

So what do I do?
I know I am going to have to be more visible. Get people talking about the dentist and more importantly ME.
I guess I am going to start with my3zips but trust me my wheels are turning.
I called the chairman of the little league and told them it is time to get my name on the back of some shirts.
I having a banner made to put on my outside sign about getting kids in for the summer.

I am not a marketing genius or anything....I am a dentist for crying out loud.
Help.
How is it for you?
Are you hunkering down?
Are you doing anything that is helping?
Are you a non insurance practice that is thinking about getting on some plans?
Tell me.

Hope you have a great weekend,
John

GO MAGIC.

Peer Review

Hey all,

Summer is definitely here in Central Florida. The highs have been the mid-90s (for you Canadians that's Fahrenheit, eh?), and its flipping hot. I must be getting old because I keep thinking about a summer mountain home for when I getter closer to retirement.
I am not handling the heat so good anymore.

Well, as I write things I will occasionally get a personal e-mail from readers. Sometimes they get my e-mail address because occasionally I will post it. (Jgammichia@aol.com if you need me). And occasionally I will get an e-mail from a dentist friend that a certain blog really hit home.

One of my friends wrote me about one of his situations, and I asked him to write a blog entry. This is a guy that my classmates and I always respected, a guy that was and is very passionate about people and about teeth. He works and lives in a small town in North Florida. He got into a situation that ended him up in Peer Review.

For those of you who don't know what Peer Review is, it is an organized dentistry thing.
I think this started a while back before our society got so litigious. So when a patient felt like they didn't get the best care or felt cheated in some way they had a governing board to review their case.

Now it is used in the same way. Some patients are not the suing type but would like the case to be reviewed. And quite frankly, sometimes it is in the best interest of the dentist to have someone look at a certain case before the patient gets all sue happy. The review board might tell a certain patient to "lay off".

So without further ado here is his story...

Have you ever said to yourself, “I wish I would have written that down!” or, “I wish they would have signed that?” Well, this doesn’t happen to me anymore because I write EVERYTHING down and they sign EVERYTHING.

“Oh, you don’t need to use the restroom? Can you please sign this waiver stating that if you happen to soil your clothing while you are here, that it is not my fault and that I freely offered my restroom to you?” OK, it’s not that bad, but close. Strange how the pendulum can swing the other way when something happens to you.

Here is my story:

Mr. P has been a patient of mine for 8 years. I will add that he is a little on the quirky side, but that didn’t matter to me, he trusted me, and I did my best to maintain his dental health. About 4 years ago, Mr. P was at my office for his yearly exam and radiographs (He put himself on 1 year recall because he says he is meticulous about cleaning his teeth almost to the point of obsession).

His previous dental work included some crown and bridge, large amalgam restoration, and large anterior composite restorations, all from a previous dentist.

So, during this appointment the hygienist tells him that his plaque control wasn’t up to par. Of course he does not believe her because, after all, he spends the first 15 minutes of every morning brushing his teeth. She takes an intra-oral photo of the plaque accumulation and shows it to him. His radiographs showed that he had recurrent decay on #8, recurrent decay around #4, and recurrent decay around #12 (which was part of a 3 unit bridge). We told him about it, and treatment planned accordingly.

He came in to see me to repair #8 a few weeks later. #8 now has 4 large composite restorations all fused together. We talked about eventual crowns on the anterior teeth, replacing the crown on #4 and replacing the bridge on the upper left. He said he was on a limited income, divorced, and didn’t want to sell his motorcycle, which was his only pleasure in life and Hollywood was not going to be calling him anytime soon.

I DIDN”T write any of that down. If I had only known!

I didn’t see him again for another year when he came in with a tooth ache on #2. #2 had a large 4 pin buildup amalgam that was unopposed. The radiograph revealed a radiolucency at the apex of one of the roots. I suggested that he have the tooth removed. He didn’t want to lose any teeth, so he opted for RCT and crown.

He had the RCT done and the crown but complained that the tooth still hurt and said that the endodontist did not know what he was doing. The final endo looked fantastic.

Long story short, he had the tooth removed, and wanted me to refund the crown money. He said it was my fault that I sent him to the endodontist. Well, I did.

The endodontist did not refund his money. In the meantime, #4 is getting worse, #12 is getting worse.

More time elapses, Mr. P comes in complaining of pain in #30, which was an old gold crown. After I scrapped the plaque off from around the tooth, there was recurrent decay right on the root surface. I told him that his home care was not as good as he thinks it is and he has to pay more attention to removing the debris from his teeth. At this point, I take a look at #4 and #12. They both need RCTs now!

I create a retreatment plan and delete the first treatment plan from 3 years ago to “keep it clean”...MISTAKE.

He tells me he can’t afford that and those teeth don’t hurt. I didn’t write that down. Months go by, and he comes in again with a chipped restoration on #9. I look at it and notice on the lingual of #8 that there is a suspicious opaque look right at the gingival margin. I take my explorer, and it literally sinks below the gumline about 9 mm. I talk him into letting us take a radiograph and there is a HUGE hole into the pulp with an apical abscess.

Nothing showed up on the last fmx. I try to explain what’s going on, and all he wants is the chip on #9 fixed because #8 doesn’t hurt. I give him a referral to another endodontist and tell him that time is of the essence because the tooth will not be restorable if we do not jump on this.

I didn’t write that down.

Four months later he comes back in with #8 hurting. Now it is non-restorable. He asked me how in the world this could happen since he comes in once year to get his teeth cleaned. I told him the decay was on the root surface of his tooth, which can progress very quickly if not taken care of (another mistake). He leaves.

Three weeks later he returns to the office with 50 pages of downloaded material on “root caries” from the Internet. Well, technically he didn’t have “root caries” he had recurrent decay that progressed to the root surface. He then wanted a complete treatment plan of EVERYTHING he needed. So my financial person remade another new treatment plan and deleted the old one to make everything clean in the computer. (MISTAKE)

So now he needs about 10,000 dollars of work. Mr. P looks in disbelief. He tells me he can’t afford that, so I suggested having the teeth removed, and wearing denture. (which ,of course, I would NOT be making). Mr. P reluctantly proceeds with the denture. Two weeks later I receive a letter, from Mr. P, telling me that he wants to talk to me and my attorney about my neglect and how I should pay for all of the extractions he had done as well as the denture (and some pain and suffering).

I wrote him back telling him that this meeting will not take place. He somehow gets referred to the peer review board and the process begins where I have to prove what I have done.

Now, this is when the sleepless nights start. This is when I can't eat because I want to throw-up. Seriously, this can wreck you for a long time. It wrecks you during all this, and it makes dentistry not as fun because you are a bit jaded.

So we started the peer review case. I knew some of the guys, but that didn't matter. It was still bad. Bad in a sense that they went through my records with a fine toothed comb.

It all finally came down to the board to review my “notes” and “radiographs” and “treatment plan”. Well, guess what? There was only 1 treatment plan, 4 years after the original radiographs! Mr. P told them that he was NEVER told about all the work he needed, and I just pretty much let him fall apart. (He did come across to our board members as aloof and quirky, see earlier comment).

Fortunately, and they were far from perfect, my notes reflected some of the work he needed. They sat me down and with a desperate explanation about deleting old treatment plans. I felt like I was in trouble. I know in my heart I didn't do anything wrong, but if you don't have the written word to back it up, it almost didn't happen.

But I had one thing in my favor....Remember the intra-oral photo of all the plaque accumulation? It saved me as well. I was cleared of all wrong doing.

Cleared is such a strong word. Let’s keep in mind that I lost about 12 pounds through the whole ordeal. So, looking back, my note taking was horrible, and my lack of attaining signatures was horrible. You can imagine things are very different now because I seemed to have a dodged a huge bullet. I wouldn't wish this on anyone. I have learned from my own story, and I hope you will too.

WOW!!!

I can tell you that I haven't have someone sign something in a long time. If they refuse x-rays, they sign something, and I can think of one other time I have someone sign something.

I am rethinking this...

Let's talk about this...

Let's ask this guy some questions about his story.

Any of you been through a similar situation?

Have a good Wednesday,
john

There is no "I" in "Team". . .

. . .but there is an "I" in "Win".

And that is what I want to do with my office—win. So what I have been reminded of this month is that I need to step it up. Because I am the only one who really cares if this thing succeeds, and I am the only one who can control the success or failure of the office.

Four years in, and I've had some time for reflection on the journey. The reason for that time is that we have been incredibly slow the first three weeks of May.

All work and no play make Ric a dull boy.

I have warned my staff (only somewhat tongue-in-cheek) that leaving me with too much time on my hands is dangerous because I have time to look at reports and production statistics and compare them to previous years. I have time to evaluate the value of each employee and start to wonder if maybe we couldn't get by on a little less overhead. . . .

I also have time to get depressed or just apathetic.

I have time to take the "tie a knot in the rope and hang on" kind of attitude.

I mean, come on, it has been four years of constant growth. Four years of constant cheerleading. Four years of constant stress. Four years of trying to create something from nothing. Four years of lonely, isolated perseverance. I want to cut myself some slack for reaching a plateau and resting, but I need to kick myself in the pants to get moving again.

I get asked all the time "what is the economy like?. . .are you feeling it?"

The honest answer is "I don't know" because we are new and still growing. I assume our growth would have been faster in a great economy, but I don't know that it would have been any easier. What I can say is that it hasn't helped me any.

We are on track for our lowest production month in 18 months (and second-lowest in 30 months). Ironically, our new patient numbers this month are the best they have been in 6 months. Our June is looking good. . .I guess this is just a blip on the radar and sometimes those blips are simply innocuous friendly aircraft—other times they are the only sign of a very large invading force. When I have too much time on my hands, I start to see blips where they don't exist.

And so I had to make some difficult changes the past couple of weeks. Not changes to my staff or overhead but changes to my attitude.

I had to remind myself that—while I have a great team and I can delegate a lot of responsibility to them—I am the one that has to lead the charge (and unlike the light brigade, I don't plan to lead them to their death). Patients come to this office because of me and the staff I have hired, the attitude I have instilled in my staff, and the quality of care and level of customer service that I require.

It is exhausting. It is lonely. It is stressful. It is necessary.

If you read this blog and are a young dentist or dental student trying to decide whether to start a practice from scratch or buy one or associate somewhere. I will not tell you what to do. I will, however, tell you that the road I took is not easy. I wouldn't do it different, but I won't sugar-coat it either. It is all on you.

If you have done what I have done in the past few years, please let me know. I would love to know that I am not the only crazy one out there. Hang in there!! The economy will get better. There are no quick fixes, no magic bullets—much like dieting, it is constant, hard work.

The voices are excited that I get to see patients today.

Have a great week!

ric

$2.15

Hey all,

You know sometimes all this blog is telling are the problems with dentistry.
That is not real my intention.
You must say to yourself sometimes that this guy is a real Eeyore.
I do, however, remember how it feels to be alone and depressed (like it was yesterday, wait it was yesterday) and I want to make sure you are not feeling the same way. So I tell you stories of the stuff that goes on in my office, and most of the time I tell you about the stuff that goes wrong. I think I do this simple because of two reasons. One, if I tell you all the stuff that is going right, then it kind of sounds like I am bragging and a bit full of myself. Two, the most important reason, I don't want to you to think that crap only happens to you.

Today is going to be about more crap. Aren't you feeling better already?

I have this family that are patients of mine, well use to be patients of mine.
You know from past blogs that I hate losing patients, so you know that I hate telling this story.

This is a family of nine. No, this is not a typo, it is a set of parents with 7 children. I have known this about this family for a long time. They live and work in Apopka, and you can't live and work in Apopka and not know this family.

About 5 years ago, the husband came to see me for a second opinion. By the way, if you don't know what a second opinion implies, it basically means that the patient is saying, "I have lost faith in my dentist for some reason or another and if I like what you have to say then I am going to switch to you." So he comes in and loves it.

He has a new patient exam and then so do 4 of the kids and then the wife. Before the husband had all of his work done, the wife gave me a call and asked if I could give them a "large family discount". Look, I don't bite the hand that feeds me, and I said, "No problem." I think I gave them 25% off after the insurance paid. I think this is fair. I mean they take a whole day of hygiene to clean their family's teeth.

All the kids are great. I think I end up seeing 6 of them. One has graduated from college and lives in Arizona or something. The boys are handsome, and the girls are darling. The dad needs quite a bit of dental work, and the wife is totally fine.

So me and the father begin this pretty good relationship. He had some old dentistry, large amalgam fillings, a pretty ugly mouth if you ask me. Over the next 5 months we do a lot of dental work together. I think I do some pretty nice work. I was pretty proud of what I did, and I think he was pretty happy as well.

Now don't think I didn't go over and above for this family. I turned on the charisma big time. Every time I saw someone for work I would call. I would send letters of appreciation ... everything I could to assure that they were happy patients.

Well they started coming for regular recall and things were humming along pretty well. I mean, as a dentist, this is what you want. You want people to come in with needs. You take care of their needs, they love you for helping them with their needs, they trust you, and then see you every six months for the rest of their life. Easy peasy. That is how you build an office full of Raving Fans.

So things were humming along, and I hear from my assistant that they are leaving the practice. (By the by, if it wasn't for my assistant, I wouldn't know half of the crap that goes on around here.)
WHAT!!!???
Turns out the wife was mad because they had to pay a bill.
I said, "What do you mean?"
Well, it turns out that after insurance paid they had a bit of a balance.
Two dollars and fifteen cents!!!
The wife calls up a bit annoyed and says that at their other dentist they never had to pay after the insurance paid.
What do you say to that?
"Well, you are not at your old dentist."
She also indicated that I could just write that off if I wanted to.

Now do you see what just happened there? We went from struggling to pay because I have a large family to unappreciative. This folks, pisses me off. I have done the best I can. I felt like I did the best dentistry I could. I gave the best service I could. And I did it at a reduced price, and all of a sudden it is not enough.
Of course I could write it off.
To me it is not the $2.15 cents. It is not the money. It is about mutual respect. You have a problem. I do the best I can to help you with your problem the best I can and you pay. This is what EVERYONE does.

Does the paying part suck? Sometimes it does, and I know that, but it IS part of it.
Maybe it didn't piss me off as much as it hurt me.

It hurts because I used to think if I did everything to help my friends they would be my patients forever. Not the case. So now I am back to doubting myself. It couldn't be the $2.15 they were upset about. It must have been something I did. I must have done something to upset them enough to let a $2.15 bill to be the mountain they are going to stand on.

Is $2.15 worth losing your dentist over?
Is $2.15 worth losing a family of 9 over?
Well it was to me, and apparently it was to them.

Man I need a drink?
Sweet tea vodka here I come (The AGD says I have to say that it doesn't condone drinking to handle all your problems.....but it sure as heck helps on days like these. )

Have a great weekend,
john

This one is on the house

Okay today's topic,

Last Friday, I woke up and did the usual brushing and flossing of teeth. I kissed the wife goodbye, and set out to go to work. Before I leave, I take out the trash, and this is when I saw it.
I had a flat tire.
Oh, SON OF A B!#$%^. My first patient is in 30 minutes, and it takes me 18 minutes to get to work.
What are my options here? Change the tire...hell no.
Call my roadside assistance...takes too long.
Take my wife's van and let her deal with this problem...I don't think so.
So I got out the bicycle pump and start to pump. After about 5 minutes and a bucket of back sweat, I thought I put enough air in the tire to at least get to a gas station to pump it up.
I jump in the car and make it to a gas station. I pump it up and get to work without incident.

I think about it all day and come to the conclusion that at the end of the day I will do the same thing. I will get to a gas station, pump it up, and then get to the nearest tire place.
So at the end of the day, the tire still had some air in it. It had enough to make it one mile down the road to the nearest tire place (I know what you are saying, "the guy works a mile from a tire place?" Well this is Apopka, I work one mile from four tire places. I love my town. I just think it is funny that the above is true).
I pull into the place and the inside is SPOTLESS. You know, spotless like there hasn't been a customer here for awhile and the front desk person doesn't have anything to do so she cleans the floor and counters so well that you can eat off of them.

So I walk in, and she jumps up to welcome me. I tell her that I have a nail in my tire and that I need it repaired. She told me to go around back and they would take care of me. Well I drove around back and they proceed to take care of it. Now this is a dirty job to say the least. All the guys that they have working there are dirty. Not dirty like with dirt, but dirty with grease and tire black all over them. Everyone smokes, so that just adds to it. And it is hot as blazes out as well.

So I stand to the side and let them do their work, not touching anything. Then a guy comes out. He is clean and wearing nicer clothes, and I recognize him. Wait a minute, that is one of my patients. And this is when, if you are anything like me, you are thinking "What is his name? Where the hell is my assistant when you really need her, she would know?" And again, if you are anything like me, you are saying, "I know I did a crown on #14 on him, and I remember that he has a 6 mm pocket on the MB line angle of #30, but I can't remember his name."

"DON!!!" That's it. I remembered. And now I remember he owns the joint.
"Hey, Don, how the heck are you?"
"Hey, Doc."

So we chit chat for a bit, and then he gets back to work. It was nice seeing him again. So the guy fixes me up, and I take the slip of paper back around to the front. The woman up at the front says to me, "Are you the gentleman with the F150?"
I said, "yes"
And she said, "It has been taken care of."
I was shocked to say the least. Thrilled, but shocked. I mean here is a business that looks to be just trying to ride out this storm, and he is giving product/services away. I guess he is thinking of the future. He is thinking one day the economy is going to come back, and I now have just spent $25 making this a customer for life. Because I tell you what, I have not stopped thinking about this all week.

What does this mean to me and you?
How can we create "raving fans"?

I think the same way Don did for me. I see the person with a pain and it turns out to be a canker sore, and I give them some Orabase send them away and don't charge them. I smooth out a chip on a molar that is killing their tongue..."it has been taken care of."
I look at a 10-year-old when the new tooth is coming in and the mother doesn't know what the heck it is. I see them in the reception area (because I already know what it is) and say, "Get out of here, your money is no good here."

But you bet your sweet tush I also say, "Don't forget to send your friends here." It is not the $25. It is the good will you are spreading. It is the "raving fan" you have just made that is going to send their friends, kids, parents, and neighbors all for $25.

My father hates it when I send people out the door without charging them. First, I am kind of old school that when someone comes in and asked me to look at something and I don't even put on gloves and I say, "yeah, that is tori, it is totally natural," I am not going to charge them $75. I still think $75 is a lot of money. And I know most of my patients do too.

I think it will only create the "damn, dentists are expensive" mentality. Or worse the, "usually I like to be kissed before I get that" mentality. So you look at someone, are nice to them, and charge them, and they leave with a bad taste in their mouth. But you say, "Hey, this one is on the house" and their face lights up like it is Christmas morning.

Now, I know what you are thinking, if I let $75 go 100 times a year, I am losing $7500.
But am I? Am I letting $7500 go or am I storing up patients for life that might spend $7500 on veneers someday?

What do you think?
What do you do?
Do you think there is any truth to what I am saying?
I would love to hear what you think.

Have a great rest of the week.
john

You Can Literally Take Me Literally

You ever have those moments when a word or phrase just gets under your skin?

Literally?

You know, those moments when people say things that are clearly incorrect, and you can tell that it is just a bad habit that they have gotten into - Literally?

Yep, that's what the voices are lauding this week. The incorrect use of the word "literally".

It started with my son. He has been saying it for weeks. I can't figure out where he first heard it, but it is now used all of the time - literally. For instance, "Dad, I am literally starving!" "Dad, I literally cannot do my homework." "Dad, I literally have to go to the bathroom." You get the idea.

Now, he is 9 so I cut him some slack. Although there have been many times when I have uttered the phrase, "I do not think that means what you think it means" a la The Princess Bride. Yet I soften my lexicogriphal bombacity and allow it to continue unchecked.

Then, I am driving in the car and an ad comes on the radio that has the phrase "it literally hit home". Now the ad was for something like long-term care insurance. I can't be absolutely certain, but it is a fair bet that whatever they were talking about did not physically strike their living abode. It might have "figuratively" hit home, "metaphorically" hit home, even "transcendentally" hit home. However, it couldn't @#$%ing "literally" hit home!!!!

That is the stuff that goes on in my brain.

Oh, and before I forget, I learned a great lesson this weekend. When watching a soccer game in the pouring rain, without an umbrella, and wearing a jacket that is - literally - not waterproof; do not put your cell phone in your pocket. It was a nice victory for the KC Fusion U-11 girls and at the same time a nice victory for life-lessons as I got to know the Sprint store repairmen.

OK, finally, I'm going to put my 2 cents into the "Wrong Tooth" conversation.

I mean, I am literally going to put my 2 cents in - John, watch your mail because I am overnighting 2 pennies to you.

Seriously though. It is a messed up situation all around. I've seen it in my short practice time, so I know everyone else has as well. You get those no-win situation patients that come in with complaints that do not match their clinical problems (e.g., small fracture on the incisal edge of a front tooth but have severe perio disease). Yes, the DDS should have had the chart (another argument for going paperless - I can pull up a chart on my laptop from anywhere in the world), but at the same time he performed the correct treatment. Hindsight is 20/20.

Literally. (Look it up, it is a medical fact that if you have vision backwards it is perfect always - never need glasses, can fly a plane or be a sniper, drive without restrictions, it's awesome. Which is why optometrists hate people with hindsight - no treatment needed).

OK, I'm out of here. The voices want me to read a book.

Literally.

Have a great week.

ric

Comments about "The Wrong Tooth"

Hey all,

Regarding Wednesday's blog, here are the 4 comments...

Anonymous said...

That is why we have discharge letters informed consent forms and specialist to refer to. You should have discharge him after your first experience. As long as you have everything documented you will be fine. Stop giving in to his demands and kick him to the curb.

May 12, 2010 10:29 AM

Gilbert Cosmetic Dentists said...

I agree with what the first post said. Be sure to have the papers ready and within your reach, so to speak.

May 12, 2010 1:49 PM

Anonymous said...

As a non-dentist, who frequently lurks on this site I find it hard to believe that you would not review a chart, especially after not seeing the patient for over a month. It sounds like you went out of your way to provide a remedy again with out the benefit of your chart, which you could not find. I am not sure what a reasonable solution should be from here but you are the professional not your assistant or the dude in the chair…

I hear a lot of “CYA” and “kick em” to the curb but no personal responsibility on your part on how you could have done this differently.

May 13, 2010 4:16 PM

Anonymous said...

In response to the last post. You are right he the dentist should have known better and not performed treatment he was not comfortable with. In the same way a can refuse treatment recommended a dentist can refuse treatment he does not agree with. Until you have been in someones shoes you don't know what it is like. People hear only what they want to hear and will LIE to you straight in your face. Been there and done that. So while it sounds bad to say kick him to the curb it is actually best for everyone involved except the lawyers!!! As long as you refer him to a specialist to get his treatment there is nothing wrong in doing it.

Now for me this was what I thought right off....

I was right on board with the other dentists about this patient until the last comment.
I realized how we (dentists) sound to non-dentist readers.
I do feel like we say CYA a lot, but that is the sign of the times.
You can't help but think that everyone is so sue conscious in our profession (you kind of get scared of it all the time)
Actually, I have become less and less as the years go on (and a bit more jaded) and think to myself "You wanna take this away from me...go ahead."

My first thought was that Dr. A got a patient that had an expensive problem. And yes, I think most people that come into our offices become a-holes, not because they are scared (which is totally justified. Sometimes getting dental work sucks, and we need to do the best we can to try to make it suck less), but most of the time they act like jerks is because they have a problem and they don't have the money to fix it.
Trust me, I become an a-hole when I am put in that situation.

So for me, it had nothing to do with what the dentist was doing. It had nothing to do with whether he had a chart or not. It had nothing to do with how well Dr. A treated him or how much of a discount he wanted to give, the guy was not going to be satisfied...because he didn't have the money to pay for it.

Now about the "do what you have to do" crap. Here is a guy that doesn't have the money to pay for a root canal and a build-up but somehow he has money to retain an attorney. I don't think so.

And what attorney is going to take this case? "You had root tips that Dr. A took out. You need a root canal on the molar behind it. Now tell me again what you want to sue this dentist for?"

I don't think so.

This dentist has nothing to worry about. The only thing that has happened here is this patient has burnt a bridge to a passionate and caring dentist.

I wrote the above and then I got an email from a non-dentist reader and this is what they said....

I sort of agree with the non-dentist comment. When I read the story, all I could think was that the whole situation would have never become a problem if the dentist looked at the chart. I don’t think that the dentist did anything wrong, if fact, I’m sure he did everything right procedure-wise, but the confusion would have been resolved immediately if the chart was available.

Another main factor is whether or not the dentist gave any sort of admission that he may have pulled the wrong tooth when he met with the patient at that evening appointment after the procedure. If the dentist implied that he was anything less than 100% certain that he did the procedure correctly, then the patient is going to feel wronged. I know that is a heavy weight to put on medical professionals, but if a doctor or a dentists wavers for a even a second, patients worry.

To your point about this guy not being able to pay, I don’t know if he’s trying to necessarily get an upgrade in service, he may see this as the only real remedy to the problem. The way he sees it, he went into the initial procedure with the expectation that he would be missing only one tooth, so the solution to the situation should involve him missing only one tooth. I understand that clinically this is wrong, but that’s how patients (consumers) think. I also understand that the dentist didn’t actually pull the wrong tooth or do anything else wrong, but that’s not what the patient thinks. The patient seems like he doesn’t have the knowledge, or at this point the willingness, to understand the concepts of the original treatment plan. He just thinks the dentist messed up and is now backtracking to cover it up. A solution for the situation might have been for the dentist to charge the patient for the initial procedure (the tooth pull), because that is what the patient requested and expected to pay for, but then do the root canal and build up for free. I’m not a dentist so this could be really expensive, and ridiculous, way to make a patient happy.

Sorry, I hope you don’t think that I’m bashing the dentist or dentists in general, I’m just giving you an idea of how non-dental patients see this situation. I think patients turn into a-holes sometimes because they are frustrated by their lack of knowledge about oral health and hate that they have to just take someone’s word for it. It’s sort of like going to the mechanic when you don’t know anything about cars. It sucks that you can’t make an informed decision, because you don’t know anything.

One last thing. A lawyer may not have been what the patient was referring to when he said that he “will do what he needs to do”. Your friend might want to check Yelp.com or other service-rating sites. He may have left a nasty post on one of those. Yeah, it seems less scary than litigation, but it’s a lot easier to throw out a lawsuit than it is to get an nasty post off a rating website (see the cover story of the May Impact).

This person, dentist or not makes a very strong point. I am really confused because I think like a jaded dentist sometimes and forget to put on my consumer hat.

Any last thoughts?

Have a great weekend,
John

The Wrong Tooth?

Hey all,
I hope you all had a good Mother's Day.
Okay, I am going to get right to it today because we have a guest blogger. (I don't want it to be all about me....well, yes I do, but I digress.)
Something happened at his office, and he wanted to tell you his story.
I am going to hold off what I think until I know what you all think.
So without further ado...

OK, so in March this guy comes in. He’s in shambles because of a horrendous toothache. My assistant gets the X-rays, and they reveal a bombed out, yet very restorable, #18 next to a couple of equally bombed out root tips that use to be #19. The patient is under the impression that #19 is causing his pain. Most reasonable dentists have seen this one before and know (instinctively) that the pain is coming from #18.

So, we get into a long conversation about a variety of options ranging from implants to root canals to extractions to bridges. EVERYTHING is covered. This dude is 26 years old and very low on funds. Antibiotics and some Vicodin are prescribed and I tell him to just let me know how and when he wants to do something. The chart entry from that day reads…he’ll decide (what to do next) after evaluation of estimates and thinking about our conversation. He then misses an appointment six days later. A full month and a half later he schedules and according to the SCHEDULE it says he wants #19 extracted. I had totally forgotten about this guy over that month and a half. Moreover, I don’t bother to look in the chart. One look at his X-rays, and it’s not even debatable that #19 has got to go. NO DOUBT!

In the midst of his mandibular block I start my little Q & A about why we would remove #19 if #18 is in so much pain. He can’t respond, obviously, so I’m just talking and expecting some sort of feedback from Kim, my assistant. Kim tells me they had just rehashed the conversation in a more concise version from a month and a half prior. I actually warn him that it’s likely that #18 would hurt even more after I take out #19. In all of this time he doesn’t say a single word that would dissuade me from removing a couple of rotten root tips that 1,000 out of 1,000 dentists would treatment plan for extraction. I go ahead and get #19 out. It took some creativity and removing the interseptal bone, but it came out.

Later on in the evening I’m at my daughter’s soccer practice, and I get a call from the patient’s girlfriend. She says he’s in a lot of pain and that they feel I pulled the WRONG TOOTH. I say “really?” I am at a loss of course. I don’t have the chart with me. I hadn’t read the chart before pulling #19. I had no reason to doubt her (or him). So what do I do? The next day, on my day off, I meet him at the office with my 9-year-old daughter. I still can’t find his chart and didn’t want to bother any one of the girls who work for me. Plus, the game plan is obvious, pull #18. He then comes at me with this one…”I don’t want #18 pulled. I don’t want to have this huge hole where two teeth are supposed to be.”

Me: Uh, what? You would have wound up missing both had I removed #18 yesterday.
Him: No, I would still have #19.
Me: Yeah, but seriously, is, or rather was, #19 a tooth that you were using. It was hidden under your gums. It was, (pause) it was already gone.
Him: Look, you pulled the wrong tooth.
Me: So, um, what do you want me to do?
Him: Fix this one (#18).
Me: You mean the one that just 24 hours ago you apparently wanted pulled?
Him: Well, considering that I don’t want to have two teeth missing and YOU pulled the wrong tooth. I’ll just do a crown after you do a root canal.

At this point, without the chart his story is sounding reasonable. I even mention helping him out with the root canal. We agree to allow the antibiotics and pain meds work over the weekend and then we’d touch base come Monday. Monday rolls around, and I request his chart only to find that there is no plan to remove #18. In fact his treatment plan very specifically mentions a root canal for #18 and an extraction for #19. There are an assortment of other ideas like implants and bridges with estimates attached. There also is nothing, I mean NOTHING that would lead anybody to believe he wanted #18 out.

Michele, my office manager, calls him to schedule a root canal for #18. She mentions how much is expected, payment wise, at the time of the appointment. Instantly he tells her that it is totally unacceptable. “Dr. A said he would do the root canal for free!” So I call him. Me: Hey, I just read through your chart and uh, well, there is no mention of us…

Him: YOU PULLED THE WRONG TOOTH AND NOW I’M SUFFERING BECAUSE OF YOUR NEGLIGENCE. PEOPLE TOLD ME YOU WERE A NICE GUY. NOW I’M SEEING WHAT YOU ARE REALLY ABOUT.
Me: You do understand that…
Him (interrupting): You do what you have to do, and I’ll do what I have to do.
Me: What does that mean? Hey, I’ll waive the extraction fee from last week and pull #18 at no cost to….
Him: I’M GOING TO DO WHAT I HAVE TO DO! click So there it is. I’m really not sure where it goes from here or what he meant by “I’m going to do what I need to do!” What I need to do is wait for an attorney’s letter I guess. Then what?

Okay, aren't you glad this doesn't just happen to you?
I just shake my head and say to myself, I am glad it was him, this time, and not me.
Do you have an opinion?
I have an opinion (that is a surprise), but I don't want to tell you yet.
Let me hear from you, and then I will write my opinion in the comment section.
Hope you are having a good Wednesday,
john

Patients doing work for you

Friday,
Need I say more.

Good week for me. It is still kind of slow at the office, but we are managing.

Before I forget...
I have decided that I want to lecture, and I want to lecture on Posterior Composite Restorations.I would like for you to help with a title that will attract people.
The title is huge in lecturing.Case and point..Drill'em, Fill'em and Thrill them. 1000's of people showed up for this class, and it wasn't even about restorations.
As you know, I am conservative in my approach to restorations. I think I can fill a lot of things that might make you shake your head, like "no he didn't".Don't forget to double click on the images to see the depth of these restorations.

And the reason I do this is to save the tooth from the inevitable crown that they are going to need.
You know once you get a crown, you can't go back. So I want to portray this in my title.
Something like "Going back to basics..fillings." or "Tick off your lab...do a filling."
See what I mean, I need help.


Today I wanted to talk to you about having patients work for you.
I am not talking about bartering; I am talking about having a person in the chair that is a plumber, and you have a leak in your house.
So you say, "Hey, can you help me with a leak at my house?"

Now you are not just picking this dude just because he is a plumber. You have a past with him, you like him, and you think he is someone you can trust.
So you ask him.
Have you ever done this?

For me it was with our air conditioning. For the last 8 years or so we have had issues being HOT in our office.
Every year we have done things to improve our conditions in the office in the summer.
We tinted our windows one year.
We added another unit the next.
The next year we replaced a unit (oh, by the way, the units are on the roof, so we had to rent one of those cranes).
So when it was hot the next year, I called this guy, who is a patient, who does air conditioning.
I said, I don't care how much it costs, I just want it to be better. I know all the units work, but it is not cool in here.
We have 3500 square feet and five air conditioning units. Are you kidding me?
I have two at my house, and I can practically make it snow.
Granted three of the five units are old, but they have all check out.
I asked this guy to come in and do a full evaluation.

So he comes back with drawings of everything we have up there. He tells me what every unit is doing. He tells me what rooms each unit is doing.
He tells me what shuts off when one turns on. He tells me what flap opens when the air pressure is done.
Blah, blah, blah.
I stopped him and said, "Listen, I don't know what the hell you are talking about. And in fact, I don't care. I care about one thing....AT 2PM, EVERYDAY, I HAVE SWEAT RUNNING DOWN MY BACK.
Can you fix it?
I don't want a quick fix. I want it fixed right, and I don't want to talk to you next year about the same thing.
He has every tech known to man walk through my office. He had the electric expert. He has the flow expert and the unit guy.
So we sit down, and he has a plan. It is a three-step plan, and it is all spelled out what they were going to do and how much it was going to cost.
Wait a minute, I do the same thing.
Again he starts with the air conditioning jargon, and all I wanted was the bottom line.
I then again asked him, "Can you fix it, and can you make it so I don't need you next year?"

Here is the problem.
The hottest months are June, July, August. Through June we realize our air conditioning is in trouble. July we have got around to hiring someone and in August they are fixing it.
So by the time it is fixed, the weather is getting a bit cooler.
We might have about three weeks of extreme heat to judge from. And we say, "You know, I think it is better."
Then next June you realized, "It ain't better".

So I did all the three phases this guy spelled out.
It was something like $10,000 by the time we were through.
And you know what, "I think it is better."

Well, it isn't.
I called them back a couple of times, and it was a lot of fumbling on their words and you need another of this and this has stopped working and "you need a pheltzer valve".
But by that time I was pissed because I did everything they said, and I still have BUTT SWEAT.

After a couple of months of back and forth, I decided to go with another company.
They decided to go another way. It was about a $1000 fix and it worked.
We have had so many people say that they are cold in our office, and it thrills me. We even have had to pull out the blankets a lot. And I love it.

But go way back in the story and remember that this guy was a patient.
I am a little pissed at him, and he probably has some issues with insecurity knowing that I might be a pissed and that his company couldn't fix my issues.
He probably knows that I got someone else because all the thermostats are new.
But I am still his dentist. I think he likes me as a dentist. I don't think he wants to go anywhere else.
AWKWARD!!!
It is awkward for me and for him. We are supposed to go back to our relationship before the $10,000 was spent.

People in my staff would say, I would never use a patient to do work at my house because things can go wrong. I get that. I think for me it is, are they fair? Are they honest? Are they treating me like they would treat their family?
I know dentists who don't live in town they work in on purpose. They don't want to see their patients out and about. They don't want to get that feeling of insecurity.
I, most of the time, like seeing my patients out. I do the best I can. I am honest. I am fair. I am comfortable saying that I would treat everyone like my family.
Now, most of the issues occur when people screw me somehow. They didn't pay their bill. They are going to another dentist for some reason or another.
The only issue I have with seeing people out is that I don't remember any names.
It's always, "Hey you?" or "What's up dude" or "Hey gorgeous".
Or that I don't remember them at all.

What do you think about this?
Do you work with patients? Has it bit you?
Do you live out of town on purpose?
Do you like seeing patients out?

Have a great weekend,
Mother's day on Sunday. And don't give me this "My wife is not my mother" crap.
Fellas, go get a card and flowers for your wife.

John

P.S. Remember I need a title for my lecture. Help.

The Best Job

What's up?

First, a couple of side notes.
Oh my gosh has the weather sucked here in balmy central Florida.
95 degrees yesterday, and it was the 4th of May. I ran at 10 pm on Sunday night, and I was a mess when I got home. I was a sloppy pig. I checked the temperature, and it was 83.
One thing this weather does do is makes it easier to go swimming. It is very warm in the pool.

Last night was the Magic's first semifinal playoff game against the Hawks.
I had plans to have some fellas over for the game. But about 2 hours before the game, I got a call asking me if I wanted to go to the game.
SURE!!
I asked the Boss and got the okay. I called all my friends and told them the party was off and I was off to the game.
The guy who asked me is a real estate attorney, and the people that gave him the tickets were a title company.
We get there, parking pass and all, and the seats are in the THIRD row. I am talking third row from the court. I am talking "a guy goes for a loose ball and jumps in the crowd, and I am catching him" third row. I am talking $300 a ticket third row.
Yes, you heard me right...$300. That means this guy, his wife, his daughter and me for $1,200.
For one game.
I don't get it. But I sure as heck enjoyed it. And oh, the Magic won by 43 points.

Topic,
My assistant asked me last week, "If every job paid the same amount of money, what would you do as a career?"
Hmmmm.

Let's mull this over together.
Now the question is NOT, "if you could do any job, what would you do?" I mean, most of us would pick a very high paying job that seemed easy to all of us.
The caveat is that all jobs pay the same.

So far I have not been able to come up with an answer.

Here is my train of thought.
I love love love doing dentistry, but it has its moments when I don't love it.
But don't you think every job has that?

I mean, don't you think being a surgeon would be cool. Yeah, except for some people dying and all.
Okay so you are not a people person. You think that being a CPA would be cool, yeah until you realize, "All I do is work with numbers and they are DRIVING ME CRAZY."
If money didn't matter, I would just love to do landscaping and make people's yards "A welcome mat for their homes." Except I wouldn't want to fight the 100-degree days and the rain and the cinch bugs.
I mean every job on the surface seems awesome (maybe except for a gastroenterologist formally known as proctologists). But I think every job has its major drawbacks.
I can't help but think that every job gets stiff after awhile. I mean, even modeling can be tiring after 6 hours of a photo shoot on the beaches of Cancun. Who would want to do this? (Can you hear my sarcasm?)

Let's take me for instance. I don't have to keep reminding you that I love teeth.
I could do fillings and cut crown preps all day and be happier than a pig in sh$t.
But it is everything else, i.e. staff, money, patients, equipment, rent, partners, outcomes, failed root canals, scheduling, did I say patients, that has a way of getting to me.
This kind of stuff can bring even the toughest/happiest of dentists to his/her knees.

So what is the answer if every job seems awesome when you get in it and every job has its draw backs?
And if you are a young dentist and you haven't gotten here yet, it is probably coming. And if you are a "mature" dentist have weathered this storm, correct me if I am wrong, but you have to do things to make your job exciting.
If all you did was drill teeth all day, I have to tell you, it can wear on you.

I haven't gotten the dulldrums really bad, but I can kind of see it coming. So in the last couple of months I have started to think of things to make this office a bit livelier.
Today, everyone brought in stuff for tacos and burritos to celebrate Cinco de Mayo.
Last week, I went and bought ice cream and root beer, and we had a little root beer float party after work.
But more than that I think it is a philosophy thing. If you have an insurance practice and you are starting to hate it...change it.
If you have a pretty nice family-oriented practice, but you are getting less and less patient with kids, then change your practice to an "adult only" practice.
I think to myself, I have 20 more years to do this (barring financial ruin), and if I am not happy doing this kind of dentistry, I think now is a good time to change.
I have a ton of options in dentistry alone.
I could do cosmetics only.
I could go back to school.
I could teach (God help those students)
I could be an associate (and let someone else run this thing).
I could sell my stuff to Heartland or someone like that.
I can do what my friend is doing and get heavy into ortho and do 25 cases a year.
Lots of possibilities.

Did I get off track there for a bit? Weren't we just talking about what I think the best job is?
What would you do?
Did you think of what that job would look like in 15 years?
Tell me, tell me, I will wait for your responses, meanwhile I have to go and fix one of the toilets in one of the bathrooms. Oh yeah, dentistry, a glory job.

Have a great Wednesday,
Don't forget tomorrow is National Day of Prayer.

Talk to you Friday,
john

Is that a party I smell?

You have to believe me when I tell you that John Gammicia and I are not just pseudonyms for anonymous bloggers.

We are real people who live in very different parts of the country.

I have talked to John a couple of times on the phone but never met him in person.

OK, so now that I think of it, I can't vouch for John being a real person - maybe he is an AGD cyborg or a teleblogger located in India??

What I can vouch for is that I am a real person - although those Matrix movies really messed me up on that "what is real" issue.

Anyway, my point is that even though we have never met; the real-or-imagined John Gammicia and I have remarkably similar lives. Our kids are similar ages, dads are in the dental field, small-business owners, "runners", Christians, strikingly handsome, excellent clinicians, married to incredible women who clearly settled for us, etc. . . You get the picture.

Actually, now that I read that, and as I recall the excellent cinematic thriller The 6th Day, starring the Governator, I wonder if perhaps I am merely a clone of John that was sent to the Midwest so that we didn't run into each other and expose the biological bastardization of humanity??

OK, so back to my point - merely minutes after reading John's post on Friday (no comment on my surgical experience during my senior year of dental school - "hey what did you do during spring break"), I got in the car with my family to travel to Topeka, Kan., for a soccer tournament. Not to try to outduel John for funniest line by a male offspring, but my 9-year-old son Brennan may have taken the prize this week. We are not more than 10 minutes from the house when I hear from the back of the car - "oh, Dad, what is that smell."

Now, that comment in and of itself is not rare in my household. "oh Dad, what is that smell" is almost an alternate way of saying, "hey, Dad is in the car" or "when was Grandpa here" or "mom told you not to eat popcorn at the movie theater". . .you get the idea.

On this occasion, however, neither my wife nor I could understand to what he was referring. Nothing in the car that we could smell, nothing outside that would cause an odor. No recent intestinal misadventures. So I had to ask him, "Brennan, what does it smell like?" He responds without hesitation - "it smells like confetti".

What the. . .????? Did you say it smells like CoNFetTi? The tinsely, shiny paper?

OK, simmer on that one for a second.

Confetti??

"You mean the paper that falls from the ceiling at parties?"

Yep, "confetti".

Busted, you caught me son, I went to Hobby Lobby today and just went nuts on the confetti aisle. You know that smell, right. You know it kind of smells like the color blue but with a little sticky note mixed in.

Love that child but that will be a story I will be telling at his wedding (which will also smell of confetti). I need to go see the ENT and get an odor test because I was not aware that confetti had a smell.

Great weekend. Lots of fun with Kayla's soccer team and the parents. The girls played their hearts out, getting 2nd place in the Kansas Governors cup. They won their semi-final game in overtime and then lost in the finals (1 hour later) to a team they had beaten in the earlier round. They were just dead tired after the 3rd game of the day (and 5th game in 2 days) in the heat. Regardless, Kayla had a very proud papa & mama and brother and sister.

No dental drama this week, just a little insight into the mind of this small-business owner.

I don't know how your office does it, but in my office I enter in the deposits at the end of the day, print the deposit slip, and take the deposits to the bank. I don't mean I enter the checks into the system throughout the day - I have staff that do that (I can do it but I don't). What I do is take the checks, cash, chickens, suckling pigs, bushels of wheat that we have received that day as payment for services and enter them into Quickbooks, print out a deposit slip, and go to the bank (that tends to define a good end to a day - money going to the bank).

Now, I have been doing this for nearly 4 years, and I have a quirky habit about it. See, it is the end of the day. Hopefully, I am a little tired from having worked hard. I have seen my staff here all day, and I have a general idea about what it has cost me to run the office that day. So at the end of the day, check entering becomes kind of a game. If any of you use Quickbooks or a similar software, you know that it totals the deposit as you enter each check into the system and this running total is at the bottom of the screen. Now, if, like me, you enter lots of smaller denomination checks into the system it can get a little discouraging to see the total creep up in small amounts. Thus, I have developed this ability to enter in the individual checks without seeing the total at the bottom of the screen.

Yep, I'm really that weird.

But this way, it is like Christmas every evening. Instead of seeing a $50 check and a $100 check and a $6 check (total $156). I get to enter in all the checks and then peek at the bottom and - wow - $2000. Surprise!! What a great day.

If I have learned one thing in 4 years of business ownership it is this - do whatever you need to do to keep yourself sane and laughing. Whether it is being addicted to the NYT Crossword puzzle or playing stupid games with the deposit slip, you gotta find the joy somewhere.

Have a great week!

ric