What's Best for the Patient?

Today, I would like to touch on a topic that every dentist deals with every day: patient autonomy and how we achieve it. I know there are a lot of sincere efforts by dentists all over the country to give the patient all of the information necessary to make a good decision based on the patient’s personal situation (finances, past experiences, personal preferences, etc.). However, nearly every practice in the country has patients that come to the realization that what their dentist secretly thinks is best, is in fact best.

Go into any community in America today and you can find a practice that only provides bridges and another that only does implants for single-tooth edentulous areas. You can find a practice that only provides posterior composites and another that only does posterior amalgams. How can we say we are giving the patient options when this is happening?

I am not saying it is the dentists’ fault at all. For one, go look at the research comparing those things. You will find that when dealing with long-term survival of anything in the mouth, the data is scarce and not definitive. Hence you can find whatever answer you are looking for. Another factor that must be considered when determining what is best for a patient is what the doctor is good at. A patient may feel that amalgams are just awful and leak mercury, but having a dentist who has never done a posterior IP composite is a recipe for disaster. Maybe the patient thinks composites leak too much BPA and want their children to only have amalgam. That might be tough job for a doc that hasn’t touched the stuff since dental school.

I want to share a case I ran across. I am stuck wondering what is best for this patient. There is irreversible pulpitis with normal PDL and normal probing on #3. We scheduled for RCT, opened it up and found a large distal crack.

At that point, I decided that since I had the time and she was numb, I would complete the endo and do a composite bonded buildup, prep, and permanently bond a temp crown and see how it felt. I explained ti the patient. “I have no idea if this will work for you in the short-term and I am very guarded about it in the long-term. I think we should leave the temp crown bonded on for six months to a year and monitor to see if there is any bone loss or symptoms. If there are ZERO symptoms and no signs of progression of fracture evidenced by probing depths, we’ll put a permanent crown on it. What do you want to do?”

Did I do the right thing? What would you do? What do you say to the patient to ensure patient autonomy in a situation like this?

Bryan Bauer, DDS, FAGD

Consultants

Wow, last year blew by! I cannot believe we made it. Like Dr. Jackson said, we made it past the Mayan doomsday only to almost go crashing off the federal fiscal cliff. How did we all make it?

Since there are so many new bloggers, I will reintroduce myself. I am Joseph Joyce, DMD, MAGD, ABGD. I am 39 years old and graduated from the University of Florida College of Dentistry in 1999. I went right into the Navy, where I was a dentist for seven years. I completed two combat deployments: one in Fallujah, Iraq and one in the Persian gulf/North Arabian Sea. I am American Board of General Dentistry certified and received my Mastership in San Diego a few summers ago. I have been in private practice in Ocala, Florida with Dr. Scott Jackson for about six years now, where every day is a new challenge. I have three boys and have been married for almost 18 years.

Well, Dr. Gammichia has ridden off into the sunset and left Dr. Jackson and I at the controls. I hope we do not crash and burn. I got into this blog thing because I was amazed at how similar John’s adventures were to how I felt or what I was going through. It was almost scary at times. I will miss his tales, but so far, there have been several inserting new blogs. John will be missed but others I am sure will entertain us. Adios, John!

Last year was very interesting. We exceeded our financial goals on production and collections, but it really seemed to take a toll on the office. We stopped having fun and everything got stressful! It all started around the election time when we were having some obvious staff disharmony. It seems that the presidential election brings out the worst in people. The stress level gets kicked up a notch with patients, as well.

Staff members were mad and depressed, work was a drag, and everyone seemed to be on edge. No one was very happy with the way things were going. The practice was still growing and patients were happy. But the yin and yang, fung shei, and mojo were all out of sorts. Dr. Jackson and I tried to fix it. We finally broke down, swallowed our pride, and decided to bring in a team-building consultant.

Let me tell you that I think I can fix anything. It took me some time to give into the idea of flying someone in, paying a bunch of money, spending a lot of time, shutting down and losing production to resolve this issue. However, I knew it was important. We have a good staff and if work is not pleasant, they will not stay. Yes, people are replaceable. But you get to know people and become comfortable with them. I just hate to see them go if I do not want them to go. To add more drama, two of the employees are our wives! So there is no straightforward solution and it is a little harder to fire them if things get out of hand. I was concerned that it might get so bad as to threaten the partnership, and neither I nor Dr. Jackson wanted that.

We flew in a consultant from Dallas. We will call her “Dr. Panther”. She has a PhD in psychology and works primarily with dental offices, helping with teamwork and business management. She has a daily fee and you also take care of her food, lodging and transportation. She offered and decided to stay at my home (with my three boys) to save us a little money. We had several phone conversations prior to her coming and we got to know her some. I was still very skeptical but tried to keep an open mind. She sent surveys to the office asking all the employees to be brutally honest and to tell her what was good and what was bad at the office. She promised that all information would all be confidential and the doctors and management would never see it.

When Dr. Panther got here, she began having long, in-depth conversations with all of us individually and observed the office. She observed how we function and interact with each other and patients. Then we spend the next two days at an offsite conference area to work out our issues and reestablish our friendships and working relationships. It was very interesting to learn how we are all different and why that is good for the office.

We learned about confronting problems and working them out as well. We learned about boundaries and limits that we should respect. There were tears and hugs, and laughter. For some, the two days were mentally and emotionally draining. We learned more about each other and that we all meant well, but just were not on the same page.

The experience was truly refreshing and gave everyone a new outlook and attitude. We already feel like much more of a team and the workday goes so much better. I only wish I had decided to do this a long time ago.

We will have to continue to work on the changes. We know we will mess up at times, but we will have to keep pressing forward. Dr. Panther will continue to work with us for six months, giving guidance and checking up on us. Staff members have already called her with questions and issues.

Properly running a dental office with 18 people can be challenging sometimes. But with the right group it, can be very rewarding!

Have a great year and go Gators!

J.J.

Are You There, Jobs? It's Me, Diana

Weeks after finishing my residency program, I packed up my things for a westbound flight and prepared to take on the biggest challenge of my professional life: starting my career as a general dentist in California, one of the most notoriously saturated and competitive landscapes in dentistry. The Golden State has taken some getting used to, and the attempt to achieve both success and personal happiness in this completely unfamiliar setting has been a pretty daunting task. But hey, if the Kardashians could make it big out here, why can't I?

To say that it took a long time to get my dental license would be a gross understatement. While I'm certain that the people working at the state dental board are all perfectly competent individuals who each care very intimately about my ability to secure a regular paycheck, I also harbor a suspicion that all mail addressed to their office may be couriered across the state via a system reminiscent of the Pony Express. And if so, it is likely one that utilizes only the losing horses expelled from the Del Mar Racetrack.

Months later, license in hand, I scoured the classifieds and Internet for open positions, only to discover that nearly every employer out there was looking to hire someone who graduated a minimum of two years ago. I found myself faced with the infamous new graduate paradox: I can’t get a job without experience. I can’t get experience without a job. Nobody cared that I had a fancy-schmancy education. Nobody cared that I totally killed it in clinic as a dental student and resident. It didn’t matter that I had a long list of references who could all fiercely attest to my razor-sharp wit, radiant charisma, and exceptionally modest sense of self.

The overarching objection to my status as a relatively recent graduate was that I wouldn’t be “seasoned enough,” a dismissive generalization that made it sound like I had to be coated in salt and pepper and then adequately dry-aged over a requisite period of time before anyone would deem me worthy of working in private practice. For a second, I wondered if my husband would mind if I sealed myself in a paper bag and sat on the kitchen counter for the next twelve months to ripen to a more desirable degree of job readiness.

I applied to every job posting anyway. Partly because someone once told me that a year of GPR may be considered by some to be the equivalent of up to three years of work experience, and partly because the prospect of spending another year assembling IKEA furniture in our apartment to pass the time was about as enticing as an invitation to ride shotgun in a car with Lindsay Lohan behind the wheel.

Upon arriving at my first interview, I became convinced—almost to the point of paranoia—that my interviewer would fire off a barrage of questions on subjects I last encountered while studying for the NBDE and/or charge me to perform a series of nearly impossible tasks under tremendous pressure. Surely I would be expected to recite all of the components of the Circle of Willis while simultaneously balancing a stack of plates on the end of my nose and calculating the number of tennis balls it would take to fill an operatory from floor to ceiling.

Luckily, none of the catastrophic scenarios I imagined came to fruition. But in some cases, they were replaced by even more disastrous queries and situations. One potential boss asked if I would be willing to get cosmetic surgery as a condition of employment. Another suggested that I consider changing my clearly-Asian last name to something more Anglicized. (Full disclosure: a part of me has always thought it would be fun to be "Mrs. Colin Firth," but I highly doubt my husband—NOT Mr. Colin Firth—would go for it.) And then there was the office that looked as though a homicide had taken place in the waiting room the night before, with staff that acted as though they were covering up a homicide that had taken place in the waiting room the night before.

That last one still haunts me. I'd rather not say any more about it, if that's okay.

Working interviews for dental associate positions are like second dates. After making it through the initial meet-and-greet, both parties have acknowledged that there’s enough interest to get together again and explore the possibility of committing to a long-term relationship. Those lingering first-date jitters (“I hope I didn’t come across as too eager!”) are still there, but these give way to deeper, more probing questions (“So, um, why did your last partner leave you?”). By the end, you’re faced with the inevitable awkwardness of attempting to discern if you like each other enough to hammer out an agreement to keep coming back for more.

While I had the opportunity to interview with some wonderful dentists whose offices I hope to model my own practice after one day, there were some I couldn’t bear the thought of going back to, despite the fact that an offer to put down roots was clearly on the table. It takes a lot to scare me—I’m from Jersey, after all—but some places turned out to be such toxic environments that I just couldn’t bring myself to return. I told myself early on that I wouldn’t resort to unnecessary upselling and overtreatment of patients to make a living. My will to survive financially is as strong as anyone else’s, but I won't destroy healthy dentition to get ahead.

I understand that dental practices are businesses that have to generate a profit. But if the dentistry I’m expected to do won’t allow me to sleep at night, it just isn’t worth it to me. I did my best to bow out gracefully at these places. In reality, all I wanted to do was run away and never look back. It’s a good thing that saying, “Thanks for the memories, but let’s just be friends!” to a prospective employer via phone or email is socially acceptable; believe me, I'm no good at break-ups.

At some points, I felt so discouraged by the repeated setbacks and heartbreak that I started to think I might be the Taylor Swift of dentists. Every time I thought I’d found something that felt right, I would wind up sitting at home, waiting by the phone, obsessively checking for imaginary missed messages that would never materialize in my inbox, and generally feeling like a total failure. This profession that was constantly being celebrated as one of the most stable, lucrative, and satisfying careers on the market was slowly leaving me insecure, destitute, and frustrated. I’d given the pursuit of a DDS the best years of my life, only to watch other people enjoy the benefits.

With a pint of Ben & Jerry’s in one hand and my cell phone in the other, I commiserated with supportive friends and family across three time zones. They who encouraged me not to compromise my standards, insisting that these employers just couldn’t see what a great catch I am and maybe they’re just not ready to give me the kind of commitment I deserve. Then I would entertain elaborate, unhealthy fantasies in which I envisioned myself accepting the top prize at whatever the dental award ceremony equivalent of the Grammys would be and triumphantly rubbing it in the faces of everyone it hadn’t worked out with. If someone in the music industry was crazy enough to give me a record deal, you can bet your lucky stars that the lyrical stylings of yours truly would make “embittered dentist pop” the next genre climbing the Billboard Hot 100 charts and giving T-Swizzle a run for her money.

In the end, my unwavering determination paid off. I am now working at an office surrounded by friendly and supportive staff who are genuinely interested in helping me learn and grow as a clinician. The truth is, I wouldn't fully appreciate being where I am today if my road to gainful employment wasn’t littered with the spoils of struggling, the mortification of mistakes, and the distress of disappointment. The thrill of overcoming the odds and landing my first real job wouldn’t taste so sweet if the journey had been an easy one. I fell down and got back up over and over again, and now I'm carving out a niche for myself in this profession with my own two hands, forging a path to greatness on my own terms. While I’m still a few years away from being able to open my own practice, I can honestly say that the future has never seemed brighter, nor the possibilities more endless, since the day I received my dental school diploma. And the best part is that this is only the beginning.

Here's to going where no Kardashian has gone before.

Diana Nguyen, DDS

A Man of Many Hats

I was born in Toronto, the second youngest of 13 kids. We all lived in the same five-bedroom house for nearly eight years before my second oldest brother, Howard, got married and moved out. Rapidly, it seemed everyone was getting married, going to university, moving out. In five years, there were only three of us left: my youngest sister, my oldest brother (who never married), and me.

My father was a clothing salesman. He sold boys- and menswear to large department store chains for Canadian manufacturers. He was so good at his job that, later in his career, he had an office in the Empire State Building in New York. He would fly down on Monday and home on Friday.

I remember when he worked at 500 King Street West in Toronto. He would leave after 9 a.m. and be home around 4 p.m. His busy time was midday, when he took his clients to lunch. A regular at the grand Chinese restaurant in Toronto's large Chinatown, he was treated like royalty and his clients were impressed. He knew all about sales, marketing and customer service. He was a natural.

I grew up around mens' fashion, and I remember that every man wore a hat. Everyone, without exception. Prior to the 1960s, hats were a necessary part of every man’s wardrobe. Back in the ‘40s, when hockey players were very poorly paid (there were no unions for players who played for the love of the game), buying a hat was an expensive thing for them. They wore 'poor boy' caps. But Toronto haberdasher Sammy Taft was a 'fan' and a natural at marketing. He announced that any player who scored three goals in one game at Maple Leaf Gardens would win the hat of their choice. And the “hat trick” in hockey was born (the term has been found in other sports going back to the 1850s but not in hockey until Sammy Taft came along).

Sammy lived a long time, and in the 80s, I bought some hats at his store. Hats were a signature style for a guy trying to be different. I love to wear hats and own more than 30 now. I have different hats for different occasions and different seasons. I still wear the hats I bought from Sammy. Quality lasts, especially when you take care of it.

Now I am a dentist, and I own my own successful solo practice in Calgary, Alberta. I work hard and have an amazing team of women who work with me. As small business owners, we have to assume a variety of roles that larger companies have separate people, or entire divisions of people, devoted to accomplish. In other words, we have to wear various hats.

We have to wear medical hats, clinical director hats, artist hats, accounting and bookkeeping hats, medicolegal hats, human resources hats, marketing and promotion hats, leadership hats, and many more. We did not receive training in most of these subjects, and some people get entire degrees to do the work in each of these areas. How do we do it? Sadly, too many of us try to do it alone, and fail. A very small number are miracle workers and achieve amazing success all on their own.

The rest of us have to hire coaches to help us navigate the nuances of small business. There are a lot of coaches out there. Some names that immediately come to mind include Don Deems (who writes a terrific regular column in AGD Impact, Ron Arndt, Steve Anderson and ToPS, Bill Blatchford, Tom Orent, Sally MacKenzie, Roger Levin, and many more. All of these coaches offer all kinds of free information. Subscribe to their blogs, read their articles in magazines like AGD Impact, get their e-newsletters. Once you have read the various materials by these coaches, pick one that resonates with your personality style, your attitude, your learning style, and hire that coach.

I have worked with different coaches, starting with some local people. As my needs changed over time, I started to work with others. More recently, I worked with ToPS (Total Patient Services). All of these coaches made a difference in my practice, and I sleep better at night knowing that the proper systems have been put into place to ensure success.

That is because small business success is based on systems implemented successfully and consistently. You don’t have to reinvent the wheel. Someone else has already done what we are doing now, and it is easier to copy success than to create mediocrity.

In the words of Roy Williams, Wizard of Ads:

“After 30 years as a consultant to dreamers and schemers, plotters and planners, insiders and outliers, the wizard has determined that commitment is the attribute most indicative of success.

Talent and intelligence, money and education, experience and passion are overrated.

Talent and intelligence play the game in their mind, rarely bothering to take action.

Money and education are satisfied with the appearance of success before it has ever been attained.

Experience assumes that nothing has changed since the last time the game was played, a dangerous assumption indeed.

When passion has faded, commitment shines bright.”

So pick a hat and wear it smartly, proudly, and with joy. I am happy to be a part of this new set of bloggers for the AGD. Until next time…

Larry Stanleigh, DDS

How Do You Define a Fellow?

There have been a lot of new faces here at The Daily Grind, and I think it is only appropriate to introduce myself. I am Colleen DeLacy. I hail from the eastern side of Michigan and the blue waters of Lake Huron. I was born in Port Huron and practice in rural Sandusky & Lexington (more on practicing in small towns in upcoming blogs). It is nice to meet you.

This year will mark several milestones for me; 2013 is 10 years post-grad, 10 years with the AGD, 10 years practicing with my now business partner, and my 10 year wedding anniversary. I guess you could say that 2003 was a busy year for me. Also, I am excited to report that I have met the requirements specified in the AGD Fellowship guidelines. I completed my application and sent it in for review. I am currently awaiting approval from the Dental Education Council and their official decision in March.

Let’s rewind. Ten years ago, as a DS4 student at the University of Detroit School of Dentistry, I was encouraged to become a member of the AGD. I honestly had not given it much thought at that time. My mind was burdened with graduation requirements, finding the perfect carious lesion for the class II prep/restore, and my August wedding. I signed the application, got some papers stating I was a member and well, that was that. Or so I thought.

I recalled my dentist and watching the letters on her signage change from “DDS” to “DDS, FAGD” and then to “DDS, MAGD.” I remember asking as a teen and undergrad student what those extra letters meant. I had always wanted to go to dental school. Even when I was young, the staff there was always very encouraging. They explained to me everything Doc. had to do to complete the requirements for those extra letters, as well as the significance of them. Frankly, though, it wasn’t until I actively began the process that I remotely understood.

Approximately one year after dental school, I finally took a minute to look at my AGD membership information. I was probably trying to find something else in the drawer when I stumbled upon the file. But it got me looking into Fellowship, or at least looking at the requirements. I printed off the application and requirements list and mentally made it a goal to become an AGD Fellow. For the first time in my life, I didn't have the rigors of school, and more studying wasn’t on my top 10 list of things do with my spare time. The CE requirements seemed very unattainable to me then and the thought of prepping for an exam of significant magnitude again seemed too overwhelming.

Don’t get me wrong: I have always been a huge proponent of quality continuing education. Fortunately for me, the owner of the practice that I joined felt the same way. He encouraged me to go to everything I could, including state annual meetings and local component society meetings. He is also a member of the AGD and understands the need for continuing education and staying atop of the information available.

Near the end of 2006, I bought into the primary practice to become a full partner. Together we purchased a second office. Sadly, in the midst of this exciting business venture, my father passed away very unexpectedly (I had just turned 30). At that time, CE took a back seat to my business and family needs (as well as my own emotional healing).

I was reminded of completing the requirements for fellowship every year as I dutifully renewed my membership. I would see the printouts in the file drawer when I put away my annual paperwork. I was going to the minimum amount of CE (very uncharacteristic) and still wasn't in the mindset to prep for the exam. I never thought it would take five more years before I was ready to even entertain being serious about my involvement and preparation for the exam. I owe my closest friend for my renewed drive for fellowship (a friendship formed in dental school). She said she wanted to take the exam and knew that I wanted to take it as well, and suggested we prep for it together. Great move!

We set a date. We originally planned to travel to Philly to take the review course and sit for the exam. We ultimately elected to take the exam locally at a testing center and rely on our own studies for the preparation. We scheduled it and stuck with the annual session date. June 2012, it was!

I knew I didn’t have enough CE completed yet and I had some organizing to do. Somewhere in during the time when I was in survival mode, I had gotten lax with sending in all my CE certificates. I had a lot of paper to shuffle and sort. There were stacks of papers and folders with CE certificates stuck in a PowerPoint handout (again, quite uncharacteristic). My transcript was a mess and it was my responsibility to get it corrected. Fortunately, the team at the AGD was wonderful to work; I would email or fax my information over and it would appear on my transcript in a fairly timely manner. Tick, tick, tick. The remaining CE hours were coming down, but slowly. I realized I had a lot to do and had to get on the ball if I was going to meet my 2012 yearend deadline.

June’s exam date seemed to approach quickly. I knew that the state board was not going to be at my office to revoke my license if didn’t pass, but I was very nervous. Although, I suppose you don’t become an AGD dentist if you are okay with failure. When I clicked the final answer, pass or not, I was relieved that I put forth an honest effort and felt good that I had done it. I walked up to the checkout staff member to turn in my scrap paper and pencil. She handed me a piece of paper with a smile, “Good job. Have a nice day.”

OH MY! This is my score?! Right here? I didn’t realize I would have the results right then. I walked out and wondered if Lisa had passed. She peeked out and a slight grin appeared and then I beamed. Thank goodness gracious! I thought I was off my game, but I was so happy to have it done!

The final step was to finish needed CE hours. I was on the AGD website at this point all the time (still bookmarked) and discovered that there are some amazing resources available for online CE. I purchased the entire 2012 Philadelphia Annual Conference CE set (which, I might add, was well worth it). Sitting in my comfy clothes on my couch with my laptop and earbuds on a Sunday isn't a bad way to keep up on CE. Of course, the AGD journal has its Self-Instruction CE, as well. In 2012, I completed 167.25 hours of CE, which is over one month’s time for the typical person’s work schedule.

What will fellowship mean to me? I am proud of my profession and proud to be a part of the AGD. Becoming a fellow is exciting for me because I have a renewed excitement for my profession and organization and have become more active (blogging here, for one example). I enjoy the opportunity to network with other AGD docs throughout the nation. It is not about the extra letters anymore, it is that I am part of an elite group: only 7% of AGD dentists achieve Fellowship*. I am proud that I set the goal and I met it. The problem with meeting a goal is that you have to set a new one. MAGD? Well, maybe...

Now I am giving you a challenge: set a goal for your fellowship if you haven’t already! It is an honor and an accomplishment. If I may offer you some serious advice, here are some tips.

1. Don’t put off taking the exam. Do it! Find a study buddy to keep you on track for the test date.
2. Complete a self audit of your CE award transcript (for accuracy) and to see what you still need. Set a realistic goal to finish it.
3. Become involved with the AGD at either at the state or national level.
4. Attend at least one destination AGD conference per year.
5. Challenge another AGD member to complete these same tasks.

Looking forward to next time,
Colleen DeLacy, D.D.S. (pre-F.A.G.D.)

*percentage taken from AGD website in the 2012 media toolkit section

I Wish Somebody Had Told Me

When I graduated from dental school five years ago, I bought a practice right away. I kind of consider the last five years as my own personal MBA program. I have to admit, it has been pretty awesome. Awesomely challenging. Awesomely hair raising. Awesomely similar to a roller coaster.

I have learned so many things. Through mistakes and blunders, lucky breaks and charisma, I am still in practice, still making a profit, and still happily married. You could say I have done okay. The following are a few things I wish someone would have told me when I first bought my practice and went into business on my own.

I wish somebody told me that I didn't have to hire someone just because they have years of experience and tons of skills.

I wish somebody told me that I didn't have to hire someone if I didn't like them as a person, even if they had more years of experience than I did and probably knew more about private practice than me.

I wish somebody told me that employees don't always do what you want when you want them to and sometimes they don't know what to do until you teach them.

I wish someone would have told me that taxes are not your friend. Get an accountant you trust, preferably someone local, in your community. They don't have to be a (cover your ears) "dental accountant." Don't hire them just because they are the biggest name around.

I wish someone would have told me that the most important time you take with an employee is when you are hiring them. Make it last. Take your time. No need to rush into something. The worst thing that can happen is that you hire someone quickly and they don't work out and then you have to hire someone else quickly, and then the cycle goes on forever. Spend time learning who is in your hiring pool and get to know them. Meet their spouse, even. As Dave Ramsey says, "Make sure they aren't married to crazy."

I wish somebody told me that owning a practice is hard. You take it home with you every night, no matter what.

I wish somebody would have told me to be a leader, to step up and lead my team. Be their leader, but be their friend. Get to know your team. Helping them reach their goals helps you reach yours.

I wish somebody would have told me to read more business and leadership books. Learn how others have done it in the past. Constantly grow and learn and improve.

You know what? These would have been great pieces of advice. It would have saved my wife some heartache, and saved me some sleepless nights. I still would have stumbled, but now, five years later, I have fallen and picked myself up repeatedly. I am happy, I am growing, and heck, I'm still riding this coaster, with my arms in the air.

I guess that's what it's all about.

What advice do you wish you had received five years ago?

Mike Lemme, DDS

Failures

Hello everyone from Ann Arbor, Michigan, home of the #1-ranked Michigan Wolverines! Wow, I’ve waiting a long time to say that—literally my whole life.

If yours is anything like mine, life has been pretty crazy lately. I hope you are managing to keep up and enjoy it a bit. I have had the pleasure of following John’s adventures over that last few years, and I hope you will also enjoy reading about mine. In his farewell post, John talked about the importance of being vulnerable and writing about things that do not go so well. In his honor I am going to talk about failures today.

It is always nerve-racking to head home at the end of the semester knowing there is nothing I can do for my patients for at least two weeks. I know that when I enter private practice, I will be able juggle my personal schedule and see a patient if I truly need to. But here at the dental school, my hands are tied. With a patient list of 55, one might think emergency calls wouldn’t be all that common. But somehow I can count on at least one patient leaving me a message saying he lost a filling, cracked a tooth, or is in pain.

I see a lot of failures in the dental school clinic. Most of them are lost or fractured restorations and crowns. Right now I am redoing a maxillary denture from my patient’s previous student that “never looked or felt quite right.” (Could you live with a denture that was 8mm too open for your bite?) Regardless, I simply cannot believe that failures are this common in private practice.

Longevity data leads me to believe that there is something going wrong in this setting. Is our problem the poor isolation of not having an assistant keeping things dry and being too busy (ok, lazy) to place a rubber dam? Are we not prepping enough retention or using subpar materials? Maybe we are trying to cure composite layers that are too thick. Or are we all too often dooming ourselves to failure by trying to make direct restorations work when crowns are indicated, simply because our patients cannot afford them?

Do you see fewer failures now? I really hope you do. How do you keep your failures minimal?

Have a great rest of the week,

Dave

Discounted Dentistry

A few months ago, I read an article in a Canadian dental journal (which I am unable to trace back) about offering discounted dentistry and how to do it tastefully if one decides to do so. This article convinced me to write my own opinion about the subject, as it has always been in my mind to do so. During the past few years of practicing dentistry outside of academia, I’ve been encountering a lot of “discounted dentistry,” which I find questionable and a bit insulting, to be completely honest.

Dentists all over the U.S. give out all sorts of discounted services to their patients in good faith to try and make it more affordable for them. It is a very nice gesture and I completely understand the motive behind it, which seems to be beneficial to both parties. However, I am challenging myself to prove otherwise by discussing a multitude of issues that arise out of discounted dentistry.

We’ve all seen signs along the side of freeways and behind office windows advertising $600 implants and $400 crowns. I admire the dentists who can make this promise, keep it, and pull through without compromising their office’s financial stability or the quality of service delivered. I’m sure that if it is advertised, it is being done somewhere by a super dentist. But I would argue that it is very difficult, if not impossible, to make this work in a private practice. With an average of 60-65% overhead and the time required to complete these services, if you run a quick calculation in your mind, you will see where the difficulty arises. To get around this, one might cut down the time dramatically and consider using less than ideal materials. This, to me, borders on ethical issues related to standard of care and such. As a patient advocate, this does not sit well with me. I would be very careful in evaluating these offers before implementing.

Another scenario we all deal with on a daily basis is patients bargaining. They ask for discounts and most dentists are too kind to refuse. I live in a family of medical practitioners and have never heard a dinner table conversation about a patient bargaining for treatment from a medical doctor. Why is it that this is so prevalent in dentistry? Why does the public think that we are salesmen with overpriced good, but their primary care physician is trusted 100 percent?

A conversation about money with a medical doctor is almost considered rude. As a healthcare provider, I assume the ethical responsibility to provide my services to every patient at a fair compensation rate. If I truly believe that is being implemented in my practice, I would have no reason to discuss discounted rates with anyone. I would be happy to accommodate patient financial issues through proper treatment planning and payment options, but never by discounting and devaluing my services. If this is done universally among dentists, maybe this culture could change for us. Maybe the public could learn to respect and value dental services just as much as any other medical service provided by the medical society.

The article I read discussed a very common situation which I had never analyzed myself. I thought it was very interesting and worthy of spreading. Many dentists offer a senior discount, often without hesitation. We all take pride in extending a helping hand to our elders and it really is our responsibility to take care of those who took care of us. Understanding their needs, however, is the essential step in being able to provide the proper assistance that actually benefits them. One third of the total wealth of this country is owned by its senior citizens. This is disproportionately high. So if you really think about it, what our senior citizens have in their hands is a lot of money and a lot of free time. This makes them the ideal patients to practice ideal dentistry on! This is what every dentist dreams of and yet we discount our opportunities and their abilities by assuming their financial difficulties and pinning an uneducated prejudgment on them. It iss not ethical and it is not fair to you or your patient.

Now, by no means am I suggesting that the senior discount should be eliminated. There are many seniors who are in need of dental services and truly cannot afford them. What I am suggesting is get to know your patient and their true needs before you make a decision on how you can assist them. Not all seniors are in need of financial assistance. The 10 percent you take off in one place could mean nothing to someone and mean a whole lot to another; disperse it the proper way.

I also have a problem with the advertising of free dental services. Too many offices bring in patients by advertising for free exams and radiographs or other services. I cannot say it doesn’t work, but it is very interesting that, despite the large number of patients they collect, many still suffer financially. I attribute that to two causes. First, a practice offers a free service in hopes that the patient will move forward and pay for other parts of treatment. Once they receive the free service, chances are that they will not continue with other parts of the treatment.

Second, advertising a free service is a note to the consumer that you can afford to do the service for free. We all know we can’t afford that. It creates an expectation for free services going forward. Or, it implies that you plan to make up for the cost with an overcharge on another part of the treatment; this is an introduction for mistrust and triggers the patient to enter the negotiating phase once the rest of the treatment plan is presented. The key is not just to bring in as many patients as you can with free offers, but to retain and engage each and every patient within your practice.

And lastly, we need to pay attention to the fact that a discount extended to patients has to be extended uniformly and not selectively. If you promise to provide a free service for your patients, you have to honor it regardless of if they pay you with cash or insurance. It is illegal to charge the insurance for a service you have advertised for free. You have to extend the discount to the insurance company just as you would to your cash patients. So next time you decide to offer free services, keep this very important issue in mind.

There are a multitude of other issues and counter-arguments to this subject and I respect all of them fully. However the points brought up here are things I have been thinking about as I start a new practice. I believe in it but that doesn’t mean I’m right. As most business decisions go, there is most likely no right or wrong answer. What matters is how well you implement what you believe is the best for you and your patients.

I am looking forward to a day when healthcare is fully accessible to all and we can provide the ideal treatment for every patient, every time. Until then, let’s choose our battles carefully and ethically.

Mona Goodarzi, DDS

Welcome to "Adventures in Dentistry: Year 34"

The last thing I remember is, “I do.”

On Oct. 2, 1978, I was minding my own business, sitting in Smokey Joe’s Grill in West Philadelphia with a bunch of classmates watching the Yankee’s Bucky Dent break the hearts of Red Sox fans just one more time. As Bucky’s blast sailed over Fenway’s Green Monster, I knew instantly she was different. My senior classmate at University of Pennsylvania School of Dental Medicine actually knew the ins and outs of my baseball, my favorite sport.

Within a matter of weeks we were dating. Three weeks later came her proposal: “We do not have to get married, but if we don’t, I’m going to do my residency in Chicago.” Considering I was going to do a two-year General Practice Residency in the notorious ghetto of East New York Brownsville in Brooklyn, New York, I felt I was in quite a conundrum. We were engaged over Christmas break. We graduated in May 1979 and wed in June. On July 1, 1979, we started residencies in NYC. Both of us had achieved fellowship in the AGD by 1985; I had my MAGD by 1988.

We are both dental junkies. We love what we do and that is a part of our personal as well as our professional relationship. We found a way to balance our lives and “have it all” through our wonderful profession. We learned early in married life and our careers that we are not just husband and wife, but partners in life.

Never average and never normal is what we, as AGD dentists, expect from our profession and our lives. Viewing our lives as a whole, we have positively integrated our involvement with and contributions to family, community, dentistry and public policy/advocacy.

We were honored with an invitation to present this past summer at the 2012 AGD Annual Meeting & Exhibits in Philadelphia. Our course was “Dentistry: The Greatest Success Story Never Told.” It was about how quality of life drives cost and innovation in oral health care and why Congress is so interested. As we are dental junkies, our hobby has been to follow our profession as it has progressed through the revolutionary times of the last 20 years. We’d like to share a synopsis of our profession’s evolution since 1965, focusing on what needs to be understood by and communicated to our patients.

It's about Buicks. Each day in my office, I have the same conversation with patients over 50. I show them images of their mouths and teeth, and the conversation begins. “You have 300,000 miles on this 1983 Buick. The frame is bent. The best long-term solution is a complete overhaul. The federal government says the standard for a 65-year-old is the 1965 Buick. If you want the current model, that can run the cost of a Buick LaCrosse or up to two Buick LaCrosses. No, your insurance does not cover this. Dental insurance changed to assistance in 1983. Dental assistance is really Buick floor mats to those companies and individuals acquiring medical insurance (which is the Rolls Royce). And yes, Mrs. Jones, I feel your pain. Many folks want to help decrease the cost of me doing by having me drive a Buick.”

My goal during this year in being honored to share my perspectives with my colleagues is to make sure everyone can fully understand our synopsis and be able to easily relate it to our patient populations.

As many of us are making resolutions in this new year, I would like to share the resolution we made last year: continuing to benefits ourselves, our community and our practice this year. Take care of yourself; you are the most important part of your practice and your life. I started my “Flat at 60” campaign to have a flat stomach for my 60th birthday in April of last year.

I have lost 44 pounds and my staff, family, patients and community love it. I cannot tell you how good it is for self-esteem and my ability to do dentistry, and to be a role model for my family and patients and community by being in great shape. Modeling healthier lifestyles and founding the “Healthiest Town in America” initiative in 2006 has raised us to a new level in the eyes of our patients and community.

If you, like many of us, were humbled during the recent downturn in the economy, you may understand that our profession is evolving. Where the dental model of delivering care is evolving to — and who will pay for it — is anyone’s guess. Trust is what we lost and that is what is needed to get back, no matter the economic times.

As we all share this wonderful profession for another year, make sure your plans for the new year take care of the most important things in your life: your health and the health of your family, patients and community. From personal experience, I can say that life as a dentist sure is fun and goes faster each year.

Enjoy the journey,

Robert J. Oro DMD, MAGD

Dental School Countdown

As a fourth-year dental student, I spent my last winter break at home in Oregon. I was thankful to get out of the chilly temperatures of Minneapolis and back to Portland for some home-cooking and catching up with friends. The break was a time for me to catch my breath amidst interviewing for GPRs and AEGDs, trying to complete competencies at dental school, and gearing up to find patients for my board exam this March. I’m sure the dentists out there really miss these days!

This past Sunday, I flew back to Minneapolis to begin my LAST semester of dental school! It’s gone so fast! I can only hope paying off all my loans will be as quick. Though my break is over, I won’t be stepping foot inside my dental school for another month. On Monday morning, I drove out to Willmar, Minn., where I will be providing care at one of the school’s outreach sites. Rice Regional Dental Clinic is associated with Rice Memorial Hospital and provides regional care for patients in 17 counties.

I am very excited for this outreach opportunity. I know it will be a real test of my clinical skills, help me pick up speed and learn to work with other members of the dental team. For those of you who have been out of school for awhile, let me remind you that we are only seeing one patient in the morning and one patient in the afternoon – for three hour appointments! I feel like I work on my social skills just as much as my clinical skills to entertain patients while waiting for start checks, prep checks and final checks. At this outreach clinic, I will likely see six or more patients a day, depending on the procedures. Any words of wisdom for how to best adjust to this patient load increase and demand for efficiency? Needless to say, I am anticipating being tired at the end of the day.

I hope to discover a groove by the end of the month and gain confidence in my skills to know that I can handle the profession that I’ve gotten myself into! And for the more seasoned dentists reading this, I hope you take a minute to reflect back on your dental school days and realize how far you’ve come since then.

As an AGD blogger,I will be bringing you news and stories as a fourth-year dental student working hard to graduate this May and then as an AEGD resident continuing to learn and develop. Let me know if you have any questions for me and I’d love to hear any feedback and/or advice from members throughout the year!

Katie Divine, Minnesota ’13

Dental-Proof Lipstick

Hi everyone and happy new year from Davis, California! Let’s hope this year will be as great as we all wish. I am excited to go on this adventure, sharing with you clips from my professional and personal experience, and I look forward to yours too.

Personal grooming, in any form, is an important requirement of the modern professional environment and the personal lives of almost all patients. That applies to us and our staff, too. We have been so appreciative of how many patients are aware that lipstick can get on our gloves and instruments and how it makes it hard for us to do our job well. These patients will ask for a tissue to wipe off their lipstick before their dental treatment and reapply it at the end of their appointment.

Recently, my assistant realized that she forgot to ask a patient to wipe off her lipstick before I administered anesthetic to numb her tooth for a filling. We rarely have to ask our patients to do so. She was surprised that the lipstick did not stick to my gloves, something that I did not notice at all. My assistant told the patient that she liked her lipstick and that she had been looking for such a product.

With a great smile, the patient took her lipstick out of her purse and showed it to my assistant. She explained that one end has lipstick and the other end has gloss. The patient does water aerobics and this is a particular brand seems to not wash off while she is in the water.

I took off my dental professional hat and engaged myself in the ongoing conversation. I do not usually ask my patients directly what their hobbies are. Generally, my conversation is somehow directed that way every time. A simple question about lipstick led to talking about water aerobics and ended with a demonstration of putting on lipstick. I paid close attention to this demonstration; I have a 2-year-old daughter and I am sure that I will be exposed to more of these concerns in the future.

A simple conversation like this does not tarnish the sanctity of the doctor-patient relationship. On the contrary, it strengthens it. There are many opportunities at our fingertips that we should not miss. It is our interest in the little things in our patients’ lives that opens the doors of communication and demonstrates our human side, that we are not robots with drills.

Our patient had a couple of laughs after such an unexpected conversation about lipstick in the dental chair. We then told her that we may share her lipstick story with others online. She was excited by the idea and certain that many people would want to know about this lipstick. When her treatment was completed, she left the treatment room without having to reapply her lipstick. As she was signing the photograph release form, she said, “That is hilarious,” and walked out laughing. What a great end to a dental visit!

Have a great weekend.

Samer Alassaad, DDS

Happy New Year!

Greetings,

Well, it's 2013. The world survived the end of the Mayan calendar, and I am just getting over the fact that I have to wait a year to watch Homeland again.

I have had time this weekend to really set my goals for the year. Now, I know I have said this before (like 40 times before), but this time, I really mean it. I am going to start exercising more. Stop laughing.

I had asked my wife to get me a remote-controlled helicopter this Christmas. Now, you have to realize that I never play video games or have had any electronic toys. I have no skills for flying remote-controlled planes or anything of that nature. She did some research and found this thing called a Ladybird. It is not really a helicopter, but a quadcopter. She thought it would be easier for me to fly because I am a beginner.

She ordered it online, and it arrived a couple days after Christmas. I was so excited! I opened the box and literally gasped. I started to read the instructions immediately because I wanted to get this baby on its maiden voyage as soon as possible. After about four hours, I still had no idea how to even turn it on.

The instructions were so difficult. I had to start searching YouTube for clues. I found a ton of videos on the thing flying, but nothing on how to turn it on. The next day, I called the company, and a salesperson knew just enough to help me at least get power to it. Now I have to study up on what an aileron is, and how to work that and a rudder. This is really complicated!

I was just hoping to fly the little bird around the yard and I’ve already spent two days just trying to figure out how to operate it. I’m ready! I had my Ladybird outside with my hand on the throttle. I gave it a little juice, the four propellers started to spin and my heart started pounding. She lifted off the ground about two feet. I got nervous and let off the power. It came crashing down. Then my wife asked to try it.

I handed her the control unit. She engaged the throttle and the Ladybird instantly shot up about 80 feet into the air. Before we knew it, my little lady flew over my house and disappeared. Now, mind you, we live on 20 acres. If anyone lives in Florida, please check your front yard. Here is what she looks like:

The 15 seconds I got to actually play with her were awesome though.

This coming year is going to be interesting for us. Our youngest daughter will be moving out to attend college in Ft. Myers (David, you are my lookout). This will leave us pretty much childless for the first time since we have been married. I have plans to make her room a recording studio/man getaway. She can always sleep on the couch if she decides to come home to visit.

I am wishing everyone a prosperous and healthy 2013. Have a great week, and have a great year.

Scott