Hodge-podge

As I think of what to write today, I have so much going on in this brain of mine that I have a hard time thinking of one topic. So I am going to talk a little about a lot of things.

I had a patient who is retiring in a couple weeks come in yesterday. She had previously seen my dad and was happy with the care she received. She has seven teeth, three on the top and four on the bottom, canines and some premolars. Six years ago she had upper and lower partials made.

There are a couple of things you should know about this story. This patient hasn't been to a dentist since she had the partials made. She is a smoker and generally doesn't care about her teeth. She is in town for a couple weeks and then is moving to the Carolinas to retire. She wanted me to make her new partials so she could have a spare. She is not interested in any fixed, only removable.

I took a look inside and noticed that five of the seven teeth the partials rested on were decayed (all one surface, facials mainly). I told her she needed to have these taken care of and then we could take impressions for the new partials. She agreed.

When she got to the front office, she asked how much insurance would cover. My front desk person went into defensive insurance mode. Isn't it funny how we react to this question? We automatically start treating this patient with kid gloves. My people explained to her that there was a chance that the insurance was not going to cover new partials since she just had partials done six years ago. My staff began to think that this patient wouldn't want the partials if insurance wasn't going to get involved. However, the patient just shrugged and said, "Well, if they don't pay, then I will just pay with a check. Is that okay?” Yes, a check would be great.

But let’s not forget that this patient just doesn't seem to get it. She thinks she could just get new partials and everything will be okay. But she hasn’t see a dentist in five years and she only has SEVEN TEETH. There is a reason you only have seven teeth: you take them for granted. As much as I talked about regular visits and good home care, I don't know if it sunk in.

I had a patient this week pay with cash. We don't get a lot of people paying with cash here. But the weird thing about this patient was that her treatment was $3,810. Who carries four grand on them? I get nervous when I have to take the money bag to the bank. So, I don't know how I would feel carrying $4,000 to the dentist’s office.

On another note ... colleges are done for the semester here in Florida and there is a small break before summer semester begins. I am seeing a bunch of college kids this week. A couple of years ago, I sent a couple of my patients off to college and they wanted to be dentists. I have kept up with them over the years. I saw one of them today and asked how it’s going.

He said he is doing great and getting ready to take bio-chem next year. When I asked if he was still on the pre-dent track, he told me that he is thinking of going to medical school. Then I asked about his friend that I got going in the dental direction. He is also thinking about going to medical school. Then he dropped the bomb: "Actually, medical school is easier to get into than dental school," he said. WHAT?!

Are kids crazy now-a-days? I know this job looks easy from the outside, with good hours and decent pay. But, come on. I have been in this profession for 17 years and I am beaten down. Don't get me wrong. I totally love it—but beaten down nonetheless.

I know guys that are physicians that graduated at the same time I did. Although they work long hours, they drive Maseratis. Not Mercedes, Maseratis. They live in gated communities that won't even let me in. Sure, they might be beaten down too, but I would rather be beaten down in a Maserati.

Ok, the last thing. When I spoke in Tampa, the Kuraray rep was in from Atlanta to see me. When we left each other, he said, "Let’s talk next week." Well a week went by and nothing. Of course, I started to think that he must have hated me and wants to find a way out of this. I was freaking out.

Turns out, he sent an email to his superiors and told them that "This is the kind of guy that we are looking for." Being affirmed is like the greatest feeling. I was on top of the world yesterday. Ladies, listen up. All a man needs is to be affirmed every once in a while. My dad had a staff meeting once to tell everyone in the office that they needed to affirm us in front of the patients more. He said it was for internal marketing purposes, but I know that it was more for him.

But the Kuraray thing is going well. It looks like they are going to sponsor me to speak at the FNDC and maybe work with me on doing a Dental XP course. I’ll keep you posted.

Have a great weekend.

john

Dentaltown

Man, have I been crazy. My schedule has been packed. Let me run down my weekend for you. We stayed home on Friday and tried to recover from a stressful week. Let’s call this the calm before the storm.

Saturday morning started like any other day. My daughter had a piano lesson at 8 a.m.(don't ask me who makes the schedule). My 8-year-old’s baseball game was at 9 a.m. I am one of the coaches, so we have to get there at 8:30 a.m. or so. I dropped off my daughter, came home, and yelled and screamed until I had a baseball player and baseball stuff in the car.

My oldest son had a lacrosse game at 10:30 a.m. So straight from the baseball game (lost 15-1) to the other game on the other side of town. It took 40 minutes just to get to the lacrosse field. They ended up losing 9-7 (this was the playoffs, too). So far, 0-2 for the day.

We came home and we had lunch. My town puts on an Art and Foliage festival every year, and it was this was the weekend. I like going, but I just have to find time. After lunch, we got in the car and went to the festival. We were there from 2:30 until 5 p.m. Then at 6:30 p.m., there was a benefit dinner for the baseball league that we play in. We got home at about 11 p.m. How is that for a Saturday?

On Sunday, I was up at 5:30 a.m. to run 11 miles; I got home about 8 a.m. There was enough time to shower and help get ready for church at 9 a.m. We had breakfast after church, then baseball practice 1-3 p.m. A baseball party from 3-5 p.m. Then lacrosse practice 4-6 p.m. We had Church Community Group at 6 p.m. at our house (the last person left our house at 10:30 p.m.).

We usually don't like doing a lot on Sunday, like sports and stuff, but it just worked out that fields are tough to get and they were in a pinch. I am telling you, it is crazy at the Gammichia house. I won't bore you anymore with that; I just thought it was entertaining.

On to today’s topic. I know most of you are pretty computer savvy. That is why you are here on a blog. In the past, I have spoken about Dentaltown. I have not been to the site in over 3 years. I was talking to someone at Triodent; she suggested I give it another try.

Let me back up. I use to go on DT when it was first starting out. I felt like everyone with a computer was an expert. I would have a dentist fresh out of school trying to tell me I was doing it wrong, giving me his opinion like he was an expert. And not in a tone that was building up. I felt like people belittled others just to feel better about themselves. I got tired of the spirit of the whole thing.

I gave it another try last week. I didn't research to see if anything changed. I didn't read a couple of threads to see the lay of the land. I just went right to Case Presentation and uploaded an occlusal filling that I had done. It is an occlusal filling – what could they crucify me with?

Well, I wouldn't say they trashed me, but it got ugly in a couple spots. The first comment was about etching the enamel. Then they got on me about not using a rubber dam. Then they got on me about that little dark area on the occlusal surface, saying I should have taken it out in the prep. One guy said I had a white line on the distal facial part of the restoration in the final shot, saying I should have gone back and removed it and refilled.

There is still some attitude that if you are not doing it in one particular way, then you are doing it wrong. There are still guys that it seems just want to break you down. But this time around, I didn't take it so personally.

Taking this approach, I can look at DT in a different light. I have begun to see that most of the dentists on there are just trying to get guys like me to do it better. Now, it does seem like there are dentists on there who are untouchable (no one trashes them when they post). But now I find myself totally addicted.

Patients are waiting for me. Hygiene is waiting for me. And I am reading threads on DT. Kind of like you guys do with my blog. DT is fascinating. It is like a world unto itself. There are dentists on there that have 15,000 posts. That is like 10 years of 50 posts a day, EVERY DAY. This is not a well-rounded dentist.

I haven't gone to many of the threads yet. I have stuck mainly to the restorative dentistry threads so far, and have been quite impressed with the skill of the dentists. I think it is going to make me better. I mean, I think I am pretty good, but there are dentists on there that put me to shame (most of them are from Europe). I look at their stuff and wonder how they did that or I am convinced they guy must have photoshopped.

This could only make me better. And who knows? I might even try a rubber dam. Do any of you use DT? I would like to know what your thoughts are. Let me know.

Have a great Wednesday,

john

Ownership... Arghhh!

Good Friday to you. Hope you have had a great week.

My father and I are putting the final touches on the "hostile takeover." Some people will call it my buying him out. Things have been going pretty smoothly, but the minute details are maddening. My father and I have always done things a bit differently. A conversation between us might go something like this:

"Hey, you wanna buy the rest of the practice?"
"Uh, okay."
"Okay, done."
"Uh, okay."
"Okay, done."

Then a week later:
"How much do you want for the practice?"
"How about X?"
"Uh, okay."
"Okay, done."

This is really how two dudes do things. I don't recommend it, because now we have to start talking about things like medical insurance for "an employee." What if this? What if that? How about if you? I think you need a professional to handle all this.

One thing that I have started thinking about is trading. I am not saying I do this, but what if one of his friends comes into the office? Can he work on his friend for free? Can he trade services?

What if (and I am not saying this is a real situation) he had an optometrist friend from the military? Say they met at McCoy Air Force Base in 1971, and since then my dad and our family have received eye care and got a professional discount of 100%. His family has received dental care for the same professional discount here. He is on a 3 month recall here and I think my father and his wife get eye care. I went to him once in 15 years. I would consider him my eye doctor but I don't have any issues so I don't go. (I know, I know I should go more often.)

I found out about their agreement when his office didn't charge me as I left. I wrote him a really nice note and told my dad about the service I got at his office. My dad then told me their relationship."OOOOOHHHHHHHHH!!!" I said.

I took one of my kids there last week and was charged, as I expected. So now the question becomes: what happens when my dad no longer owns the business? Do I have to tell this guy who hasn't paid for a dental cleaning in 40 years that it is time to buck up? What about all the other "arrangements" my father has?

And that is just one thing. Now that I will own everything, I have to change the credit cards to my name. The office card that we have now has 350,000 sky miles that are mine. And do I give him a credit card? (Totally off the subject, but I had a patient that came in today that has 1.8 MILLION sky miles. Wow! He could go on a first class overseas flight with his wife over 150 times.)

What about his lab? I am partial to my lab (no pun intended). Mainly, my fixed lab. I don't think his lab is nearly as good as mine. My guy is local and is around the office all the time. And his work is really nice.

What about vacations? I guess he gets none because he is basically an independent contractor. See what I mean about the details? And that is only what I could think of off the top of my head. Disability? No. Is he is the bonus pool like the other staff members? What about if he starts to have a crappy attitude? What if he starts talking down to patients? Well, it is my practice now and I have to police everything. Do I send him to the schools? Uh, no. Do I send him to Rotary?

I think my head is going to blow off. Thanks for listening.

Have a great weekend,

john

My Crazy Weekend

Happy Wednesday. I am sorry about not doing a blog on Friday. I gave my second paid lecture in Tampa. I thought I might get a blog in, but my fingers were shaking so much that I couldn't even type.

I left my house at 7:30 a.m. to take my son to school and headed for Tampa right after. The GPS said it was a one hour and 38 minute ride. So I would get there at 10 or so. I had a lunch planned with the Kuraray folks at 11:30 a.m. anyway.

I was driving with the air on and could feel myself getting hot. The air was freezing but I was sweating. My hands were shaking on the drive. This was not going to be good. I had not been sleeping well either. I don't know why I was so nervous.

I got there early, so I sat in the lobby of the hotel and worked on my lecture. (Yeah, adding new stuff to your lecture 1 hour before game time is always good.) I got myself so worked up over this thing. I think it was because of all the science stuff I added to lecture. I borrowed some slides from Kuraray and 3M and I just didn't want to sound like an idiot talking about this stuff.

I also added some composite science. You know - the difference between microfill, microhybrid, nanofill and nanohybrid. I am still trying to convince myself that I understand all this. I am pretty confident in the dentistry, but the other stuff is pretty tough for me, especially because it is ever-changing (and I slept through that class in dental school). But if I am going to be an "expert," I have to know this.

Lunch went well. The lecture also went pretty well and there was a pretty good turnout. The Kuraray people were there but both of them had work to do; after the first half of the lecture, they stepped out to do work. Totally understandable.

But the first half of the lecture was the buildup to the good stuff. Kind of like when you have a salad and maybe some chicken, but you know this restaurant has great dessert. You are just trying to get to that hot lava cake with ice cream. Well, the second part of the lecture is all photos of teeth – my wheelhouse.

The Kuraray folks got to see me fumbling and bumbling, trying to talk science. They didn't get to see me really shine. But I still think they liked me. We talked about doing more stuff together. They have great products, so I think it is a good fit.

I was wearing a suit and could feel myself getting very hot. I started the lecture with, “Is it hot in here?" I knew I couldn't take off my jacket because I was sweating through my shirt. Gross, I know. The audience was freezing and I was full-on sweating. But at the end, nothing but relief. I don't know where the time went. "Oh my gosh. I am done. Thank God.”

There were a lot of good questions and a good discussion. I talked to people afterwards. They came up to me and told me I had done a great job. I could see a lot of speaker evals, and they were all straight fives.

Even though I was so-so on how I felt, I think they really liked the lecture. Even though the sponsors didn't see the second part of my lecture, they will get the evals and that is all that matters.

That’s two down and 248 to go (I estimated it would take 250 lectures for me to afford the Replica Cobra and the mountain home I want).

But that was only the beginning of my weekend. Friday night we had some people over. Saturday morning I ran 12 miles at 5:20 a.m. Then I had to be out the door at 8 a.m. to get my oldest to his lacrosse game. I left the lacrosse game early to get to my other son's baseball game that started at 10:30 a.m.

I had a friend from dental school in town; he asked if I wanted to play golf with him. I got the green light from the wife. Tee time was 1:30 p.m. I thought about it and realized I haven't played golf, (without a kid or without it being a charity scramble) for over 10 years. It was fun.

You think that is a long day? Not quite. See, on Thursday, someone asked if we could use 2 tickets to The Lion King, playing here in Orlando at 8 p.m. So, straight from golf to the shower, then to the bar for an appetizer and a beer, then the play (very nice second row seats). The Lion King was really good, but seeing The Lion King for free was even better.

Next day, up and at ‘em for church. After church was a charity kickball tourney I signed the family up for. Then back home for a couple of hours before our Bible study started. Then I ran 5.5 miles at about 9 p.m. And then I crashed on the couch.

Now, that is an eventful weekend. Good thing I have Monday off. This time of my life is so crazy. I love every minute of it.

(my 2-year-old with Noah's gear on)

Every day, it is something different. I am telling you, every day!!! It is crazy, but awesome.

Soon I will be able to play golf whenever I want. But not now. See you Friday, john

Gray

Greetings,

I was finishing up a root canal on a long-time patient of mine yesterday. After my usual post-op speech, I was walking out of the operatory and happened to catch a glimpse of myself in the mirror on the wall. I know I’m not going crazy, but I don’t remember having this huge patch of gray hair. It literally looks like someone hit me upside the head with a bag of flour. I’m not kidding. I didn’t look like this last week, I’m sure of it. This is all happening at a supersonic rate and I’m pretty sure who to blame it on — my kids.

I have all girls. That sentence alone should be enough to explain the hair. Trying to keep up with different boys is exhausting. Looking back, I could have avoided all this worry and stress by never potty training them. Think about it: supplying them with diapers for the rest of their lives is a small price to pay if I don’t have to fight off boys. I can’t think of a better deterrent than having to help “change” your date in the middle of a movie. I can just imagine the look on the boy’s face when I hand him a diaper bag and say, “Here, you are going to need this.” I would have never had to worry about finding diapers that fit; they go from stages to pull-ups to Depends. We can even go green and just hire a diaper service that delivers cloth ones! The landfill would appreciate it.

I will admit that the “driving lessons” added a little speckle of white on the old roof top, too. I don’t know how many more times I could have said, “Stop stop STOP STOP STOP STOP!”

Perhaps, it’s all part of life: slowly losing your gut lining to the point that prune juice is the only thing that will stay down. I mean, when you think of girls, you think of “sugar and spice and everything nice.” To be honest, it has been nice. I wouldn’t change having my girls for anything. There are a wide range of emotions I have gone through (and still go through); from “beaming with pride” to “what have I done wrong?” Even though they are totally different, they each add to my gray in their own lovely little way.

Bill Cosby once said, “Gray hair is God’s graffiti”. He must have gotten me when I wasn’t looking. (Or maybe I was looking.) Below, you can see the lightning bolt of gray on the right side of my head. I will probably look like a Q-tip by the time they get married, but I wouldn’t have it any other way.

Have a great week!

Scott

I Can't Afford You

Hey everyone,

I hope things are going good for you. It has been crazy here. I am speaking on Friday, so I am so freaking out. I added some new material about the science of bonding and (I don't know if you know this), but I am not that scientific. So I have to learn this stuff and I am totally going out of my comfort zone. But then I move on down and talk about composites and realize I don't really talk about science here. That means I am going to have to learn this, too. I just want it to be great.

Anyway, it seems I forgot to put up the x-ray on Friday. I was talking about when to crown a cracked anterior. I told you that I won't consider it until I start seeing radiographic evidence of the crack. Well, look at this one.Pretty crazy, huh?

I met a very nice 65-year-old patient yesterday; we got along great. This patient came in for a new patient exam after having not been to a dentist for about 8 years. They had really nice teeth, with no decay and pretty good dental work in the past.

The last thing I do in my exam is a full perio probing. I was surprised to see that they had quite a few 6mm pockets. Turns out that in the past, they had lost both of their lower first molars. The upper first molars super erupted. So when the dentist went to restore the lower endutulous areas with bridges, the dentist also restored the upper first molars too. The dentist did root canals and then put crowns on them and did a very nice job. But all around all the dental work are 6mm pockets with bleeding.

I educate my patients on gum disease in the pre exam interview. I have a chart and I walk through the disease process to get them to understand their mouth. They are able to follow along with what I am going to do in the exam. By the end of the probing, if I have said, “Six, five, six, six, six, three, six, three,” the patient knows we have to talk.

I sat this patient up and we talked. I told them that I thought this was treatable non-surgically but that was going to take some work. I recommended a gross debridement and then two quads of root planing. This patient went up to the counter, made some appointments, and left.

They called about an hour later and said that they really liked the office but couldn't afford the work. This particular patient had dental insurance (but not very good insurance), and we guesstimated that they would pay a little less than half. So, out of pocket, a tad over $300.

This brought up much discussion in our morning huddle. I started to hear all the things the staff have been hearing. “Oh, I don't trust anyone to work in my mouth except Dr. Gammichia. But I get my cleanings at the clinic down the road." One patient got their x-rays at the insurance dentist and then got their cleaning here.

Here is my thing. We still have some work to do in the educating of patients. A cleaning is not a cleaning. But how would they know that? Is an oil change an oil change? Well, it is to me. And I know that it is not the same at every garage. Is a loaf of bread a loaf of bread? I think if you ask Merita and Country Hearth, they would say no. To me a loaf of bread is a loaf of bread. Probably terrible examples, but you get the idea.

My patients should know when the cleaning appointment is 60 minutes here but when they are rushed out of the clinic on their insurance in 15 minutes. That cleaning might consist of just a polish, or worse, having been cavitroned and then that’s it. It is what it is. So this patient is going to go to the dentist on "the list.” What will their mouth look like in four or six years? It will be a lot worse, and they will get shipped over to the clinic's perio surgeon. And that is going to cost a lot more than $300.

I know not everyone can afford the dentistry I can offer. I know that the economy is totally in the crapper. But I feel like I am fair. I have a service that is second to none (well, close to it), and we do work here that we are proud of. We get people better. Listen I am not crying a river. I have awesome patients that love me. And they tell me too (which makes my head really swell). I have a wonderful practice and love coming to work. I love my staff and I think they love me. Things are really good here But this is definitely an issue.

On the other hand, I had a patient came in today that works at an RV dealership here in Orlando. They sell RVs that range in price from $5,999 to $500,000. Guess how many they sell in a month. I have asked some patients that question today, and all the answers were all about the same. They all guessed somewhere between three and 10. The guy told me that in an average month they sell 100, with about 30% being of the larger, expensive kind. This was shocking to me. I can't sell 10 crowns a month to people that need them for their health, but they can sell 100 RVs a month?

What do you think? Are you hearing the same thing? Let me know.
john

Exit, Stage Left!

Remember that blog a couple of months ago about the associate that could be my grandfather that was working here? Just wanted to give an update on the semi-retired associate dentist that I was telling you about.

Well today was it; we informed him that it was the end of the road. It was not fun. I feel bad for him and his situation, but his practice style and philosophies were just too different and causing too much upheaval with the staff. Most of all, was the realization that even though were not doing the dentistry, our business could be held liable for any problems that arose. The practice owns the charts and the patient hands the money over to our business and they walk through our front door, so everything he does in some way reflects on us. That did it for me!

Most of the comments I got from the original piece about this issue said to “get rid of him immediately.” It just took us a little time to get there. Telling people that want to be here that we do not want them here is the part I hate about being a business owner. The bad part is that we hired an extra assistant to work with him; without him, we do not need her. She knew this could be coming, but I still feel bad. We are going to let her sub if someone is out and if a position ever comes open and she is available, we will give her a call. We are giving him a few weeks to wrap up cases and then it is done.

I hope that I am ever in the position that I have to work in my 80s. I am sure that bad things can happen, but that is have short-term and long-term disability out the yin yang to cover physical issues. I know one dentist that does not believe in insurance. I hate paying the premiums, but I would hate even more needing it and not having it.

We are saving for the future: 401k, used to do a Roth, a few other little things here and there. I probably should be doing more, but if I stay healthy, I should be able to work another 25 years and still retire before 65. I know that more issues will arise even after he is long gone, but we will have to put out the fires one by one. I see now why so many dentist partnerships break up. It is hard working with a dentist who just does things differently than you.

Well, I am not sure how we are going to handle bringing in another dentist in the future if one approaches us. But I know we have learned a lot from this little adventure.