Noise in the System

Hello again everyone. Happy Spring. It is amazing how fast the time flies. It seems like just a month ago, it was the start of a new year, and now we are almost 1/3 done with 2013.

Did you pay your taxes? I know of several dentists that are in the dog house with the IRS and two that are about to go the Big House. Who in their right mind thinks they will be able to get away with not paying taxes? I don’t like to pay taxes, but I like the repercussions even less.

There was a football coach of a major university that would use the term “noise in the system” when people would criticize the team, a player, or a coaching call. That is how he described all of the outside issues that would distract the team focus. We have so much of that in dentistry.

The noise in the system I have seen comes recently from a friendly MD who likes to get on national TV and tell everyone how bad dental radiographs or amalgams are. These issues distract me and my dental when we have to reassure our patients and undo the myths and ideas that he has put in their heads. I know some of the patients believe me, but others just believe the talking head on TV. It can be draining when I hear about all the “horrible” things the dentist does to you. He is telling viewers what, when, and how their dentists should be treating them! Should it not bother me, or what? All I know is that it irritates the heck out of me most of the time.

Have you heard the commercial on XM radio talking about bleaching your teeth? It says that their system will even bleach crowns, fillings and veneers? What is it? Is this substance some new miracle potion that defies the laws of chemistry and physics? I have to explain when patients give me the third degree about why my stuff is not as good as the stuff on the radio.

“Ohhhh! You want the real good stuff?” Sometimes I just want to hand them a bottle of correction fluid and leave!

Have a good week.

JJ

Committing to Adapt

We all have natural tendencies and preferences; behaving opposite them requires a lot of energy and can wear us down. Imagine what could happen on a road trip where one person enjoys the experience of being on the road while the other just wants to get to the destination.Regular stops for scenery and snacks then become a disaster.

We come across similar experiences every day in our dental practices. Let us assume that you are the quiet, task-oriented person but your patient gets comfortable by talking and expects you to do the same. Or, let us assume the opposite where you are the outgoing, people-oriented person and your patient just wants to get things done and get out. Regardless, it is all about understanding ourselves and others, and adapting.

From the moment our patients begin to interact with us, they give us clues that let us know how they want us to approach them. For example, a patient who answers the health history’s “Yes/No” questions with further explanation could be a detail-oriented one. We’d better not ignore any of the information. Unfortunately, there is no absolute mathematical equation that explains the reasons behind people’s behavior.

I believe that I am naturally an introvert. After a long day of work, I need a quiet break to recharge; a true extrovert prefers to go out and chat with someone. My natural tendencies used to control my behavior. Instead of mingling with my team when I had available time at work, I used to sit in my office and read a dental journal “to become a better dentist.” I was shocked when I learned that our team members felt that I did not care about them. Imagine how my patients felt!

In an effort to become a better patient care provider and dental team leader, I ventured into the world of behavior analysis. I was attempting to understand my own behavior and that of others. For almost a year, I had phone training for half an hour with a behavioral specialist every other week.

The DISC behavioral language worked for me. It simply measures behavior and how we communicate. Behavior is divided into four groups:

1. Those who state more than they ask, and tend to be blunt and to the point. They focus on results and thus need to direct us. They get angry easily, so attend to their needs immediately.

2. Those who tell stories and anecdotes and digress during conversations. They focus on the experience and they need to interact.Give them chance to talk and share your personal stories.

3. Those who ask more than they state and use a slow pace. They focus on listening to understand. Get to know them well on a personal level.

4. Those who like facts and prefer less verbal, more written communication. They focus on gathering data. Be ready to quote research.

Our whole team completed one of these questionnaires to determine each member’s behavioral style. Everyone committed to adapting, including the doctors. Maybe in the future, patients can complete one of these questionnaires so we can serve them better.

Samer S. Alassaad, DDS

Love Me or Leave Me

I think I gave up on wanting everyone to like me a long time ago.

I’m probably a perfectly likable individual, if you ask most people. I’ve got decent table manners, maintain good personal hygiene practices, and can recite scenes from a wide range of romantic comedies from the late 90s with stunning aplomb. But as a dentist, I’ve learned that most of my patients are primed to hate me before I even have a chance to finish introducing myself.

If I had a dollar for every time I’ve heard a patient say, “No offense, but I really HATE the dentist,” to my face, I could probably pay off the student loans of my entire graduating dental school class. My three-year-old niece is harshly reprimanded by her parents for yelling, “I DON’T LIKE YOU!” at the people she feels uncomfortable being around. Why does my largely grown-up, educated patient pool get away with essentially doing the same thing? I don’t walk into my gynecologist’s office and loudly declare my disdain for what she has to do every year to evaluate my reproductive health. And trust me, I’d much rather see a syringe loaded with septocaine coming towards me than a shiny metal speculum ANY day.

When I first came face-to-face with dentist-hate in my pre-doctoral days, I felt compelled to instantly forge a lasting emotional bond with my patients that I genuinely hoped would change their opinion of me and my profession for good. I apologized profusely when they winced in pain upon injection of local anesthetic. I took it personally when someone complained about the cost of dental treatment or made snide remarks about how my livelihood was sustained at the expense of theirs. I desperately wanted them to understand that I wasn’t the enemy, and if they could just find it in their hearts to look past the white coat, they might just see that I only wanted the best for them. I could be their friend.

Nowadays? I know better. I may still be relatively new to this, but it didn’t take long for me to realize that it is far more important for my patients to respect me than it is for them to like me.

And yet, when I take a close look at the evolution of our profession, it becomes increasingly clear that the practice of being “liked” has become inextricably linked to the practice of dentistry. The advent of social media and the Internet forces us to present ourselves not only as healthcare professionals with enough knowledge and experience to be respected, but also as personalities imbued with just the right amount of character and likability that people feel they need to see in order to believe they’ve made a favorable cerebral connection to us.

Both old and new dentists alike seem to be fully cognizant of the paradigm shift in the dentist-patient relationship. Every time I check my email or go online, I’m bombarded with requests to visit my colleagues’ newly minted Facebook and LinkedIn pages and click “Like” or “Endorse” so the entire universe can have visual confirmation of my support for their career achievements and endeavors.

Yelp reviews and star ratings can, in some instances, make or break a dentist’s reputation. Professional consultants may charge exorbitant fees to help make dental practices more accessible and inviting to new patients. I even saw a CE course in a catalog offering to teach dentists how to use Twitter, promising that the acquisition of a skill mastered by pre-pubescent schoolgirls and most of the “Real Housewives” cast members would convince patients that their dentist was worth investing time and money in because he or she clearly had one steady, gloved finger pressed firmly on the pulse of the new millennium in healthcare.

It’s surreal to watch modern dentists’ professional identities slowly spiraling into some bizarre form of commodity fetishism [somewhere, my college friends are squealing with joy at the inclusion of a Marx reference in an essay about the dental profession] in which society can determine our intrinsic value based on how much we appear to be sought after compared to others of a similar composition.

Is there any way to avoid getting sucked in? [Somewhere, the same group of college friends is now snickering most immaturely.] As a new dentist, do I start bribing friends and businesses to follow me on Twitter to make me appear well-liked and well-connected? Should I create fictitious Yelp accounts to write fake 5-star reviews of myself so my colleagues and patients will believe I’m worth my salt?

Wait. I think I finally made the connection to the “seasoned enough” description.

Or do I keep calm and carry on, without ever worrying if my own level of professional likability isn’t meeting the industry standard? My mildly-seasoned suspicions postulate that the answer inevitably lies somewhere in the middle of these two extremes. I should care enough to ensure that my patients perceive me as a warm and trustworthy professional to whom they can openly express their dental concerns without fear of judgment or condescension, but not care so much about their personal opinions of me that it compromises my ability to provide them with the best care possible.

And that’s not to say that I don’t occasionally wonder about those of you who visit The Daily Grind on a regular basis. I don’t write these entries with the specific goal of appealing to any audience in particular, but I always hope that you’ve enjoyed what I had to say, and that maybe, somehow, I’ve connected to you in some way.

After all, I’m just a girl... standing in front of a blog... asking you to like me.

Diana Nguyen, DDS

Spring Cleaning

Spring is here! As I write this entry, I realize that the weather is far too nice to be inside; I’ll make this brief. We often hear the saying “spring cleaning” being thrown around this time of year. It is a reminder to clean up the garage, throw away the junk we’ve collected over the past year, or spruce up the yard. For dentists, it can serve as a reminder to get our house in order. Check your CE credits. Have you fulfilled (and exceeded) your requirements? Run some office reports. Are you on target to reach your goals? Perform staff reviews. Is everyone contributing at their highest levels? Use spring time to make corrections, as we only have eight more months to ensure we have a wonderful 2013.

Jason Petkevis, DMD

Are You Texting Yet?

“Please thank Dr. Alas for remembering my birthday.”

We get this a lot at my office. How do we do it? My office , admittedly, is not the most high-tech office out there. You won’t see it featured in any of the dental publications as “Office of the Year.” We don’t have digital x-rays. We still use paper charts, and you won’t see a Cerec machine anywhere near my office. But the important thing is that my patients view me as being very high-tech and up-to-date.

How do we get so many compliments about our office being high-tech? Get the patient where they are. Literally. If you have not yet begun using text reminders in your office, get ready to make a phone call to sign up.

Using text reminders, you can reach patients on their cell phones while they are at the store, their kids’ school, or the gym. Wherever they happen to be, you are there too! These days, people live their lives staring at their phones. Even while they are sitting in your dental chair! (That is a topic for another blog.) Imagine not having to leave messages on answering machines that may or may not be retrieved.

Let’s assume it is 8:15 a.m., and you have a hygiene cancellation for 10 a.m. How quickly can you fill that? Our record is 30 seconds. Yes, that’s seconds, not minutes. Our average is about 2 minutes. We maintain a list of people who ask us to call them when we have any openings. I’m sure your office also maintains such a list. But rather than making several phone calls chasing people down, we send a group text and the first one that calls back gets the appointment! How long does it take you to fill that appointment?

The use that really gets us the compliments is reminding our patients about their appointments. We remind our patients two weeks before their appointment and then again two days prior to their visit. We used to send postcards to remind patients of their hygiene appointments. The cost of the texting service is offset by no longer purchasing and mailing postcards. With postage rates so high these days, the service pays for itself with the savings in postage.

Instead of having the patient fill out a postcard after each recall appointment, we make their six month appointment in our regular practice management software. That’s it! Two weeks prior and then two days before their appointment, the computer automatically reminds them!

How does all of this work? The texting computer program connects to your practice management software automatically. It gathers the appointment times and sends each patient a text reminder. On the patient’s end, they can press ‘yes’ to confirm or ‘no’ to let you know that they’ll need to reschedule. All of this happens automatically. You receive an email letting you know the patient’s choice. If they need to reschedule, you simply text them back from your computer to find a more convenient time.

The best endorsement this system has received is from my front office manager. She has jokingly (I hope, told me she would quit if I ever got rid of this service. After more than 30 years, she swears that this is one change that has been a quantum leap in making her job easier.

Finally, the computer sends a patient a message on their birthday. Patients love this feature. It surprises me still that patients call us up and say, “Please thank Dr. Alas for remembering my birthday.”

Do your practice a favor and start texting!

Andy Alas, DDS

Vertical Bitewings

Every state or national dental meeting has multiple practice management programs on the agenda. Inevitably, these are among the most well-attended seminars at the meeting. The common themes at these courses include improving your recall system, your case presentations, follow-up systems, phone skills, scheduling and marketing. While dentists and their teams leave most of these programs excited for all of the changes they are going to make, the excitement and the follow-through wane over time. Perhaps that is because you don’t leave these programs with any concrete changes to implement or true idea of the financial implications of the suggestions.

The best systems in the world are only as effective as the diagnosis about which the patient was educated. Even the best office manager or schedule coordinator cannot put patients on the books for treatment that wasn’t diagnosed. The goal of this series of posts is to open doctors’ and staff’s eyes to all the dentistry that is right in front of them. The amount of dentistry that is available to do on your current patient pool and the underutilized treatment procedures/codes is astounding. In each post of this series, I will discuss one or two treatments or practice management suggestions that you can utilize the second you put down the article. We will look at the financial implications of each and extrapolate the results over the typical dental career.

Each of the tips will be accompanied by clinical photos or case reports to support the concept. The goal is that every idea turns into a win-win situation. It is amazing how thorough, thoughtful dentistry not only turns out to be best for the patient, but also adds to the production of the practice. I will discuss concepts that benefit the patient, protects the dentistry you perform, and enhances everyone’s quality of life by decreasing patient chair time and adding to your bottom line.

Let us begin with your hygiene department and available treatment that can be produced. In the vast majority of practices in the United States, patients receive prophylaxes twice a year. In the typical practice, dentists perform radiographs once a year. What form do these radiographs take? If yours is like most practices, you perform four horizontal bitewings that look something like this:



This is the classic four bitewing series, ADA code D0274 . What do you notice as you look, however, at this next series of radiographs?



Here we see anterior teeth and we can see much further apically. This is the seven vertical bitewing series. This series not only helps us examine the upper and lower anterior teeth, but also shows us the crestal bone in much greater depth and detail. Compare the vertical bitewing of the #3 and #30 areas to the horizontal radiographs of the same area. It is clear how deep the periodontal defect is. You cannot appreciate this on the horizontal bitewing.

This series of radiographs is better for the patient, as it gives us more diagnostic information. It turns out that we can charge (and insurance pays) more for this series of radiographs. This is the definition of a win-win situation: better diagnostic information benefits the patient’s oral health and a greater fee benefits the practice. Let us examine the immediate impact of the implementation of seven vertical bitewings on your practice.

My calculation is based on the following assumptions: eight hygiene patients a day (we will assume ½ of the patients in a typical day are due for radiographs), 200 hygiene days a year, and a fee difference between four bitewings and seven vertical bitewings of $30. You can, of course, plug your own numbers into this equation:

4 (one half number of hygiene patients a day)
x 200 (hygiene days a year)
x $30 (fee difference between 7 VBWs and 4 BWs)
______________________________________________
$24,000 increased production by converting to 7 vertical bitewings

By simply changing your recall protocol so that you take seven vertical bitewings instead of four bitewings, you can easily generate an extra $24,000 in production per year, based on this example. This doesn’t even take into consideration the difference in diagnostic information and increased treatment you will find during your exams. This calculation is based on conservative assumptions. For many of you, the increased production can be much greater. Extrapolated over the average 35-year career of a dentist, this could result in an extra $840,000 in production. This is certainly a nice start for a comfortable retirement.

This is the first of a number of suggestions that I will present over the coming series of posts. Next month, we will step back and start where all patient relationships begin: the new patient experience. We will discuss how to maximize this critical event and make it more financially productive by decreasing the lost overhead of new patient no-shows. As we progress through the series, I will speak about specific treatments, under-utilized ADA codes, and missed diagnoses that will add production and profitability.

Until next time, open your eyes to the possibilities.

Christopher J. Perry MS, DMD, FAGD

Infection Control

A few days ago, I received an email titled: “Every dentist should know.” I opened the attachment and there it was: the story of Dr. Wayne Harrington of Tulsa, Oklahoma, being investigated by the state dental board, the state bureau of narcotics, and the federal drug enforcement agency. The Tulsa Health Department has warned 7,000 patients of his that they may have contracted HIV, hep B or hep C from his procedures due to poor sterilization practices. During the investigation, they found numerous issues in that practice that had to be addressed. (ABC News, Mar. 29, 2013)

Another email followed with the same title, this time with an article speaking about an incident in the St. Louis area in 2010 where 1,800 veterans were put at risk of HIV and other diseases form dental tools that had not been properly sterilized between patients.

My whole body shivered for a moment. All I could think of was where my own limits would be on this issue. Sometimes, I think all human beings are capable of the same actions and what separates us is our limits, our tolerances, and our control levels. I wondered what situation I would have to be where I decide that the value of practicing with poor sterilization would be greater than putting 7,000 patients at risk of contracting a lifelong infection. I couldn’t find where that limit would be for me or for anyone. This was some of the most disturbing news I have ever read about in my field (it was quite a shocker to read the responses to it, as well).

As a way to prevent this, some suggest patients ask their providers what their sterilization practices are and demand explanation. Have we really come to the point where we need our patients to keep an eye on us so we can “do no harm?” Is it not the very essence of every healthcare professional to do no harm? This is not the responsibility of the patient. Patients shouldn’t be going around interviewing dentists to find the ones who practice good infection control! It upsets me to see how one person’s madness has created a situation where distrusting your dentist is being advertised and normalized.

I wondered how this issue could be dealt with in-house. Maybe there should be higher restrictions on licensing renewals and more stringent training required. This episode was unbelievably large in scale, and I doubt that there are any more like it. However, not everyone practices very strict infection control fully; it is assumed that if the bulk of it is practiced, attention to detail is not necessary. I disagree. I think it’s the details that make the bulk work properly.

This is an incredibly sad situation. My heart goes out to every person who was exposed because of one person’s lack of responsibility. This is a good time to reflect on the issue and evaluate our own personal commitment to our patients and make adjustments if we need to. However small, these adjustments will make a big difference in one person’s life and that makes them worth doing.

Mona Goodarzi, DDS