When we talk about delivering comprehensive dentistry there are many steps in arriving at a diagnosis.  A comprehensive diagnosis not automatically connected to the delivery of extensive or expensive dentistry.  We like to begin our initial examination by taking time to try to get to know our client as a person – what are their likes and dislikes?, what kind of life are they living at the moment?, what are their goals in our office?, does our emotional intelligence suggest that we can work well together?  Do we feel that there is a good possibility that we can build a relationship of trust and respect?  In many cases this will take quite some time but we can usually tell if the “chemistry” is good rather quickly.  There is no point in wasting your client’s time or your time if you cannot get along in the long run.

Before we begin our examination process we like to ask two questions.  “After our discussion so far, are you comfortable allowing us to thoroughly evaluate your oral health?”  If we do not get a yes to this there is no point in going further.  If you do get a yes, the manner of the response will tell you something about the person if your emotional intelligence is working.  The second question is; “Are you comfortable with me telling the truth as I see it about everything I see”?  You may be surprised by some of the answers you get to this question.  Many people fear the worst or do not really want to hear about or admit the level of neglect in their oral health.  If the client does not want to ‘take ownership of the problem” that is a strong negative red flag in our office.  If the client does not own the problem there is nothing we can ”fix” that the client cannot destroy.  How often have we heard, “Doc, your filling broke” when the patient arrives with a 10 year old restoration with a broken cusp from chewing ice.

As you can see our diagnosis begins long before we are worried about teeth and gums.  We want a 30,000 foot view of the person attached to the teeth, we want to know who referred them and why.  Once we have permission and we believe we are the proper office and now is the proper time, we proceed with our exam (See: Back to Basics – What Constitutes a Comprehensive Exam).  Once we have the data in hand it is time to diagnose.

You can use our system (See: Back to Basics – Diagnosis), Frank Spear’s system, the Pankey Institute  approach or others.  Be consistent.  Review all the complete stomatognathic system, evaluate all the data, and look at the big picture as well as one tooth at a time.  Forget about money, insurance, time or fear.  Think about what the data is telling you – from the moment you first met this person until now.  You data may be telling you that this case needs multiple disciplines to reach your patient’s goals.  However, the family has two kids in college.  It is appropriate to discuss the totality of the case with this person but also morally right to discuss how to put the person in a “holding pattern” until the time is right for them to move ahead with comprehensive treatment that they can afford.  We owe our clients the very best that we can deliver in our diagnosis.  It is up to them to determine the outcomes that are suitable for them at this moment in time.  Remember, if you always tell the truth you do not have to waste time trying to remember what you said.

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On Philosophy, Insurance and Fees

Only about one half of our patients are covered under some form of dental benefit plan.   The national average is about 60 per cent of folks have a dental benefit plan.  Over 95 per cent of those with a benefit plan get coverage through their employer sponsored health plan.  It is too soon to tell what the effects of the Affordable Care Act (“Obama Care”) will be on dental coverage.  No matter what happens in the world of dental benefits we want to restate our philosophy regarding patient care.  We believe that our examination, diagnosis and recommended treatment have nothing to do with whether you have insurance or not.  Our goal is to provide care for our clients based on the outcomes you desire at the highest standards we can provide.  For most of those folks with insurance the amount of coverage has not increased in many years even though we all know costs have continued to go up.  In the past year or two several companies actually decreased the benefits they will pay out.  In an effort to force our office into being a participant in an insurance company plan the companies will not pay us on the same schedule as participating dentists.  They also try to force patients to see participating offices by withholding benefits if you see dentists outside the “network”.  In essence the insurance companies want to set the fees paid to our office and to determine what services we can deliver based on whether they will cover the service or not.  We don’t work for the insurance companies.  We work for you – our clients.   Our goal is your maximum health and well-being through education and prevention.  If treatment is needed we will discuss the financial issues before we begin.  We will provide care with respect and in a pain free manner.  We believe our client is the final arbiter of care.  We will still file your insurance paperwork for you but we work for you not the insurance company.

What about our fees?  Our fees for services are the same whether you have a benefit plan or not.  We believe that it is patently unfair that we would discount fees to a segment of our patient population because they have a dental benefit package while our non-insured clients pay more.   This is the insurance industry/government getting in the middle of our business.  They are telling dentists “work with us and we will send you more business”.  However they will demand we charge a lower fee, they will determine what services we deliver.  Dentistry is not a business where you can turn up the speed on a machine and produce higher volume to cover lower fees.  We still treat people one at a time.  This is sold to the employer and employee on the basis that if you see “our doctors” you will have little or no out of pocket cost. 

All we have to offer to our clients is Care, Skill and Judgment.  If we are going to prosper in the dental care business we must cover the costs of running a business – payroll, overhead, facility, reinvestment – and - we must make a fair return on investment – profit.  The level of service by every member of our team must be so superior to our competition that our clients are willing to pay for the “value added experience”.  There is no specific formula to create this experience.  For some it will be superior technical skill, for others it will be special behavioral talent.  If we listen to our clients we will know when we are getting the right combination to develop true long-term relationships based on mutual trust and understanding.  Our system must work with the terrain we are in.  Every member of our team must believe in our philosophy and have a passion for the delivery of great care.  We must great communicators and be accountable to others and ourselves.  We must be committed to deliver the highest standard of care we are capable of.  Finally we must go back to the very basic belief that the patient determines the outcomes that will be delivered, we must mutually agree on the means to “get there” and we must agree that the “fee” is appropriate for all concerned.  We respect the fact your trust in our care, skill, judgment and commitment to life-long learning has allowed us to prosper.  We honor your willingness to invest in dental health and well-being.  

All you have is Time

I practice in a small group setting with two other doctors.  When we built a new office a few years ago we decided to have our “private” office space as one room.  We have enjoyed this choice as we can banter back and forth during the day discussing everything from sports scores to case management and the latest antibiotic management regimes.  This open style also exposes our personal management styles as we can see the area we use for our desks.  What you see in each doctor’s area speaks volumes about personal style and self-management skills.

Early in my career I had a long conversation with Dr. Loren Miller at the Pankey Institute about how he developed his outstanding practice and still made time to teach.  One comment he made still is in my mind today.  “Son”, he said, “you have to get control of your time.  Then you can do some straight line thinking.”  After forty years I am still struggling with “getting control of my time”, but I continue to make progress.

Time management does not make you a rigid person.  In fact, the better you are at managing your time the more flexibility you have.  Key elements in time management can be found in Steven Covey’s Seven Habits of Highly Effective People.  Understand the difference between what is important and what is urgent.  Begin with the end in mind. Take time to “sharpen the saw”.

Learn to determine what things in life are truly important and you will eliminate many urgent, stress producing situations.  Some things are very simple – like being at work at the proper time.  Other things are not simple – like how to manage an issue of poor staff performance.  The key element is to determine the level of importance of the issue.  If it is important then deal with it now or create the time to deal with it and stick to that promise.  If an issue is not important do not waste time on it.  Most “urgent” issues are not really that important.   Delegate someone to deal with the issue or communicate that you will not be involved. Understand that you are not in control of many elements of life, let them go and focus on what you can control and make better.  This sounds easy but is extraordinarily difficult.  This is where the “straight line thinking” comes in.  Not as in rigid, but as in focused, open and analytic all at the same time.

Take time to think about what you want to see as the result of your actions before you act.  You would never start restorative care on a complex case without a comprehensive exam, diagnosis and treatment plan.  Why would you treat your personal and family life with less care, skill and judgment than that of your patients – and vise- versa?   Before you pick up a piece of correspondence or a patient chart commit that you will not put it down until you have completed the work involved with it.  This is the biggest time waster I see with most dentists.

  I see desks with piles of opened correspondence, unfinished charts and journals with dog eared pages.  These items are then picked up, put down and pushed around on the desk for days at a time while staff waits for a decision that could have been made in five minutes of focused, active concentration.   Don’t tell me that you don’t have the time!  All you have is time.  Each of us has 1,440 minutes in every day.  How we allocate them makes all the difference.. 

Consider making some changes in your personal schedule so that you can have some time to yourself.  Give your mind some “time off”.  This is time when our mind “resets” and subconsciously comes up with answers to the problems we agonize over every day.  This is Covey’s time to “sharpen the saw”.  Whether it is an hour off or two weeks off we all need time for recreation – think of it as “re-creation”.  Build time into your life for something more than just work.  Find a hobby or avocation to get your mind off work and develop new skills.  The mental “exercise” helps strengthen our mind to manage the stress of everyday life.

Here are some bullet points to consider trying:

Look at your desk – What can you throw away, put away, delegate?

If you pick it up – don’t put it down until you have finished with it.

Put it back – papers, books, tools – it will be where it belongs when you need it again

Make a list – At the end of the day make a short list of what you want to get done tomorrow.  Then let go of those issues until tomorrow.

Make a schedule – for chart review, morning staff meetings, vacations, family time, exercise                                             

Pre-block – productive time at work, staff meetings, vacations, CE time, urgent care time

Make a file – Tear out and file the articles you want to read and carry them with you to read when you have to wait somewhere.

Work on being an active listener – The person perceived as having the greatest social skills is the best listener.

Commit to a tiny change for the better and stick with it – measure your progress – celebrate your success.

You have only 1440 minutes in tomorrow’s time bank account  -  spend them wisely, with love and joy.