​​Inside Dentistry, February 2019, Volume 15, Issue2
As the average retirement age of dentists continues to increase on a yearly basis, one can no longer rely on standard retirement principles to secure his or her financial future. Historically, the national retirement rate of dentists has fluctuated in correlation with the state of the economy. Although an economic downturn, whether it is due to an event as significant as a recession or one of lesser impact, such as a short-term decline in the stock market, directly affects the "nest egg" that professionals work so hard to build, designing an effective retirement plan requires more than navigating the ebb and flow of the economy.
To maximize your potential, it is important to diversify your retirement strategy at every stage of your career by addressing recent regulatory developments, pursuing creative investment options, consulting the experts who are crucial to create a well-rounded portfolio, and learning how to successfully transition a dental practice.
Retirement is often the first time that dentists will lack steady cash flow, and with no pension, they have only what they have saved and invested for this day. Retirement planning is an individualized process because each dentist has a unique set of requirements and desires related to their lifestyle. However, there are some guidelines, tools, and tips that can benefit all dentists, regardless of their specific goals.
Strengthening Your Retirement Strategy
Workforce Status
Many dentists are nearing the traditional age of retirement. Currently, 40% of dentists are 55 years or older, whereas just 27% were in that age demographic in 2001.1,2 However, in a recent survey, 46% of participants said changes in the economy are forcing them to continue practicing past their expected retirement date.3 According to the American Dental Association (ADA) Health Policy Institute, the average dentist currently retires just before turning 69, whereas in 2001, the average retirement age was about 65.4Generally, there is plenty of work for dentists to continue working late into life, as the supply of dentists is not in equilibrium with the market. The Health Resources & Services Administration estimates that there is currently a shortage of 10,802 dentists in the United States.5 However, the per capita supply of dentists in the United States is projected to increase through the year 2037,6 with some analyses suggesting there is evidence for a surplus of dentists by 2040.7
Planning for retirement is relevant to clinicians at every stage of their careers. For the majority of older Americans, their biggest financial regret is not beginning to save for retirement early enough.1
Relevant at Every Career Stage
Successfully transitioning into retirement requires planning. Although some studies suggest that planning should begin at least 5 years prior to retiring,8 many believe that retirement is something dentists should start thinking about at the start of their careers. Calculating the amount of money one will actually need is the most crucial and often overlooked step in retirement planning.9 Planning for a successful retirement requires establishing clear goals, committing to a well-structured savings plan, focusing on reaching your goals, and oftentimes, consulting experts for help so that you can reach your objectives as quickly as possible.
Mark Kleive, DDS, a private practitioner in Black Mountain, North Carolina, is about halfway through his dental career. "Most dentists start their careers without much extra cash flow to save, so an individual retirement account (IRA) or a savings incentive match plan for employees (SIMPLE) IRA works great," he says. "When cash flow improves, the option to save larger amounts of money becomes available. In an individual IRA, a person who is less than 50 years old can now contribute $6,000 annually, but in a Safe Harbor IRA, he or she can save nearly 10 times that amount."
The type of retirement planning steps you take may greatly depend on what stage of your career you are in and which options present themselves. "I was out of school for 5 years before I could save a penny. I had too many expenses and spent most of my remaining money on amassing more than 500 hours of continuing education," remembers Robert Margeas, DDS, editor-in-chief of Inside Dentistry. "With that being said, my advice to younger dentists is to start a 401(k) as soon as possible." The guidance of a finance professional can be invaluable in helping you figure out which plans make sense at different stages in your career.
Surviving Fluctuating Conditions
Many dentists who are actively planning to retire in the next 5 to 10 years are members of the baby boomer generation. Since they began working, the world has changed in many ways that affect life in retirement, including a shift from employer-managed pensions to individual-managed 401(k)s, a drastic increase in the cost of healthcare, and several economic recessions that have caused professional and market losses. Many dentists saw a significant decrease in revenue in the years after the 2008 recession.10
Surviving fluctuating economic conditions requires diligence and patience. To mitigate the effects of these fluctuations, talk to a financial planner for help with setting up a well-diversified portfolio.
Periodic Reevaluation
In addition to developing and sticking to a budget and investment plan, periodically reevaluate your budget to capitalize on any shifts that could allow additional funds to be directed into an existing retirement investment plan. There is also the possibility that investments will not pan out as hoped, but it is always better to know sooner than later so that adjustments can be made. Oftentimes, brokers will charge for the initial valuation, then perform updates annually for a lower, set amount.8 Smart dentists will reevaluate and shift their retirement plans several times throughout the course of their careers to maximize retirement savings.
Retirement Options
A recent ADA survey found that dentists will need funds from four different sources in order to retire.11These expected sources of income in retirement included private savings such as IRA, simplified employee pension, or 401(k) funds (62.4%); social security (13.4%); sale of practice (12.7%); and other (12.5%).
The survey also indicates that dentists expect to live on an average of $127,000 per year when they enter into retirement.11 Having a clear idea of how much you will need in retirement is critical to formulating a successful retirement plan, and understanding the investment plans and tools at your disposal is necessary to optimize that success.
Defined Contribution and Cash Balance Plans
Defined contribution plans, such as a 401(k) or SIMPLE IRA, are small business retirement plans with mandatory employer and optional employee contributions. For the employer, these contributions are tax deductible, and for the employees, the plan is funded with pretax dollars taken directly from their paychecks. With a Roth IRA, the individual does not get deductions when putting money away, but the money in the account is not taxable and is not taxed when withdrawn.
Defined benefit plans, also known as cash balance plans, allow the employer to both contribute and deduct more than other programs.12,13 The effort and costs associated with establishing and maintaining a defined benefit plan are worth considering carefully. An enrolled actuary should be used to determine the funding levels and sign the annually filed Schedule B (ie, Form 1040) included with tax returns. Furthermore, because the employer is guiding the investment decisions of the plan, they assume all the investment risk. "In the event that the retirement plan loses money, the practice has to make it up," warns Bruce Bryen, CPA, CVA, principal consultant at RKG Tax and Business Services, Fort Washington, Pennsylvania. An employer will most likely want to ensure that either a financial advisor or wealth management professional works with them in structuring, rolling out, and administering the plan.8,12
Contribution limits consider how much money is needed to fund an individual's retirement by the time he or she reaches retirement age, based on actuarial assumptions. Utilizing wages, ages, interest rates, mortality rates, and other factors, the plan's actuary will calculate the contribution maximums based upon the number of years that remain until the individual reaches retirement age. In practice, what this means is that older owners will have a higher available contribution deduction than younger owners, because the older owner has less time to accumulate the necessary funds before reaching retirement age.13 Notably, tax regulations do require that plans cover a certain minimum number of employees and that those employees receive a certain minimum benefit in the plan.
HSAs and 529 Plans as Retirement Tools
A health savings account (HSA) is a tax-advantaged medical savings account available to taxpayers who are enrolled in a high-deductible health plan. It can also be thought of as a supplemental investment tool to help improve your financial picture in retirement. A 529 plan is a similar tool, but geared toward future education costs, which may be helpful for people with children. Money is deposited tax-free, and it is not taxed upon withdrawal as long as it is used to pay for education.
Oftentimes, dentists have various sources of savings to draw upon during retirement, such as registered plans, corporate savings, non-registered cash accounts, life insurance cash values, government support, and hard assets. It is important to schedule withdrawals from these various sources to maximize government benefits and minimize tax payments. A financial advisor should formulate a withdrawal plan for the dentist, with the goal of providing a steady stream of income, even during periods of short-term volatility. A defined process should be in place when the dentist retires.8
Meeting with a certified financial planner will force you to inventory all of your financial assets. You may even discover forgotten retirement accounts that could move you closer to your goals.
Key Players in Your Retirement Strategy
Retirement planning requires knowledge of tax laws, compound interest, the present and future values of money, and investment strategies. It is difficult, if not nearly impossible, for a dentist to stay up-to-date with all of this knowledge while simultaneously building a practice, which is why many consult financial experts when it comes to retirement planning.
Unfortunately, only 26% of dentists use a certified financial planner.2 Seeking assistance from a certified and trusted financial professional can help you better understand your options, including saving in ways that offer tax advantages, remaining invested after taking required minimum distributions, and evaluating your practice in preparation for your transition. Although you may find a professional transition service that meets all of your needs, those services often call upon a specialist for nonstandard cases, which is something that you can do too.
"When I'm talking to new clients, I'll explain to them that I need to know everything about them, not only about their business but also their life circumstances, in order to develop the right strategy for them," says Bryen, "This process needs to be very individualized."
Lee Ann Brady, DMD, a private practitioner in Glendale, Arizona, started thinking about her retirement as soon as she started her career. "I work with both an accountant and a financial advisor. I take advantage of both tax-advantaged and other savings vehicles. I have an employer-based plan at my office, which also includes my team as a benefit for them. The process has included HSA plans, disability and life insurance policies, and IRA and 401(k) plans," she says.
John Cranham, DDS, clinical director of The Dawson Academy, started working with an investment advisor just 5 years into his practice. "I knew I was not good at managing money, and I knew I needed to save for retirement, but I had no idea how much," he says. Planning early and effectively is an important component of ending up where you want to be.14 "I just listened and did what the financial services firm said to do. Time, discipline, and sound, conservative advice have worked well. This process also really removed my stress. Once I took care of my retirement savings each year and kept up with my bills, I didn't worry about spending money. It definitely made life more enjoyable," says Cranham.
Selling/Transitioning Your Practice
Knowing the monetary value of one's practice, the tax ramifications, and how the sale or transition will take place are vitally important components of retirement success.
Accurate Valuation
"A dentist's largest asset is likely to be his or her practice. Therefore, it is prudent to know the value of your practice at all points throughout your career. This will enable you to do estate planning; complete a competitive analysis in terms of strengths, weaknesses, and opportunities; prepare a letter of instruction; and maximize revenue opportunities," recommends Keith Drayer, vice president and general manager at Henry Schein Financial Services.
Having a valuation early on allows the dentist to address areas that fall short so that the eventual sale price can be maximized.8 Drayer recommends that dentists begin working with a transition consultant approximately 5 years prior to selling their practice. "They can help identify opportunities to optimize revenue in the last few years and to increase the sale price at the time the dentist decides to sell." A broker would then market the practice until the right buyer is found.
Internal and External Transitions
Whether a dentist chooses an internal or external transition may depend on his or her retirement work plan. If the dentist wants to walk away without any further commitment or responsibility, an external transition may be the most appropriate.
However, if the dentist would like to continue working in some capacity or would simply like to ensure that the practice is in good hands, an internal transition could be the best choice. A dentist may also choose to simply alter his or her work schedule rather than retire early. "I have reduced the types of procedures that I perform, and I do what I enjoy most," says Brady. "One of the gifts of developing financial security is that you have the freedom to make these types of decisions." Similarly, David Burt, DDS, a private practitioner in Allentown, Pennsylvania, has developed a sleep apnea practice within his dental practice. "I want to slow down, but I don't know that I want to retire until, maybe, I physically have to," he says.
 "Internal transitions can be complicated," warns Drayer. "The best way to approach them is to set the sale price or formula at the time the associate or family member joins the practice and to get it in writing. Having things in writing will lead to a smoother transition and eliminate ambiguity." An internal transition may also require a significant time commitment in terms of training.
On the other hand, there are benefits to internal transitions. "If there is a qualified associate working for the selling dentist, plans can be made to have that associate acquire the practice in a timely and cost-effective manner. The associate will have the necessary clinical skills and administrative experience, so there will most likely be a smooth transition," says Bryen.15
Taxes and Regulations
One of the biggest challenges of accumulating personal wealth is exposure to taxes. In fact, minimizing taxes is the second most pressing area of financial concern for successful dentists.12
Tax Considerations
Ongoing changes to the tax laws will affect your retirement plan from start to finish. When selling a practice, taxes must be considered, and only the after-tax amount will be available for spending. A tax accountant can structure the sale of the practice to maximize this after-tax amount, estimate how much will be owed in taxes, and work with a financial planner or advisor to minimize the dentist's tax burden throughout retirement.
Taxes are also an important consideration for short-term financial planning. "The potential for practice owners to lower their current tax bills is often noted as an important benefit to starting a retirement plan. The contribution deduction allowed for owners for their own contributions, as well as for those that they make on behalf of their employees, can often have a significant impact on their tax bills," says Michal Levy, lead director and chief operating officer of the Funds Management Group at AXA US.
The federal government allows individuals aged 50 years and older to save additional, tax-advantaged funds in a retirement savings plan through catch-up contributions. As your retirement age grows closer, it's important to take full advantage of being able to save more money.10
Regulatory Changes
With recent changes in the tax laws, some dentists may be able to write off an additional 20% of their taxable income after all of their deductions and before computing their income tax liability. Income that can be used to claim this 20% deduction is designated as "qualified business income." This type of income comes to the dentist if his or her practice is structured as a partnership. Some of the restrictions and limitations include disqualifying income levels, wage limits, and the inclusion of other income not defined as qualified business income. The complexity of this new change in the tax law is best navigated with a financial professional.
Adapt and Evolve
Retirement planning is an ongoing process. The strategy you adopt should evolve throughout your career and change based on your ability to contribute, your calculated needs, and the tax and regulatory environment within which you are planning. "Start planning as soon as possible. It's all about the time in the market, not timing the market," advises Margeas. The journey to retirement is a long one. The better the financial shape you get in now, the smoother your journey will be going forward.
References
1. Health Policy Institute. Supply and profile of dentists. American Dental Association Website. www.ada.org/en/science-research/health-policy-institute/data-center/supply-of-dentists. Updated January 2018. Accessed September 19, 2018.
2. Levin R. The 10th anniversary of the Dental Economics-Levin Group Annual Practice Research Report. Dental Economics Website. September 22, 2016. Accessed September 19, 2018.
3. Health Policy Institute. HPI: Average Dentist Retires Later. American Dental Association. Aug 20, 2018. Accessed September 19, 2018.
4. Health Resources and Services Administration. Health Professional Shortage Areas. U.S. Department of Health and Human Services website. https://bhw.hrsa.gov/shortage-designation/hpsas. Updated October 2016. Accessed September 19, 2018.
5. Munson B, Vujicic M. Supply of Full-Time Equivalent Dentists in the U.S. Expected to Increase Steadily. Health Policy Institute Research Brief. American Dental Association. July 2018. Available from: https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0718_1.pdf?la=en
6. Eklund SA, Bailit HL. Estimating the number of dentists needed in 2040. J Dent Educ. 2017;81(8):eS146-eS152.
7. Bell C. "Survey: Most Americans have financial regrets, particularly about saving." Bankrate Website. https://www.bankrate.com/finance/consumer-index/financial-security-charts-0516.aspx. May 17, 2016. Accessed September 19, 2018.
8. Chen W. Making plants to retire. Dental Abstracts. 2016;61(2):65-66.
9. Pride JR, and Hufford BC. Ready… set… retire. Dental Economics.  June 1, 2001. Accessed September 19, 2018.
10. LoPorto S. 6 tips for boomers preparing for retirement. American Dental Academy News Website. March 19, 2018. Accessed September 19, 2018.
11. Black D. Where is your retirement income going to come from? Dental Practice Management Website. http://practicemanagement.dentalproductsreport.com/node/33545?page=0,1  November 30, 2016. Accessed September 19, 2018.
12. McNeely TJ.Retirement planning beyond the 401(k) for the entrepreneurial dentist. Dental Economics Website. https://www.dentaleconomics.com/articles/print/volume-108/issue-3/money/retirement-planning-beyond-the-401-k-for-the-entrepreneurial-dentist.html. March 20, 2018. Accessed September 19, 2018.
13. Kaplan MR. "Tax savings with the hybrid retirement plan of the future--cash balance plans. Northwest Dent. 2014;93(1):37-8
14. DuPont G. Some thoughts on preparing for retirement. Dental Economics Website. https://www.dentaleconomics.com/articles/print/volume-107/issue-11/practice/how-dentists-can-begin-preparing-for-retirement-now.html. November 9, 2017. Accessed September 19, 2018.
15. Bryen B. How to transition your practice to an associate. Dental Practice Management Website. January 31, 2017. Accessed September 19, 2018.

What Do Your Clients Think?
When is the last time you parked in the parking lot in front of your office and looked around like a new, or old, client coming to your practice?  Try it.  Just sit in your car for a minute and look around.  Do you like what you see?  What image is it presenting to folks who don’t know what a great group of people are behind that front door?  Is your office really projecting the “value added” image you and your team think it is?
When you get out and walk into the office notice the entrance and the front door.  Is it welcoming, clean and functional?  I recently visited an office that looked nice from the parking lot but when I opened the front door the handle felt like it was going to fall off in my hand.  Little things mean a great deal when folks don’t know you.
What do you see when you open the door?  A welcoming space?  A smiling face?  The office I visited had the reception area positioned so that it caused a traffic jam as you walked in.  Inbound people were running into outbound people causing confusion if not HIPPA violations.  I had been told this doctor and team were caring and skilled but without prior knowledge I would have been less positive at this point.  
I was greeted warmly and confirmed my name and appointment time.  I was then handed an iPad with instructions to: “please follow the directions and fill in the forms”.  The funny thing is that I had filled out all the same forms on the doctor’s website the night before and sent them in as directed.  I decided not to make an issue of this and filled things out again (but I was not happy).  Then when I turned in my iPad, I was handed additional paper forms to read and sign – I had filled those out on line too.  By now the doctor’s skill and great staff were a bit tarnished in my view. 
I took a seat in the reception area, where the chairs were lined up with no room between them.  I was beginning to feel like I had come to visit a bus stop. People came and left and I waited.  I had arrived a bit early, but my appointed time brought nothing but a smile from the reception desk.  Finally, some forty minutes late the doctor came and escorted me to a treatment room.  He had multiple staff in the office talking to one another but not recognizing that I was present or that the doctor was running late.  It was nice to meet the doctor but it seemed odd that he was filling the staff roll.   He was knowledgeable, concerned and often interrupted by staff.  It was immediately clear that he was not managing his practice, it was managing him.   
Once we had established my issue he was focused and very skilled.  My treatment was quick and comfortable.  It was easy to understand why some people feel he is special and will put up with the rest of this dysfunctional office.  But, he could be so much more successful with so much less stress in his life.  Part of his problem is that he is working so hard to overcome the people and systems that are poorly designed or executed he does not have the energy to make positive change.  When I wrote the check to pay for my treatment I did not feel that I had a “value added” experience. 
This doctor may be special but much of what he surrounds himself with is not.  However, just fixing “systems” will never fix the problems in this office.  The core issue is the doctor and his philosophy.  All the so called “value added” items mentioned above will never change until the doctor realizes his behavior is what creates the atmosphere he is living with. Until he decides that he wants change and expresses it in his behavior, teaches his team about his new way of working and requires accountability, nothing significant will change.
What makes you special is much more that you.  It is owning and sharing a philosophy that is client centered.  Your philosophy will express itself in your level of accountability and the accountability of your team.  Where team members care about a loose door handle and are not afraid to address it. Where people don’t “need” treatment they choose outcomes that lead to better health.  You, doctor, must be accountable.  You must find team members who will live the philosophy and are experience accountable as well.  Then you can focus on the myriad of things and systems that demonstrate your care and concern for the whole person that sees the experience of your office as truly value added.
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A clear , concise and consistent message from team members demonstrates to your clients that there is good communication in the office.  Team members do not need to memorize a specific response for every office situation – that sounds fake.  However, areas where there is repetition should be shared and discussed with the team so same message is coming from everyone managing the issue.  This can be practiced in a team meeting by role playing the issues and coming to agreement on the best responses.
  Below is an article by Dr. Levin on scripting:

Having a documented scripting system creates consistency among team members and leads to a more comfortable, streamlined process to which your patients will respond by accepting treatment
.
Roger P. Levin, DDS, MBA

Having effective communication skills is necessary for you to have a successful practice in today`s competitive times. As we at The Levin Group have learned through over 12 years of consulting to more than 2,200 practices, your verbal skills can make the difference between high-level success and an average practice.
In our consulting programs, our clients document all verbal skills that are repeated more than once. Having a documented scripting system creates consistency among team members and leads to a more comfortable, streamlined process to which your patients will respond by accepting treatment.
Verbal skills or "how you say it" can simply skyrocket your case-acceptance rate and production while developing better patient relations. This article is based on a book I created, titled Management Scripts for Effective Communication with Patients. Remember, these scripts are a guideline for doctors, current staff and training new staff. After you have studied these scripts, you need to modify them to fit your comfort zone.
Script 1:
Greeting and guiding patients by phone
Customer service and the image of quality begin with you. A less than perfectly answered telephone demonstrates that the office is not ready to assist patients. The telephone is your lifeline. Whether it is a patient or the referring dentist of a new or current patient calling your office, it is essential that the conversation be handled in a professional manner that emits feelings of concern. Callers must perceive that your staff members care about solving their problems and taking care of their treatment needs, starting with the initial telephone call.
Many front-desk coordinators will ask new patients why they chose this particular office. Because many practices gain new patients from current patients, it is appropriate to ask and to learn this information so that you can thank the referring patient, which may encourage additional referrals.
Script 2:
Meeting and greeting patients in the office
When greeting current patients, you should be just as enthusiastic as if it were their first visit to your office. You want all patients to feel as if your office has opened especially for them. If the front-desk coordinator is busy with the telephone, checking out patients or other administrative details, it is likely that patients may not be properly greeted. Patients should be greeted by name. If you are the only person at the front desk and on the phone when patients arrive, nod to them and acknowledge their arrival. Ignoring a patient`s arrival evokes a negative impression.
This simple exchange, or some version of it, should be standard. Patients never get tired of being acknowledged or feeling that you care about them. Everyone likes to feel special. They tell other people about it, too.
Script 3:
Emergency patients in pain
Communicating with current patients who are experiencing an emergency situation is critical. This is the ultimate test. Whether real or imagined, these patients believe they have an immediate and serious emergency. You can use this situation to enhance a patient`s loyalty to the practice. You have the opportunity to perform productive treatment in most of these cases.
You will want to suggest a time that will not disrupt your schedule. It is unwise to ask the emergency patient, "What time will be good for you?" Emphasize your concern and your willingness to see patients at a time when the doctor can perform treatment for their painful problem. Always present the benefits to the patient.
Script 4:
Scheduling patients
All patients should be guided into appointments. The key to scheduling success is to appoint patients where you want them, but do it in a way that convinces them that you are trying your best to make it as convenient for them as possible. Convince the patient to schedule when you want them to by making it to their benefit. Successful scheduling also has much to do with having confidence, being assertive and having good verbal skills.
The scheduling coordinator should guide the patient into taking an appointment that works well with the practice`s schedule. There are many reasons for scheduling patients at particular times, such as coordination with lab pickup and block scheduling, but make it to their benefit to schedule the appointment when you would like them to schedule it. Managing patients is far easier when they feel that you are focused on them. It is best to give patients a few choices, but patients should not dictate your schedule - you should.
Script 5:
The hygiene pre-appointment system
At The Levin Group, we recommend that patients be pre-appointed for their next hygiene visit before they leave your office. This leads to increased productivity, recare efficiency and improved patient retention. Before implementing a recare system in your office, ensure that each staff member understands his/her importance and learns effective verbal skills for communicating this to patients.
When you tell patients the benefits to pre-appointment scheduling, they feel that the focus is on them and their needs and that they will get the appointment that they want. Also, you give them advance notice by sending the postcard and, if they have a scheduling conflict, they have plenty of time to call and reschedule. As patients return to your office, the pre-appointment system that you put in place will become natural and nearly every patient will be happy to schedule their next hygiene appointment.
Script 6:
Handling cancellations
Cancellations are a major problem for many practices. In the average schedule, one or two cancellations can make a profitable day unprofitable. The front-desk personnel have a challenging opportunity to reduce the number of cancellations when patients call to cancel. It must be handled diplomatically, but firmly. We train our patients to respect the office, but we must do this in a way that helps them feel that we are doing them a favor.
The previous script does not focus on concerns about filling time. Instead, it emphasizes that additional problems might result unless that appointment is kept. The front-desk coordinator reiterated the doctor`s concern and requested that patient be seen as soon as possible. Notice that the front-desk coordinator did not make it easy for the patient. She did not tell the patient that it was OK to miss the appointment. She did tell the patient that if the appointment was missed, it might be a while before another appointment could be scheduled.
Suddenly, we are creating a higher level perception of value and stimulating a greater need on the part of the patient for keeping that appointment. In many cases, the patient will call back and offer to rearrange his or her schedule to keep the appointment. The problem is that we have allowed patients to think that dental appointments are easy to change without any financial or physical penalty. If we convince patients that there may be additional damage to the teeth resulting in more expensive treatment, and they always assume that more work is synonymous with discomfort, we have an opportunity to encourage our patients to keep appointments.
Script 7:
Making a collection call
Collection calls are critical to your practice. While tact and courtesy are necessary, the ramifications of not collecting money within a reasonable time frame can be extremely detrimental. The doctor does not get paid nor receive late payments with interest. The patient may be turned over to collections and then follow through with a malpractice suit in retribution.
Collection calls must be transacted in a way that is firm but will not create an angry liability. Your objective is to persuade the patient to make payments, and a one-on-one telephone call is the best solution.
This first collection call should be pleasant and solicitous. The financial coordinator should make a note of when the check should have arrived in the office and make sure to follow up. If there is no follow-up and the payment does not arrive, the patient will assume that the overdue payment is negotiable. You must create a system in which the financial coordinator is aware if the check does not arrive when it should.
All members of the dental team must have accurate, consistent and sufficient knowledge and information of office policies and strategies, which are part of any management system. This way, your patients will feel confident that they are receiving the highest quality of care and will be more likely to accept treatment. By creating detailed scripts for your staff, everyone in the office will be able to communicate effectively and consistently with patients.
Most people coming into your office will be reluctant. No one truly enjoys coming to the dentist. However, your goal should be to make patients as comfortable as possible so that they have a pleasant experience when they visit your office. Scripts allow you to present yourself effectively and communicate with your patients so that they feel good about their decision to come to your practice and confident when accepting treatment.
*******
Script 1:
Front-desk coordinator: Thank you for calling Dr. Martin`s office. This is Jenny speaking. How may I help you?
Caller: Hi, my name is Ed Miller and I would like to make an appointment. I`m a new patient.
Front-desk coordinator: That`s wonderful, Mr. Miller. We love to see new patients. How did you find out about our practice?
Caller: My friend Kathy Olsen told me about the office. She really likes all of you.
Front-desk coordinator: Oh, Mrs. Olsen is great and we treat many of her family members and friends. Dr. Martin sees all new patients first and performs a comprehensive examination to evaluate your gums and teeth. He also will determine the best course of treatment for optimal oral health. What will work best for you, Thursday at 10 a.m. or Monday at 2 p.m.?
[Proceed to take all patient information.]
Script 2:
Front-desk coordinator: Hi, Mr. Roberts. It`s always a pleasure to see you. How are you today?
Current patient: I`m fine, thank you, Sally. How are you?
Front-desk coordinator: I`m great. By the way, Dr. Wilson is running on time, and we should be able to seat you at 2 o`clock. I knew you`d be pleased to hear that.
Current patient: Terrific. I have to get right back to the office.
Front-desk coordinator: Why not have a cup of coffee, enjoy one of our magazines, and relax until the doctor is ready?
Current patient: I will. Thank you.
Script 3:
Front-desk coordinator: Good morning. Thank you for calling Dr. Frank`s office. This is Joanne speaking. How may I help you?
Patient: Hi Joanne. This is Helen Miller. I have a really bad toothache, and I need something done now. It seems to be in the area where Dr. Frank has been working.
Front-desk coordinator: I am sorry to hear that you are so uncomfortable, Mrs. Miller. You know, it`s important to us to help any patient with an emergency as quickly as we can. Can you describe where you are having pain?
Patient: Yes. It`s on the upper right back tooth. I think that`s the area that Dr. Frank is treating.
Front-desk coordinator: I`m sure that Dr. Frank will want you to come in as soon as possible. We will be able to see you at 10 o`clock, and at that time Dr. Frank will be able to do something to make you more comfortable.
Patient: Thank you for getting me in right away. I`ll be at your office by 10 o`clock.
Script 4:
Scheduling coordinator: Mrs. Murray, Dr. Jones said that your appointment went very well today.
Patient: Yes, it did.
Scheduling coordinator: Dr. Jones asked me to schedule your next visit within the next two weeks. What will work better for you - Monday the 5th at 10 a.m. or Thursday the 8th at 2 p.m.?
Script 5
Hygienist: Mr. Fisherman, we`d like to reserve your six-month recare appointment now so that we may continue to monitor your periodontal maintenance. During this appointment, Dr. Cone also will be examining that bridge on the upper left to be sure that no problems exist. I know that you like early morning appointments, and I can schedule for 8 a.m. on Tuesday, June 14.
Just address this postcard and you will receive it two weeks before your appointment. In the meantime, here is my card - feel free to call me if you have any questions.
Patient: Well, I`m not really sure where I`ll be in six months.
Hygienist: I can certainly understand that you may not know your schedule, but I do know that you like early-morning appointments before going to work. They are very popular times and, if you do not pre-appoint now, I know that you will be disappointed to not get the time that you need. I will, however, send you that postcard two weeks before your scheduled appointment. Can you do me a favor?
Patient: Sure. (Normally, this will be the response.)
Hygienist: When you receive the card two weeks before your scheduled appointment, could you call me immediately, not the day before, to either confirm or reschedule so that we can work with your schedule? Otherwise, I would be worried that you would not get the time you need.
Patient: I guess I can do that.
Script 6:
Front-desk coordinator: Thank you for calling Dr. Wilson`s office. This is Janet speaking.
Patient: Hi Janet. This is Mrs. Roberts. I have an appointment tomorrow with Dr. Wilson at 2 p.m., but I won`t be able to make it.
Front-desk coordinator: Oh, that`s a shame! I know that Dr. Wilson was very concerned about that tooth and wanted to see you as soon as possible to avoid the chance of further damage. The problem is that if you are not able to keep your appointment tomorrow, it will be about six weeks before I can get you back into his appointment schedule. Is there any possible way for you to make it? It is important.
Patient: My boss just scheduled a meeting, and she needs me to be there.
Front-desk coordinator: Would you like to check to see if there
is any way to change the meeting
since it was just arranged? I just wouldn`t want to see any further damage in that area that could require additional treatment.
Patient: Let me check, and I`ll call you back.
Front-desk coordinator: Thank you. I`ll look forward to talking to you soon.
Patient: Yes. I`ll call you back in about half an hour.
Script 7:
Financial coordinator: Hi, Mr. Anderson. This is Jane from Dr. Lane`s office. How are you today?
Patient: Hello, Jane. I`m fine thank you.
The response is usually cool when a patient realizes that this is a collection call.
Financial coordinator: I`m certain that this is an oversight, but we have not received your payment for $275. I wanted to let you know this as soon as possible so that we can bring your account up-to-date. For your convenience, we can put that on a Visa or MasterCard.
Remain silent and let the patient speak next. This is sometimes difficult and uncomfortable, but silence in this situation is a very powerful tool.
Patient: I don`t want to put it on my credit card. Instead, I`ll send you a check this afternoon.
Financial coordinator: That will be fine. I`ll look for your check on Friday, Jan. 8. I appreciate you sending it right away and I`m sorry to bother you.
Patient: Oh, that`s OK. I just simply forgot.

 Doctor – Is it time to raise your fees again?
A number of sources recently have reported that dentists are experiencing increasing fee resistance.[1][2] A portion of our colleagues around the country are so insurance dependent that they essentially have no control over fees. While we may be looking changes in the model of dental practice as we move into the future, what can we do now to counteract the continued spiral of increasing fees for our patients and still be realistic about the necessity to raise fees?
We owe our patient the courtesy of explaining all the treatment options available to reach the patient’s desired outcomes and we owe them the courtesy of explaining the fees involved if they want us to use our care, skill and judgement in treatment.  In a fee for service world our fees are controlled by the perceived value we deliver to our clients.
We see far too many dentists working very hard, fearful of annually or semi-annually increasing fees and struggling financially.   Then they have to make a large fee increase to stay in business and wonder why they have fee resistance.  I am totally in favor of making a decent profit for the care, skill and judgement we deliver.  If we are going to stay in business we have to be profitable.  Increasing fees may not be the only solution, especially in an environment of increasing fee resistance.  Everyone is not covered by an insurance plan nor does everyone have money in the bank to cover expensive dental fees.
What can we do as providers to control costs (keep our fees reasonable) for our patients?  I challenge you to answer the following questions before you bump up your fees just because you can or because you feel you have to in order to pay your bills.
Write down your personal philosophy of care and share it with your team.
Determine your production per hour for the dentist and each hygiene team member.  Decide what you would prefer that number to be.  Share this with your team and discuss why it is, or is not possible.  This will be a learning experience for all involved.
Define your true overhead – take out all the doctor perks, superfluous expenses, items used for labor and lab fees.  Carefully evaluate your staff expense – are you getting a good return on your investment? Do you have a real team that is growing and learning?  Are you overpaying for supplies? Each of these questions may lead to other questions that need to be answered.  The goal is to find where dollars are slipping through the cracks.  The small things do matter.  If you can decrease overhead by three percent on a million dollar practice this is $30,000 in profit, five percent would be $50,000.  A good goal according to the Levin Group[3] is overhead of 60% or less.
Look at your schedule for the past three months with your team.  Discuss what things could have been done to make it less stressful, more efficient and more profitable. Do this when you do not have a time constraint as this will very likely lead to some heated discussion in several areas.  If the team decides to make changes put it in writing and do them in small steps with specific dates and times for the team to meet and discuss how things are going.  If this is a new concept to you consider looking into Mike Scott’s Total Accountability Training[4]
 Items every office should be doing:
Schedule in ten minute increments
Schedule in time blocks based on what you want to produce in that block.  Eg. Tuesdays 8 – 12 goal $3,000 – could be crown and bridge, endo, implants or a combination.  Do not fill the block with procedures that don’t meet goals (like urgent care, denture checks or small restorative) until the day before if it is not filled.  Build the production blocks around your doctor’s best work times.
Develop a true business plan – If this is unfamiliar ground talk to a consultant or your accountant for help. Put this in writing for 1yr, 3yr and 5yr increments.  Share this with your team members.
Provide true comprehensive exams, lifetime plans and financial options for every patient.  Learn to do this and train your team by doing this for your team and for yourself.
Provide comprehensive care not one tooth dentistry – go back to school and learn more about doing the parts of dentistry that you really enjoy.  Think about places like the Pankey Institute, Spear or Dawson.  Join a Seattle Study Club group in your area.
Cost is a values based idea.  Fine dining vs. Burger King.    What experience are you delivering in the mind of your patients?  What sort of patients are entering your practice?  What do new patients experience when they enter your practice?  What sort of patients do you want?  Are you willing to make the changes necessary to attract them?
We are training our dental students to think like their medical counterparts regarding fees.  Our new graduates want to demonstrate their skill by doing a procedure but are uncomfortable with the idea that they should have to have a relationship with the patient that will justify the fee that is involved.  This has a great deal to do with how our health care system and providers (doctors, hospitals and insurance companies) have separated the delivery of care from the associated cost of care.  From this thinking we get the concept that everyone is “entitled to care”.  No matter what you are told – there is no free lunch.  Someone is paying for services rendered.  The further you separate the provider from the fees the less impetus there is to control cost. And, the less likely that the relationship between provider and patient is one where the patient will take “ownership” of their responsibility for their own health.
We understand that increasing fees is a part of the business process necessary to remain profitable.  When we raise fees we believe in following the Collier Advisors model[5] of small regular increases that reflect the cost of doing business.  Before you set fees make sure you know your numbers, get your overhead under control, deliver the maximum possible value to your clients and be proud to discuss fees in an open and honest manner.  If you care more about your patients and delivering the highest standard of care you are capable of than you do about money – the money will come.
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[1] Roger Levin, Levingroup.com, Recent lectures, 2018

[2] Marko Vujicics, JADA, March 2018, Vol 149, 167-169

[3] Roger Levin, The Levin Grooup, Recent lectures, 2018

[4] Mike Scott, Total Accountability.com

[5] www.Collieradvisors.com

​What Makes You so Special?
If your office is stuck in a “one size fits all” process of bringing new clients into the practice, it is time to take a few minutes and watch some of David Arvin’s[1] videos on the customer experience on You Tube.  Our clients come in all ages, sizes and experience levels.  It is our obligation and opportunity to meet them where they are on an emotional intelligence level.  The moment your client understands that you recognize their individuality and are listening for their concerns, mental and emotional, doors begin to open.
Consider the different mindset of a sixty year old looking for a new dentist and a twenty five year old.  Both clients probably found you by asking friends about their dentist.  But, while the sixty year old will show up for an appointment and then determine whether they like your office, the twenty five year old will have made many judgements about you before coming in the office door. The sixty year old may not want to fill out office forms on line, while the twenty five year old will expect that as a given.  The twenty five year old will have checked your website and be looking for reviews on line.
 Both clients will judge the telephone skills of your staff, but in different ways.  Your older client may be slower to respond to questions and be pleased to speak about the person who referred them.. The younger client will be interested in whether you can text them with appointment reminders.  Both clients will respond well to your staff if the staff has the emotional intelligence skills to grasp the difference in the person involved and respond to that difference in the proper way.
As professional we all recognize that there is a significant amount of data that should be gathered with a new client to meet the professional standard of care whether at age sixty or twenty five.  However, the explanation and education of your client about why you need this information may be radically different.  You can only move forward with this process when you and the team have established a relationship that allows you to understand the outcomes the specific person is looking for in your office and you have asked for, and received, permission to move ahead.
 
 
What makes your office special is the ability of you and your team to ask the “right” questions that allow you to understand your different client’s perception’s and to then respond in an appropriate way.  The more you and you team work on developing these active listening and emotional intelligence skills the better your reputation will be in the community you serve.  This reputation is really your brand.  You don’t own it.  It is earned.  It exists only in the mind of your clients.
You and your team need to spend time together working on your “aspirational brand” – what you want to be known for.   You also need to agree as a team about key philosophical and technical elements that you will say no to.
You want to be recognized as the very best at whatever it is that you and your team aspire to.  That is what makes you special.
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1 Arvin, David, www.visibilityinternational.com, Customer Experience 

​Our Dental Care System is not Stuck ; it is Misdirected
The recent article by Dr. Marko Yujicic in the ADA Journal [1]suggests that dentistry is stuck with an outdated paradigm.  Our assessment is that educators and politicians are trying to push dentistry to follow the failing model of medical care delivery.    As a long term provider of care under a fee for service approach, I find his emphasis on moving dental care into the realm of the medical model unsuitable.  I agree with Dr. Vujicic that dental health is an essential element in overall good health.  I even agree in principle that covering preventive services under Medicaid/Medicare would be a good idea.  However, those of us who have tried to be good Samaritans and serve those on Medicaid have found the system is as badly broken as the VA system.  Our contention is that no one practicing comprehensive care can serve the Medicaid population, operate a business like office and make a profit under the current system. 
In the article we note the continued use of words that come from the medical model of care such as “what patients need” vs. what outcomes patients want and are willing to pay for.  The end users – patients – should be the final arbiter of what they need.  We, trained professionals, may understand what might be in the patient’s clinical best interest.  However, telling patients what they “need” does not lead to patient accountability or buy in. One key element in improving our care system is improving our dental education system to include training in the behavioral aspects of care and in emotional intelligence.  Patients with low dental IQ’s may make choices that we might deem not ideal.   However our role is not to “fix” people.  Our role is to help patients understand the outcome of those choices and most important help them understand that they own the outcome.  Then, and only then, we should strive to help them find an affordable path to care.
The value proposition, if we focus on outcomes based care, comes from patients choosing the outcomes that matter to them relative to cost of achieving those outcomes.    The profession should focus on trying to make sure that no one is denied care based on economics.  However, the profession should not and cannot be put in the position of providing care for those who are unwilling to be accountable for their own health.  In my area we address a portion of this problem with local dentists working together to provide care under the umbrella of a community wide free clinic.
Among my peers who are small town, middle America, outcomes based, fee for service providers, demand for paid care continues to be stable or on an uptrend while free clinic care is trending down. 
 There is no question that the impact of the insurance based medical model has caused us to need to spend more time to develop relationship based care and an understanding that all parties involved in the relationship must be accountable in order to achieve success.  For our elderly population that may mean forgoing discretionary restorative care so that available funds can be used for preventive services to prevent the need for further care.  Just because “it is covered by your insurance” does not guarantee that a procedure is in the patient’s long-term best interest.
True fee for service care is not based on the number of procedures completed.  That concept was developed by the insurance reimbursement model.  Fee for service care is based on reaching outcomes that the patient defines, and the patient and provider agree is achievable clinically and economically.
We do not agree with the article mentioned by Dr Vujicic by Porter and Lee[2] which treats healthcare as a risk management proposition.  We do agree with Dr. Vujicic that systematically measuring oral health outcomes in ways that are relevant  to patients is an important step needed to move away from a procedures based mentality prevalent in the profession today.  Provider reimbursement when insurance is involved should move away from counting surfaces restored and allow freedom for the patient to allocate their allotted benefit funds for the outcomes that best suit them.  Patients can be incentivized to be more proactive when they make choices that measurably improve their oral health (reduced decay rates, better periodontal health) and dis-incentivized when they fail to be accountable (not utilizing sealants, failing preventive care visits).
Dentistry is finally being recognized by the medical profession as a part of the family of the healing arts.  As such it is critical that dentists develop patient management systems and communication systems that make it easy for an interdisciplinary team to work together on the patient’s behalf.  Far too many dentists do not make the effort to develop relationships with their medical or specialist peers.
 Finding others with similar practice philosophy is a strong motivator to remain a continuous student throughout your career.  One easy and enjoyable way to do this is through quality CE providers such as the Pankey Institute and membership in some form of study club like the Seattle Study Club.  Every member of the office team should feel empowered to speak up and reach out to, and for, the best interest of the patient.
There is a segment of the population that, for numerous reasons, is not seeking or receiving dental care.  Our experience is that low dental IQ is more of a factor in not seeking care than economics.  Like Dr. Vujicic, we believe, our senior population would benefit from the inclusion of basic preventive services under the Medicare umbrella.  However, even if that entitlement is put in place it is not likely to be fully utilized.  Until individuals take ownership of their own health, no system of “free” benefits will resolve the matter of people making poor choices in health care.
The worst thing dentistry can do is to try to model future care based on medical practice.  The medical system is broken and has been moving the wrong way for a generation.  Medicine is now an industry that is controlled by insurance companies, hospitals, the government and large group practices.  The care delivery model in most medical offices and hospitals is little different than the process control utilized in the average manufacturing plant.  Until we move medicine into a model that recognizes the importance of defining what the patient sees as ideal health and holds them accountable, while working together, to meet those goals we will continue to over prescribe drugs, over order diagnostics and strive to “fix” patients because they “need” care. 
Practicing the profession of medicine or dentistry is not simple.  However, the core elements of delivering care in a manner that is patient centered and economically feasible have been well defined.  In John Torinus’ book “The Company That Solved Healthcare[3]” he outlines proven methods that work in our current environment and can be implemented with relative ease if we have the will to do so.  However, moving from the current model of medical care delivery will be difficult, if not impossible.  Politically we continue to move toward a system that teaches patients that they are “entitled” to care no matter what behaviors they exhibit. 
 
Nowhere in our system of care are we realistically addressing the epidemic of obesity, continued smoking, lack of exercise, excess use of drugs and sugar.  These are all elements that our patients can control if they choose to do so.  If we do not understand the behaviors our patients choose, how can we rationally expect to help them achieve the outcomes they express to us?
Moving to a single payers system will only exacerbate the situation; drive costs higher and penalize those who practice a healthy lifestyle. Would we agree to begin significant restorative treatment on a patient who continues to consume six Mountain Dew sodas a day?  Our medical colleagues feel pressured to provide treatment no matter what choices their patients make.  Thankfully, most dentists have the common sense and moral strength to say no in a situation like this.
 Dentistry should not be a “fix it” profession.  We are, or should be, driven to help patients determine what they want as an outcome for their oral health.  After thorough diagnosis and open discussion of the patient’s situation we can offer the means to achieve their goals.  We should understand and respect that economics will be a factor in people’s choices.  Only when we have mutual agreement about the patient’s desired outcomes, the means necessary to achieve them and the prices (time, money, effort, stress) involved should we consider moving on to treatment.[4]
Those in dentistry who are practicing outcomes based, patient centered fee for service care are not stuck.  They are thriving.  Those who see delivery of care as best provided under the corporate model or single payer system are not paying attention to the continued disintegration of relationship based care under our current medical model.  The forces of politics and economics are deeply embedded in the systems in place today.  It is unlikely that radical correction will take place any time soon.  Dentistry would be wise, especially at the level of our national associations and educational institutions to refuse to allow our medical colleagues to guide us into the morass of the current medical model.
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[1] Vujicic, Marko Phd, ADA Journal 201801.006

[2] Porter, Michael; Lee, Thomas; Harvard Business Review, I The Strategy the will Fix Healthcare,  Oct 2013

[3] Torinus, John Jr, The Company That Solved Healthcare, Benbella Books, 2010

[4] Roth, Sandy, Personal correspondence, 1994

Doctor You May Have a Target on Your Back
Lately the media has had a field day with the issue of sexual harassment in the workplace.  No one should deny that the issue should be addressed.  However, the media hype and sensationalism is overshadowing the right for the accused to be considered innocent until proven guilty.  This is a societal trend that is exposing some much larger themes all of us – especially those in the field of dentistry – should be paying attention to.
In their 1997 book “The Fourth Turning”[1] Howe and Strauss discuss in detail how and why the current era is, and will continue to be, a time of disruption and discontinuity.  While one may choose to disagree with their concept of the cyclic nature of history, we can clearly see evidence in society today that supports the idea that we are in a fourth turning period.  We see this expressed in terms of political upheaval, loss of civility in society and expression of suppressed anger among groups of people who self-identify as repressed.
Why is dentistry potentially in the cross hairs for sexual harassment claims?  Dentistry still has more male than female doctors, although the mix is changing.  Most dentists operate in solo offices employing a number of ancillary staff who are primarily female.  The profession of dentistry involves high intensity and physical intimacy with both patients and staff.  However, we should remember that sexual harassment can take place between members of the same or opposite sex.  Therefore, great care should be exercised to maintain professional relationships. It is critical that doctors and staff have training in, and practice the use of, Emotional Intelligence in all interactions with the office team and patients.   Often the doctor, patients and staff have long standing relationships that can lead to feeling that the group is really a large family structure rather than an employer/employee/ professional relationship.  When this relationship changes for some unknown reason the doctor/employer can be at risk for a claim of sexual harassment.
Our view is that it is only a matter of time for the “trickle-down effect” of the media hype to infect the profession with harassment claims.  If the claims are true and can be proven then the offender deserves punishment.  If the claims are unproven, however, and used to take retribution against someone they could easily ruin a dental practice.  Take action now to get the target off your back.
 Whether you are practicing in a metropolitan area or a small town the stigma of a TV crew pushing a microphone in your face or the face of one or your staff showing up on the evening news would severely damage your practice and your life.  Thoughtfully assess your management style and human resources practices.  Take action now that demonstrates you are accountable and hold your staff accountable to prevent sexual harassment in any form.
When did you last review and update your office policy manual?  Does it have a specific section on sexual harassment prevention?  A few states mandate sexual harassment prevention training but most do not. What other human resources practices might put you at risk?  How do you handle hiring and termination interviews?  Do you record them, with permission, or have a third person present?  Your employee files should be just as detailed and meticulous as your patient files.  And they should be in a secure location.  Take a look and confirm that you have clear and detailed information that is unbiased in the files that records and supports the actions you have taken.
Doctors, take the time now to participate in training your office in the prevention of sexual harassment.  Consider making the training part of your yearly mandated training just like updating your CPR program.  You can hire an outside firm to do this as a lunch and learn session or use one of the Power Point files that are available from numerous sources on the internet.  An example is noted below. [2] 
As our society continues to evolve and societal norms change, this and other behavioral issues will emerge as triggers of emotional frustration or opportunities to grow and mature.  Be accountable and help those around you understand that accountability will prevent the need for looking over your shoulder to see if there is a target on your back.
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[1] Howe and Strauss, the Forth Turning, Broadway Books, 1997

[2] https://www.nrcs.usda.gov/Internet/FSE_DOCUMENTS/nrcs142p2_007821.ppt

Your Technology Choices
My study club recently used the “To Scan or Not to Scan” video lecture by Dr. Paresh Shah as an evening program.  Early on, some folks were not sure it would be a worthwhile evening.  However, the program sparked extensive, and sometimes heated, discussion.  My comments are not intended to push in one direction or the other regarding scanning.   Rather, they are meant to help us see some of the elements in our decision making process that we may be unaware of that impact the choices we make.
Personality style impacts decision making.  Many of us in the profession adhere to the old saying, “better the enemy you know”.  Meaning, I know that the process I am doing meets the clinical standard of care and that is good enough.  Some might say that what I am doing may be “outdated” but I know how to do it and do it well.  I am comfortable with the process and my clients are not complaining.  Why should I change? 
Others enjoy trying different ways to achieve a clinical goal, especially if it involves learning a new technique.  Others may be interested in reaching the goal faster or with greater economy or patient comfort.
For those who are comfortable that their clinical process is delivering the highest standard of care that they are capable of there is probably no argument that can convince them to consider a change.  For the remaining group that would consider change there are some serious questions that should be answered before taking any action.
Vendors make profits for their stockholders by selling us “stuff”, much of which we do not need.  If we are considering a change, like moving to scanning for impressions, there are going to be serious costs involved.  The costs involve much more than dollars.  Let’s list a few things to consider.
Are you changing technique for the “Wow factor”?  If so, be very careful as the wow factor goes away very quickly in many cases.  A more critical question is whether the new technique helps you deliver care to your patients at the highest level you are capable of. 
Are you willing to make the investment of your very valuable time to learn the new technique to its fullest use in your practice?  This is a key reason why so many offices have lots of expensive “junk” sitting in a storage room.  Doctors get sold on the “Wow” and never make the time to learn to use the new equipment and incorporate it into their practice routine. 
Forget about how much the new gadget costs or is supposed to help you earn.  If you lack the commitment to learn to use it and train your staff to incorporate it into your practice you have thrown your dollars down a rat hole. 
Do the basic math on any significant purchase.  Take the vendor’s projections and then make them real using your own numbers.  If the claim is that you will save time on a procedure, what is that worth based on your specific hourly production?  What will you really do with the time saved?  How will your office schedule have to be changed to take advantage of the projected time saved?  Are there other potential savings you can take advantage of – like dental materials, reduction in appointments or less lab costs?  This is all “pie in the sky” if you are unwilling to commit to the work needed to learn to use your new toy and get your staff on board to make things work in a new and better way.
Vendors claim that you may be able to delegate tasks to staff that you have been performing with new systems and equipment freeing up more productive time.  Are you willing to take the time to train your team to do the tasks, and more important, are you willing to trust them to do the tasks?  Can you delegate in such a way that you still feel you are in good control of the final outcome and remain within the practice laws of your state?  One good way to test your thoughts is to determine whether what you are delegating can be remediated if it does not meet your standards.  If it can be remediated it is probably legal.
This is where the excuses start.  “I don’t have the time to do the training.  My staff is not capable of learning to use the equipment and systems. It is too expensive.”  If this is what you believe it is true!  No matter what your vendor sells you it will end up in the closet.  Know yourself before you spend the money.
Are you willing to do the homework to understand what new technology might improve your practice?  Are you willing to include your staff in the decision making process?  Are you willing to hold yourself and your team accountable to incorporate new process and equipment into your office?  Do you have the right people on your team that you can trust to make this work? Have you “run the numbers” based on the way you practice, and do they make sense to you?  If you can answer yes to all of the above there is a good chance that whatever you spend on new technology it will work for you to improve your life and enhance your patient’s experience.
To scan or not to scan is not about how much it costs or how much it saves.  It is all about your commitment, knowing yourself and your people and your philosophy.  For some – don’t waste your money.  For others – spend the money and enjoy the ride.
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Envy – Excuses are Not A Plan

I recently read a post from the Benevon[1] website discussing some of the reasons that non-profit board members just can’t seem to get engaged with the organization.  The excuses are many and varied but they all come down to a form of envy.  We are talking here about a form of envy that is not just “stuff oriented”.  Such as when we see the kid next door with a new skateboard or fancy bike and we want it, or want him not to have it.   That’s envy in its basic form.   I am talking about the envy we feel in dental school where we look for reasons why we did not get a perfect test score and our friend did.  In our professional lives we see others who seem to easily achieve success and find ourselves making excuses about why we can’t achieve the same thing.   What we often don’t realize is that it is easy to spend much of our day living with and talking about life from an envy point of view.  Here are several examples.

Let’s say you are at a study club meeting and see another doctor from across town.  You know she is practicing a high level of comprehensive care because she has shared some of her cases at your meetings.  It is very easy to say to your friends, “We just don’t have the luxury of her upper income clientele.  I don’t know where she finds clients willing to pay for multi-year cases.”

You attend a one day CE course and the speaker suggests that one good way to move your practice into a relationship based, values driven model is to take at least two weeks off.  One week would be spent going back to school to learn more about emotional intelligence and relationship development.  The second week would be spent with your spouse or significant other in a good location enjoying some time for self-reflection, planning and practice of the skills learned in week one.  It is very easy to say, “I don’t have time for that.  That is a big expense and too much time out of the office.”

You have a broken appointment and take a few minutes to look at one of the video clips on the SSC Facebook page.  The clip is talking about the value of a comprehensive exam and how your staff is a critical factor in developing relationships and trust.  You find yourself saying, “That is easy to talk about on a video but my staff is just not motivated.  We don’t have time to do all those steps.  Patients just want the minimum especially if it is not covered by insurance.”

You are looking at your quarterly reports from your practice management software and comparing your numbers to your last quarter, and to numbers in one of the myriad of dental publications.  You look at your hourly production compared to the national trends and don’t like what you see.  You say, “I can’t believe those numbers.  Those practices must be charging higher fees than we do.  I can’t imagine being able to squeeze in one more person in my day, and those Hygiene checks are a major interruption in my day. “
 
Do any of these sound familiar?  They should.  I have heard every one of these multiple times and many more interesting variations.   In fact I have used a few of these myself over the years.  These are just excuses for staying stuck in familiar unproductive patterns.

  Rather than allowing yourself to become distracted by envy and comparisons with others, consider the fact that until you choose to make your situation better it will not change.   Seattle Study Club members have demonstrated that you can practice comprehensive dentistry in just about any location and demographic if you are willing to take the steps necessary to achieve that goal.  Goal is the operative word.  You must be honest with yourself and those around you about your goals.  And you must be willing to make short term sacrifices that allow you to move obstacles out of your way. 

Getting out of the envy/excuse cycle is not easy.  Blaming others for your lack of success in any venture whether it is business or golf is much easier than owning up to the fact that you have not done the necessary homework for success.  Consider the following as an outline to get away from the envy/excuse cycle.  It is not easy but it definitely worth the time and effort.

Make some private time to look at the big picture of how you would really like your life to be – personal, professional and financial.  Think only about the outcomes you would like to see for you, your family and those who work with you. Don’t worry about how you will get there at this point.   Just let your mind get out of the envy and excuse cycle and dream good dreams.   Write down your thoughts and put them where you can see them daily.  Give yourself permission to make changes for one month.  You need absolute clarity of your personal philosophy, your practice philosophy and your goals for your finances long-term. This is the time to use a consultant if you are unsure of yourself.   By consultant I mean anything from a psychologist, life-coach, mastermind group, pastor or dental practice consultant.  You must be clear about the outcomes you want and honest with yourself about your commitment to reach your goals.  Money spent at this stage on clarifying the outcomes that you want will save you from wasting time and money later trying to “fix” things that are not fixable due to fundamental lack of clarity and commitment to a strong personal philosophy. 

Now share your thoughts with your family.  This will take guts because you are letting everyone see more deeply into your inner self.  You may need to modify some things based on family input.  Most likely you will be surprised by your family support and desire for common goals. Let everyone know that at this point these are your dreams.  You have no idea of all the steps that will be involved to make them reality.  What you are asking is whether your family and later, your team are willing to be a part of going where you would like to go personally and professionally.  You are not asking for excuses about why you cannot reach your dreams.  You are asking whether these members of your life are interested and willing to join you on a new path.  Again this will be difficult as you may get serious push back.  You are pointing out that life as you see it is not what it could be.  Members of your family and team will likely see change as disruptive and negative.  Understand that at the family level you may get input that causes you to modify your dream plan.  Only you can determine the level of changes that still allow you to reach your master goals.
 
  At the team level you will need to accept that there will be only two options – buy in or move out.  Again, this can be traumatic as what you might consider valued team members may be unwilling to move from their “safe” job position to accepting the challenge of change for the better.   Now is the time to give people a chance to buy in or out.  Don’t waste time trying to bring people along or implement change with a team that is not 100% committed to the practice goals. 

When you have your family on board and clear about the long-term goals and your team on board and clear about the practice, it is now time to begin the real work.  Sit down as a family and start to work out an action plan to get from where you want to be back to where you are.  That’s right - work backward.  Look at the obstacles at the end of the road and start breaking them down into smaller and smaller pieces.  You will be surprised many of the things you thing are big problems are not problems at all.  They are simply excuses that must be let go.  When you have defined all the obstacles you have created an action plan to move toward success.  Now and only now, should you begin the same process with your team.

Once you have your family supporting you and a plan in place your team will sense your commitment and comfort with the goals for your professional life.  Get the team together and reaffirm your long-term goals, your willingness to be accountable and your commitment to success for every member of the team.  Start the action plan process with reaffirming the big goals and begin breaking down the big problems into little pieces.  This is the first point in the process that you should consider making any physical changes in the practice other than determining if there are team members who do not want to be “on the bus going to the new destination”. 
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At this point you should have a course charted for you and your family and a course charted for your professional life.  Count on the fact that many course corrections will be required.  However, you now have a plan, a family who is part of the plan and a team that knows you are committed to success for the whole office. Let go of the envy and excuses and enjoy working and living with a plan.
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[1] www.benevon.com/ 

Where Are My New Years’ Resolutions?
How is your resolution list looking?  Mine is on my desk where I can see it every day.  In fact it is right next to my smart phone and my computer screen.  Those two items are wonderful tools that allow procrastination to sneak in and try to screw up my life.  Psychologists see procrastination as a kind of avoidance behavior, a coping mechanism gone awry, in which we “give in to feel good”  According to Timothy Pschyl[1] often this behavior is due to fear or anxiety about the important task awaiting us.  Then procrastination kicks in and we engage in some activity that feels good, then we feel guilty about not getting our real task done and look for another activity to make us feel good. 
This negative feedback cycle is enhanced by the incredible technology that we have at our fingertips.  In his recent book “Thank You for Being Late” Thomas Friedman[2] outlines the societal changes he has seen around the world since the advent of the smart phone and internet have become ubiquitous.  Picture this.  You sit down to review your office P&L.  While your computer boots up you check on your Facebook account, stream some music and text your wife about dinner plans.  Suddenly an hour is gone and your P&L is still waiting.  We have allowed the age of instant gratification to subvert our attention from something of lasting importance.   Now we leave the office for dinner feeling guilty about what we did not get done. 
Procrastination does not make us a “bad” person but it does waste precious time that could be used for more viable long-term goals.   We cannot tell ourselves or others to just stop procrastinating as it is so tied into our deeper psychological issues about gratification, fear of failure and our sense of lack of control of our lives.  However, we can recognize procrastination for what it is and forgive ourselves when we realize we have been giving in to the behavior.  Next we can recognize that we can overcome procrastination by following the NIKE phrase “ Just  do it” – whether we feel like it or not.  Accept that we may not feel like it but if the task is there get started on it. Once we get engaged in the task we usually find it is not so bad after all and we feel good when we get it done.  Follow the old African proverb about how to eat an elephant – one small bite at a time.
When we see ourselves, or others, as having a time management problem, we might want to consider the idea that what we are dealing with is an emotion management problem.   This leads us back to Friedman’s book.  We now have a generation that has grown up in an instant gratification world.  It is imperative that we learn about critical thinking and emotional intelligence and teach these concepts to our children.  Everything we do does not bring instant gratification.  Sometimes we just have to get on with tasks even if we don’t feel like it.  Procrastinators are dreamers.  They will tell you about the wonderful dental practice they will build one day.  Yet they will not do, or train their team in, the basic steps of a true comprehensive exam.  Change is hard, but it is easier when we give ourselves permission to recognize our fears and take small steps to move to a better future.  This leads to the issue of accountability.  Until we learn to manage procrastination it is very hard to hold ourselves or others accountable. Check out Totally Acciountable.com.


 
Visualizing our decisions using the Eisenhower Matrix as described in Covey’s “Seven Habits of Highly Effective People[3] will help us keep moving in a good direction.  When we review our daily “To Do “ list and assess where the items fall in the matrix we are less likely to let our emotions prevent us from getting to work on what needs to be done.  Equally important we prevent, as much as possible, spending time in quadrants 3 and 4 and work on things in quadrants 1 and 2.

I am absolutely certain that the “procrastination bug” will bite me frequently.  However, I have rewritten my New Years’ resolutions onto a sheet with the Eisenhower Matrix – along with a few other “to do’s” .  Even on days when I would really rather do something else the matrix is keeping me on task and helping me feel better and more free of guilt when I walk out of the office at the end of the day.  Here’s hoping you make time to rewrite your resolutions and end up feeling better at the end of your day.
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[1] Pychyl, T., Procrastination Research Group, Carlton Univ., Ottawa, CN

[2] Friedman, T., Thank You For Being Late, 11/2016, Farrar, Strauss & Giroux

[3] Covey , S., Seven Habits of Highly Effective People, Stephen Covey.com

​What Do You Think?  - Confirming Communication and Accountability
A recent experience working with a boat yard in another state brought to light the difficulty of establishing two way communication, mutual understanding and accountability.  When we discover a disappointed client or unhappy staff person take a moment to reaffirm that you are truly in communication with the person involved.  Too often we falsely assume that we have open lines of communication.  We make statements or requests and assume that the other party involved grasps our understanding of an issue because they say “OK” or because they don’t question our ideas.  Only later when one or both parties are unhappy with the outcome do we discover that both parties idea of a good outcome have been left unmet.  Here are a few pointers we learned in our recent boating experience that can be immediately applied in your office and daily life.
 We purchased a boat in Maryland in July and had it stored at a nearby boatyard where we were referred.  We created a list of some work to be done on the boat in preparation for taking it to Florida via the Atlantic Intercostal Waterway in late October. Over the course of the summer we had numerous conversations with the yard as well as email conversations about the projects and the timing of our arrival to pick up the boat.  However, when we arrived we were disappointed to find all the projects were not complete.  We found the workmanship at the yard was excellent but there was apparently no master plan expressed to the staff about when our projects were to be completed.  And, there was not sense of accountability on the part of the yard manager.
Just because you are talking does not mean you are communicating.  Communication requires a speaker and a listener.  In order to understand the speaker the listener should be asking the speaker questions.  If you are discussing a project as the speaker and the listener responds “OK” with no questions, that should be a red warning flag.  If you don’t get any questions someone is not listening.  Stop and ask the listener “What do you think?”  If they don’t have any comments or questions they have not been listening.   Either they are not focused on your project or they think they know what you want.  Require that the listener describe to you what they believe you want as the final outcome of the project before agreeing to move ahead.  Especially with staff, do not assume “they know what I want”.   With clients ask them to describe what they think the final outcome will feel like or look like and listen closely for signs they might be expecting more than you can deliver.
 
 
If you are working on longer term projects with multiple steps demand a written estimate with a completion date.  Unwillingness to provide these items means either the provider does not have the experience to know timing or costs or is unwilling to be held accountable.  We should have put a hold on our projects when an estimate was not forthcoming.  However, we were lulled into a false sense of confidence because the yard has a reputation of doing very high quality work.   As a provider, don’t let a referred client lull you into promising more that you might be capable of delivering.  Follow the old saying, “Under promise and over deliver”.  And, “get it in writing”.  Provide clients with multi-step cases a written timeline and cost estimate even if they say they don’t need it.  These steps help both parties be accountable.
Be accountable and demand accountability.  Our experience with the yard started well and ended with disappointment.  When we felt things were going downhill we should have followed Mike Scott’s rule of accountability. ACCOUNTABILITY: Doing what you said you would do, as you said you would do it, when you said you would do it- PERIOD![1]  We did not demand accountability as we felt we had several months for projects to get done.  When the first completion date was missed we should have had a conference call with the yard manager and the yard owner to determine what was going on.  In your office if you have a case that will be late don’t delegate the phone call to your client.  Do it yourself.  Apologize for the delay and ask if there is anything you can do to help out until you can move to completion. Usually clients understand.  Your willingness to reach out and help can reduce frustration for your client.
Provide constructive feedback and be a good listener.  In our case we were frustrated that we had to wait to leave on our planned trip.  Rather than get angry we decided to get things done right and move on.  However, after getting past the emotional aspects of the matter we took time to write the owner a letter explaining our disappointment.  We did not just complain.  Rather we pointed out where we felt there was poor communication or accountability and the steps that could prevent that in the future.  In the office, rather than grumbling at a staff person when you don’t get the result you thought you asked for, ask a clarifying question.  “Can you tell me why we are doing _______?”  You might not want to hear the answer but it will clarify the level of communication going on in the office.  When you have an unhappy client, put your emotions on the back burner and thank the person for their willingness to express how they feel.  You may feel their concerns are not justifies but their feedback provides insight about how others see you and your operation.  Don’t be in a hurry to do anything but listen.  Often that is all the person is looking for.  Once you demonstrate that you are really listening emotions tend to calm and rational discussion can begin to take place.  You may not be able to solve the issues of all who complain but when you convince them that you honestly listened they are less likely to bad mouth you to their friends.
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[1] Mike Scott and Associates, Quotes to live by, Totally Accountalbe.com

​Last week I met a doctor from New York State who sold his practice in January.  He stated that finding a buyer had been very difficult.  He tried marketing the practice on his own with no success and finally ended up using a practice broker.  In the end he had to discount his sale price and carry a portion of the debt for three years.  Much as we do not like to admit it, this is the current trend in practice sales in much of the country as discussed in a white paper by Charles Blair[1].  Although he is no longer an owner he has concerns about the practice viability as he is at risk for a portion of the debt.  He has a good relationship with the new owner and is trying to maintain a mentor relationship with him. He has noticed that the accounts receivable has moved up significantly since the sale and asked for ideas about how to address the matter.
We believe that there are probably several issues that need to be addressed – 1. The new doctor fears rejection. 2. Staff not 100% committed to new provider’s success. 3. Accountability issues.
A new provider has two issues to address even when they have been introduced to the client base and have a reasonable level of experience.  The new provider subconsciously does not want to be rejected when treatment is proposed.  Even though this feeling is unspoken clients may feel it.  This may lead to a lack of clarity about treatment proposed or fees involved.  When this happens staff will sense the change and be less assertive in setting up treatment and fee arrangements.  The new provider and old provider will naturally have different styles and differing trust levels with clients.  In some cases it may take several years before clients trust grows to the prior level.  In some cases clients will depart. The key to managing this aspect goes back to the principles expressed by Sandy Roth of ProSynergy[2].  Before any treatment takes place:  All parties must be clear about the outcomes desired,  All parties must agree on the means to achieve the outcomes,  All parties must agree on the prices involved. The doctor and every team member must use this model exclusively in discussing treatment of any sort with clients.  This is not a script it is a philosophy.  Dentistry is optional and the patient is the final authority on whether to move forward with treatment or not.
The team must be 100% committed to the success of the practice.  The practice is their reason for existence.  No practice equals no job.   The team must be committed to helping deliver the highest standard of health care that they are capable of and supporting one another in that goal.  As the new team leader the doctor must address this issue openly.  In a practice transition there will be a period of chaos where some staff yearn for the “old ways”, fear new leadership and test the boundaries of accepted behavior. 
The new provider would be wise to set aside several hours for a mandatory team meeting to review and clarify the philosophy of the practice and set goals and objectives that the team can agree on.  If that is not part of the skill set of the provider, bringing in a consultant would be money well spent. Rest assured that a practice transition where there are staff mergers and/or a new provider moving into an office with long-term staff there will be emotional turmoil.  Staff turnover may be necessary to develop a loyal team.  The only way to address this is to meet the issue head on and allow open and honest discussion.  Triangulation, back room talk or negative attitudes cannot be tolerated.
The new provider must demonstrate that he/she is accountable and require accountability from every member of the team. Mike Scott[3] has some excellent material on this topic on his website and is an excellent lecturer and consultant in this area. The doctor must demonstrate absolute accountability as the team leader.  Only then is it possible to expect accountability from the team.  Team members who are not accountable must go.  Everyone in the office team knows who the “bad apples” are.  Eliminating these bad influencers improves moral and frees up significant time and energy that was being wasted on gossip and excuses that can now be used to address A/R issues.  Carefully developing trust through the Outcomes, Means, Prices model, clarifying philosophy, goals and objectives and creating an atmosphere of accountability should move the accounts receivable in the proper direction.
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[1] Blair, Charles, Eight Game changers in Dentistry, White Paper, Charles Blair.com

[2] Roth, Sandy, Personal Communication, Prosynergy.com
 

[3] Scott, Mike, Lecture Material, Totally Accountable.com