Here are four letters that should be immensely important in the vocabulary of a dentist, MBWA, a management principle that I think more dentists need to understand. Tom Peters was a popular management guru in the 1980’s. His first book, “In Search of Excellence”, sold over 3 million copies in its first four years of publication. One of the most important points from Tom Peter’s musing was a principle of supervision. He calls it, “Managing by wandering around”. Managing by wandering around is just what it sounds like, when you don’t have a patient or when you are between patients, walk around the office and see what’s going on. Don’t park yourself in your private office. I never put a private office into any of my practices. If you look at most dentist’s offices they are junk collections of wasted space that only serve as a diversion to good management. I’m always amazed at the number of dentists who retreat to their offices in their free time and play with their cell phones when they should be seeing what’s going on around their business. MBWA isn’t spying and you have to be sure that it isn’t construed as such by your employees. You need to circulate around, observe what is happening, and pitch in to help if you can. You’ll get a feeling for how phone calls are handled, you’ll hear financial arrangements being made and you’ll be able to observe how the front desk greets the patients coming in the door. MBWA is a valuable instrument in your management tool bag.

The next principle is to engage your employees. I always pack a bag lunch and eat with my staff. It’s less expensive than going out, it can be more healthy and most of all, it allows you to meet with your employees in a friendly neutral environment. You’ll find out things about your employees that you never would have if you locked yourself in your office. It makes you more approachable and more human, and thus you are on your way to developing a better team and becoming a better leader.

Finally, respect your employees. I believe that you shouldn’t ask anyone to do a job that you wouldn’t, or haven’t, done yourself. You don’t want your employees to think that you believe it is beneath you to do certain tasks. If a dirty job needs to be done and you’re not with a patient, then start it yourself, ask for some help and turn it over to someone else as the task progresses. One time we had a water line leak in the roof on a Sunday. I went into the office to get some papers that I needed and found the ceiling tiles lying in 2 inches of water. I started cleaning up, I called my office manager and she came by, she called some other employees and we had it cleaned up and ready for the next day in three hours. Now that’s a team! If I didn’t respect them, they wouldn’t have had any motivation to come in and help on that Sunday afternoon.

It takes a strong team to run a good dental office; it takes good management to direct that team and it take a good leader to build that team. Do these three simple things and start enjoying a better, more stress free dental office.

My daughter and son in law recently bought a new business. As part of their financing package they got a loan from the Small Business Administration. They were, of course, required to submit a business plan, (as an aside, do you have a business plan? Did you write one when you purchased your practice? I will address business plans in a future article). I’ve written business plans, I teach students how to write business plans, but there was one section that I hadn’t thought of before. The SBA required them to write an exit strategy for their business. I began to think how valuable this is, and how it could help dentists in planning for their future.

Have you ever thought about how you will leave your practice? You’ve probably had conversations with yourself in your mind. You’ve probably thought about how you will sell to an associate and train them to continue your practice. It’s easy to mull these topics over subconsciously, but in doing so we miss the details necessary to complete the task properly. Verbalizing your plan to a spouse or friend, or even better yet, writing down your plan makes it more concrete. It becomes a promise that you have made. You are more likely to carry out a verbalized “wish” than one that was mentally contemplated. So what is an exit plan or strategy? It’s a plan detailing what will happen to your business in the case of your death, disability or more likely, how you will structure the succession of your office from one generation to the next.

Many of you might have a buy sell agreement with a partner. Often funded by insurance, it’s a plan for allowing the purchase of the practice by one partner in the event of the death or disability of another partner. They are popular and your lawyer can help you structure this type of an exit strategy. But what if you are the sole owner; does anyone know what to do with your practice if you can’t be there anymore? I have seen practices sit for months, being attended to the best they can be by volunteers, other area doctors and relatives while the value of the practice decreased daily.

It’s far more likely that you will practice successfully in your practice for 30-40 years and then sell it to another dentist. Have you thought about how that will happen? I remember when I was looking for association opportunities. Doctors would take me to lunch and mumble some vague sentences about buying them out eventually. I see many disappointments, partnerships broken apart and associateships ended because of the vague expectations of each side. The owner doctor expects too much, the younger doctor thinks they have received too little. Sit down at your kitchen table and begin to construct a procedure. Think about what has to happen to accomplish your “transition”. Get some structure on paper. Then discuss it with other people. It doesn’t have to be a secret, everyone is allowed to retire or change their careers if they so desire.

Most practice brokers are experienced in transitions. They make a living by selling practices and so they have unique insight into the problems of transition. Many of them give courses addressing just that topic. Take a class early in your career on practice transitions and think carefully about what will happen. Then go home and write down on paper, as part of your business plan, how you will exit your practice and when that will commence. Even if the anticipated strategy doesn’t materialize as you planned, you had given it some thought. Doing something is always better than doing nothing. When playing tennis we see the person receiving the serve jump up in the air just as the serve is struck. They don’t usually jump in the correct direction of the serve, but the fact that they are moving makes them more likely to successfully return it. This analogy applies to your practice. Make an exit strategy and consider it a living document, revisit it periodically during your career.

Having an exit strategy can make the process of managing changes in your practice easier. Make sure that you think about where you are going. Remember what Stephen Covey said in his book, The Seven Habits of Highly Effective People, “Begin with the end in mind”. If you don’t know where you want to end up, how can you plan out a route to get there?

I have a dentist friend who is retiring soon. You might say to yourself, “Good for him, after working 30 or 40 years he deserves to enjoy life and the fruit of his labors.” Now, what if I told you that this dentist was 39 years old and had practiced for only 12 years? You might think that this dentist was just reaching his prime and still has a lot of his life yet to live. How can he finance the remaining 50 or 60 years of his life? Why is this dentist retiring? One word says it all, burnout. At 39 years old with only 12 years of practice under his belt, he was tired of dentistry and wanted to get out. What caused the burnout? Micromanagement was the culprit.

Dentists are prime candidates to be micromanagers, they are particular and they work with specifications and tolerances that require precision. They know that even small errors can cause failure of the case. Therefore, to keep failures to a minimum and make sure things run smoothly, they micromanage. This particular dentist entered all the treatment plans in the computer himself, he double checked all of the outgoing insurance forms and submitted them at the end of the day. In addition, he discussed all the fee arrangements with the patients. He used an assistant but not four handed, the assistant mixed materials, seated the patients and cleaned the room. No one made a decision or completed a task that wasn’t reviewed by the dentist. I think that it started out innocuously, the dentist shared a task, it was done wrong and so he took it over, then another task had problems and the dentist did that one also. Instead of taking the time to address the problem and correct the system, the dentist did it himself. It’s a slippery slope and before he knew it, he was doing almost everything alone. He prevented errors but stifled creativity and burned himself out. Avoid micromanagement by allowing yourself these three freedoms; spread the load, share the wealth and enjoy the feast.

Spread the load; not only does this ease the burden on you, but it affords you more flexibility and broadens your perspective. I took a management course in an MBA class. One of the requirements was a day long, outdoor, problem-solving retreat. Throughout the day we were required to solve problems with our group. By the end of the day I had learned the power of the team. Five brains are better than one; recollect Aesop’s fable about the bundle of sticks and the single twig. As a team, our problems are solved more creatively, they are solved faster and the solutions are better than those that are fashioned alone.

Share the wealth; how can you expect people to perform for you and care about what they do if you don’t reward them? Give a person a task to do, let them know what you expect from them, pay them properly and enjoy the freedom that giving away a task gives you. That doesn’t necessarily mean that you totally abandon overseeing the project or task. You can check periodically for waypoint goals or have the employee give you periodic reports. A good manager, (and remember that a manager is different from a leader, they are two different roles), keeps tabs on their people, but she doesn’t run them. Some dentists like incentive programs for performance. I’m not a fan of them; I think that if improperly done they cause back biting and they undermine teamwork, however, some managers use them very effectively.

Enjoy the feast; the result of your parting with the total responsibilities of your office will be a longer more stress free career. Dentistry is a very demanding occupation, we are dealing with people, they are anxious and we are asking them to give us money for our services. When you share the pressure with your employees you will be free to do more of the things that you enjoy. For many dentists that means doing dentistry. The comment that I hear from dentists continually is, “I enjoy doing the dentistry, I dislike dealing with the problems.”

Look at yourself realistically, gaze deeply into the mirror and ask yourself if you think that you can do a task better than your employees. If you say yes, then try to resist the urge to be a micromanager, just as a spouse can help you deal with problems in life, a good office team, who is empowered to solve problems, can take the weight of the practice off of your shoulders. Enjoy the three freedoms and appreciate your life.

Do you remember when you were in junior high school? The teacher had given an exam and you did quite well on it, but some of your other classmates didn’t do so well. The teacher scolded all of you and you thought, “Why are you yelling at me? I did well.” This column is somewhat like that. So if you read it halfway through and think, “This doesn’t apply to me”, then stop reading, skip to the next page and be happy that you’re not one of the minority that I’m talking about. This column is aimed at that 2%-3% of the dentists who care more about the money they can make in dentistry than the well being of their patients.

What stimulated this article is a call I had last week from a recent graduate of the dental school. She has been in her new association for about two or three months now. She was distress by a discussion that she had with the owner/doctor that morning. It seems that she saw a patient last week who was scheduled for root canal therapy. After she seated the patient, she reviewed the diagnosis, as would any conscientious doctor. The decay was deep, but the tooth was asymptomatic, it tested normal with ice, there was no tenderness or swelling over the apex and no sensitivity to percussion. The patient’s caries risk was moderate because of the length of time between check up appointments but there were very few restorations in this patient’s mouth. She numbed her patient and cleaned out the decay. There was no exposure and so she placed a liner and restored the tooth. The owner/doctor was upset because she didn’t do the root canal. “What’s going on? We had a signed treatment plan. Don’t you need the money?” was his complaint. The conversation continued on to her lack of production. The owner/doctor said that he expected her to be able to see at least 40 patients per day, including the hygiene checks. In addition, the owner said that she should be able to file, fill and core a molar endo in 1 hour. I’ve been in practice now for 33 years and I can’t do a molar endo in an hour, let alone be able to core it also. The associate doctor went on to tell me how other associate doctors in this practice told her that they heated up endo files, pushed them into the gutta percha, cut them off to length and called that their post. She should do the same, they said, “it’s fast and it works, the patient will never know the difference.” She told me about another patient that she had seen for a toothache with an endodontically treated tooth that had been “filled” 8 millimeters short. The root canal therapy had been done in that office and now she had to deal with the results of a poorly done procedure. She was obviously distressed and didn’t know what to do. We had a long discussion.

I was furious when I got off the phone. How can a doctor treat his patients that way? Are they merely objects available for him to use for profit? What is he going to do in 5-10 years when all of those inadequately treated patients return? How does he sleep at night? I hope that my long discussion with the associate reassured her that there are many moral and ethical doctors out there who would never think about doing such things. I know that these doctors represent a minority, but it insults and infuriates me to hear these reports. With the economy the way it is and the difficulty people have paying their bills, there is a lot of pressure to produce more and collect more. But as trusted healthcare professionals we have a moral and ethical responsibility to our patients to be altruistic when it comes to treatment. We are required to do what is best and to leave our financial well being out of the equation.

As I write this I am thinking that maybe this column isn’t aimed at the 3% of the dentists out there who are unethical. We probably can’t change them. Let me instead dedicate this article to the new graduates struggling to form their ethical and moral standards in dentistry. Be strong; uphold what you know to be correct. Most dentists out there are doing good, honest, principled dentistry. When you find yourselves in a position like this associate did, don’t compromise. Look for a new position and keep your standards high.

This is a short paragraph that I wrote a few years back after a discussion with a hygienist about some calculus that she had found on a patient. The radiographs from the previous maintenance appointment showed calculus in the same area. The hygienist was complaining to me that her colleague wasn’t doing her job properly. After she presented her argument to me, I asked, “wouldn’t it be logical to believe that a patient builds up calculus in the same areas between each appointment? It could be either because of poor hygiene, anatomical variables or structural differences in the patient mouth.” “Isn’t it possible that the previous hygienist saw the calculus, cleaned it off and it formed in the same spot between then and now?” She admitted that “yes that was a possibility.” It got me thinking about the many barriers that we put up that impede teamwork and cooperation, and so I wrote this ideology.

The foundation of the team is laid in trust. Not only must you trust your teammates to do their job correctly, but you must trust them to stand by you and support you at all times. If a hygienist finds a ledge of calculus, or a doctor finds an open contact, the assumption by the person finding the mistake has to be that it was initially done by the other teammate to the best of their ability and the best as could be achieved on that patient at that time. That is to say that we trust our teammates to always do their best and in return they trust us to support them. This trust then allows us to maintain an open discussion of techniques, treatments and research to use as a basis for evidence based treatment options for our patients. We should be able to disagree with one another and not have our feelings hurt or feel rejected. This principle has to be grounded in a mature adult relationship within the team. We aren’t a group of gossiping waitresses, fragile ego-centric junior high schoolers or immature children. We are professionals. The term professional means a highly educated person, who enjoys considerable work autonomy, a comfortable salary, and who is usually involved in a creative and intellectually challenging occupation. Because of the personal and confidential nature of most professional services and the necessity to place a great deal of trust in them, most professionals are held to higher standards.

Running dental office is very much like conducting an orchestra. Talgam, a conductor turned business consultant, talks about that process. He reminds us that like all types of leadership, it’s not about the conductor. I’ve said this before in my article, “Leadership, What Isn’t It?” He begins with Carlos Kleiber, considered by some to be one of the greatest conductors of all time. Watch him as he conducts the New Year’s Eve Concert of the Berlin Philharmonic, if you follow classical music you have heard this music many times before, but to watch Kleiber conduct it is a joy. Talgam says of Kleiber,” [A conductor's] happiness does not come from only his own story and his joy of the music. The joy is about enabling other people’s stories to be heard at the same time.” Leadership doesn’t direct, it conducts. Talgam says it well when he reminds us that when it is done well, it’s a freedom. “The forces of the process itself keep everyone in place.” What a concept, leadership so well done that it needs to be merely conducted, not ordered, and the flow of the process provides the direction to the players involved allowing the process to be completed with great satisfaction for all involved. With leadership like this, the conductor not only creates the process but also creates the conditions in which the process takes place. Then she allows it to occur. Can you imagine the empowerment that this type of leadership gives to people and how satisfying their jobs can be? Can you imagine the level of service that they can deliver and the cooperative power of all of the employees brains working together as a whole?

Talgam also illustrates some examples of other types of leaders. Riccardo Muti for example, his is a more dictatorial style. There is no room left for creative interpretation on the part of the orchestra. He is more of a director than a conductor. He was voted out of his conducting position by his own orchestra in 2005. People want to be appreciated for what their contribution to the process can be. If you don’t let them there will be unrest and underachievement.

The next conductor featured is Herbert von Karajan, of the Berlin Philharmonic. His is an example of a conductor who doesn’t “lead”, he “suggests”. A body of people needs more than suggestion to operate as a whole and as I suggest in my article, “The Longing for Leadership”, people want to be led. However that leadership has to walk the fine line between being dictatorial and being laissez-faire. As Talgam suggests, the authority needs to be there when it’s needed. Talgam maintains that control doesn’t have to be a zero sum game.

The video finishes with a remarkable piece showing Leonard Bernstein “conducting without conducting”. Talgam calls it, “getting to the point of doing it without doing it.” Bernstein conducts via minor body movements and facial gestures, the orchestra knows that he is in control; they know what he wants and look to those subtle movements to give them direction.

Take the twenty minutes to watch this video and then reflect on your own style. Think about how you could move towards this place of “leading without leading.” It can be done and the results can be remarkable.

I’ve owned my own practice; I’ve worked in three or four others and, because of my position teaching practice management at the University of Detroit Mercy, I have the opportunity to talk to a lot of dentists about the products and supplies that they use. How do you decide what products to use? I’ve observed that there seems to be three different methods that dentists employ to select products to use in their practice; advertising, “common sense” and evidence based.

As dentists we are greatly influenced by advertising. We get it in our journals, it is pitched to us by our salesman and we get it, often unconsciously, at continuing education classes. How many times have you come back from a class and purchased supplies recommended to you by the person giving the class? How many times did you continue to use them? I know that in my case I had a cupboard full of materials and supplies that I purchased and either didn’t use or found to be inadequate. I’ve worked in offices where the owner gleaned samples from manufacturers and used those, reveling in the fact that she had saved money. She bragged that she never had to buy composite or bonding agent; she used samples all the time. Would you want a composite done on #9 in your mouth by a dentist who saved money this way? Isn’t this experimenting on a patient?

Another way that we decide what products to use is to via our common sense. It stands to reason that the new materials are better than the old ones. It seems logical that nano filler particles would increase bond strength in adhesives, it makes sense that a lower contact angle for impression materials would result in a better impression. But is it true? Does common sense always reign in dentistry? It seems logical to me that it is better to clean out an occlusal groove with a round burr before it is sealed in order to prevent recurrent decay, but that’s not the case according to the ADA’s EBD website It’s better not to touch the tooth with a burr. Just seal it up, “Routine mechanical preparation of enamel before acid etching is not recommended”. Clearly, common sense isn’t a good way to evaluate products.

If you graduated before the 90’s you weren’t taught EBD in school. Some of you might eschew EBD, thinking that it could be a way to allow insurance companies to restrict benefits. There are three parts to EBD, the first is “best evidence”, what do the studies show? This means studies from good quality, peer reviewed publications. The second part is the clinician’s clinical expertise. How well is the clinician able to carry out the procedure and what is the clinician’s experience regarding this material? How well does that material work in the practitioner’s hands? The third part is patient needs and preference. We all know that what the patient wants has to be an important part of our treatment decision. If you use this three phased approach, then EBD cannot be used again you by an insurance company hoping to control costs by dictating materials and procedures. I believe that with proper oversight by our associations, EBD is the best way to decide what products and techniques to use. With the advent of computers in every office and the readily available resources that we have over the internet, EBD in your office can be easily accomplished and should be utilized whenever you contemplate a move to a new material or device. Go to PubMed.gov, it will take you to NCBI, the National Center for Biotechnology Information. Set up an account and you can quickly and easily search articles. Go to the ADA’s evidence based website, http://ebd.ada.org., there you’ll find systematic reviews, critical summaries and recommendations. Use these sites to help you with your decisions on dental materials.

As humans we are greatly sensitive to bias. Both conscious and unconscious bias taints our ability to make reasonable, rational judgments. We need to use scientific data, proof and testing as our basis for evaluation. Evidence based dentistry can, and should, be easy. Don’t risk your professional reputation or the health of your patients to hearsay, conjecture or “common sense”. Utilize the resources that we have available through our local and national organizations. Stay up to date, be aware of changes in recommendations and supply your patient s with the excellent treatment that they deserve and you will have an easier, more rewarding practice.

With the economy the way it is today, especially here in Michigan, I see more and more dentists struggling to maintain. Their revenues are down and they are worried about making ends meet. Not knowing what to do they start to accept more PPO’s. We all know that PPO revenue, for most dentists, shouldn’t exceed 20% of total revenue. That’s easy to say when things are good. That’s hard to follow when times are difficult. The problem is that when you do that, you are trying to have it both ways.

Did you ever think about how you compete? Do you know what that means? Do you have a business plan? Do you have a business model? Do you know what that means? How many models of competition are there?

There are two ways to compete, on price or on product differentiation. You can compete on one or the other, but not both. Most dentists compete on product differentiation. Their business plan, and their business model, is based on competition by product differentiation. Look at figure #1.

Figure #1

What this illustrates is how we set up our business models differently, depending on how we choose to compete. If you are going to compete on price, you determine the price point at which you can deliver the product, then you gather your resources, and set your level of service based on your ability to deliver the product at that price and make a profit. If you compete on product differentiation, you set up your level of service, gather your resources and then set your price, based on those inherent predetermined service and resource levels. So if you are competing on product differentiation, and have your resources and service levels set up to achieve that, trying to compete on price will be an exercise in frustration and financial loss.

So what do you do? How can you cope in today’s economy? Assuming that you compete on product differentiation, I suggest a five-point strategy:

1. Have a plan
2. Examine your costs
3. Scrutinize the PPO’s in which you participate
4. Brainstorm inexpensive methods to provide high levels of customer service
5. Do a reflective study on your total office attraction

Let’s look at each one of these individually.

Have a plan. Most dentists go into business without a business plan. They buy a practice or, (rarely), start one from scratch and set up policies and systems as they are needed. Little or no thought is given to the interactions of business systems or the ramifications of office policies. There is no cohesive, logical plan. I believe that you should always have a plan and never make any policy or system that you haven’t comprehensively explored and discussed with your office manager.

Examine your costs. During those times when things are good and making money is relatively easy, we get complacent and add bulk and frills that we really don’t need. Look for those things. You may consider refining your office hours. In my office we were so busy in the late 1990’s and early 2000’s that I booked my hygienists through lunchtime. We were able to get two more patients per hygienist per day that way. One doctor would always remain in the building during lunch and that doctor would provide supervision and complete the exams. When things started to slow down and holes appeared in the hygiene schedule I discontinued the lunchtime patients. We all took lunch at the same time. We closed the office for an hour and put on the answering machine. This moved the hygiene patients into the morning and afternoon and helped to fill in the schedule. Payroll was reduced and productivity was increased. We became more efficient and our schedule was filled again.

Look for un-necessary frills you put into place. We had a magazine subscription to almost every magazine available. We looked at the list and pared it down to 6-8 popular magazines. I stopped the homemade cookies, the multiple flavors of coffee and teas, we still had coffee, regular and decaf, and store bought cookies.

Don’t scrimp on your supplies, nothing is more frustrating than not having the materials you need or using materials that cause you to have to redo a procedure, but investigate lower priced alternatives. We were using expensive PVS for impressions for temporary fabrication; we switched to a low cost generic, not for our final impressions, just for our temporaries.

Remember that the fastest way to decrease your payroll’s percentage of production is to increase production, not to decrease your payroll. You need a certain number of people to perform the necessary functions in your office. Take a lesson from the retail sector. Do you notice how customer service has decreased in the past number of years? The stores are employing fewer and fewer people to do more and more jobs. Have you tried to call in a retail store for information lately? Have you seen what a mess the stores are? There are too few people to do the needed tasks. Don’t buy into that philosophy. Work hard to increase your new patients and your office production.

Scrutinize the PPO’s in which you participate. Too many dentists panic and just start accepting PPO’s. Don’t sign up with a PPO unless you have a good reason for doing so and you know it will benefit you. If you feel that you need to accept a PPO, look at the patient mix that you have. If you have a lot of teachers, and you don’t participate you have a built in referral base among that group that might increase your revenue. However, you need to take into consideration that the existing patients you see now from that group will enjoy the PPO discount in the future. You would probably do better to not participate in that group and find another group that has high enrollment in your area, but that you don’t have great participation in. This goes to my previous point, have a plan, think things through as much as possible.

Brainstorm new methods to provide better customer service. If you are competing on product differentiation, then you need to differentiate your product. Start with a brainstorming session between you and your office manager/receptionist. Remember that there is a right way and a wrong way to brainstorm. Sit down in a room together; insure that you will be uninterrupted. Set the rules: there is no wrong or bad response, all responses are written down, implications or tactical arguments aren’t examined at this stage. Say what comes to mind. The object is to stimulate out of the box thinking. Later, you can examine each one of the responses and toss out the ones that are obviously bad. Then examine the ones remaining and see if they can be carried out. What you’re looking for is easy, inexpensive, different ways to increase customer service and thus increase your internal referrals. We all know that our best referrals come from our current patients.

Do a reflective study on your office’s total attractiveness. By this I don’t mean just the aesthetic attractiveness of your facilities, although I believe that having a clean, up to date facility is very important. What I’m talking about is asking yourself this question. “Why would a patient, who doesn’t know me, want to come and see me as a dentist rather than the dentist down the street?” What makes your office more or less attractive to patients? What makes your services more attractive? What makes you more attractive to potential patients? If you can answer those questions, you’ll be well on your way to attracting more new patients to fill out your schedule.

Things are tough in Michigan, indeed across the nation now. I still see many dentists who are doing well. What makes them more successful? They run lean, efficient but still attractive offices. They provide high level of customer service while still controlling costs. They realize that they are competing on product differentiation and they resist the impulse to try to compete simultaneously on price and product differentiation. Examine your procedures, your costs and your systems. Tighten things up, spruce things up and stay positive. Take more time to communicate with your patients. People need dentistry and they will pay for dentistry. Show them why they should do that with you.