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Debt and Cash Flow

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by Howard Farran, DDS, MBA, Publisher, Dentaltown Magazine

There is not a billionaire on earth who doesn’t use debt to benefit business. Even if you started saving money the day you were born and never spent a penny, you’d die before you’d ever see your bank account reach a billion dollars. Billionaires borrow other people’s money (OPM), whether through stock or bond offerings or a bank. They buy or build something and then they pay back the loan.

You could have worked a minimum wage job for 40 years, saved money and paid for dental school in cash. But instead most of us took out student loans. You may not be a billionaire, but you used OPM to build your career. This was smart debt.

The same goes for purchasing equipment in the practice. The adage “you have to spend money to make money” is true, and it often entails other people’s money to get to that point. This isn’t to say you should blindly go into massive debt. Analyze the ROI on a piece of equipment. What will the benefit be to your practice and how long will it take to pay back the loan?

It’s a privilege to borrow

It’s a privilege to be able to borrow money. Third world countries don’t have this option. Debt is leverage, but it’s treated as an emotional decision.

I graduated from dental school in 1987 with $87,000 in student loans. That’s in the $220,000 range today. I paid it back after graduation while working as a dentist because the lowest-paid dentists made $50 an hour. That’s 10 times what I would have made working and saving money at that minimum wage job. If I hear one more dental school graduate whine about his $300,000 in student loans, I’m going to slap him! Those loans took him from earning $5 an hour to $50+ an hour

I often hear dentists say they don’t want to purchase a CAD/ CAM or CBCT unit because they don’t want to go into that kind of debt. You have to look at a number of other factors besides the sticker price of a piece of equipment like that. What will having your own CAD/CAM unit do to your lab bill? If you’re doing more crown and bridge work and slashing your lab bill in half, how long will it actually take you to pay the loan off? Does the technology attract more new patients because of same-day appointments? Does adding a CBCT unit mean you can start performing more complex implant procedures in your practice?

Work with a dental CPA

Work with a dental CPA to see if a big purchase is a good move. When I say dental CPA, I mean a CPA who works exclusively with those in the dental profession, not a CPA who has one or two dental clients. To find one, check out: The Academy of Dental CPAs (ADCPA.org) and The Institute of Dental CPAs (INDCPA.org). These professionals specialize in dentistry and can help you to best determine if a purchase will be beneficial to your individual practice.

Look at the reports that matter

There are three main reports when you’re looking at your practice finances: the statement of cash flow (Fig. 1), the balance sheet (Fig. 2) and the statement of income (Fig. 3). They’ll all reflect debt differently.

Your statement of income (P&L) shows numbers like depreciation, deferred taxes, etc. It’s mostly used for tax purposes.

Your balance sheet is only used when you’re trying to get a loan. It’s not used to make business decisions. Debt will always make your balance sheet look ugly. The statement of cash flow is what actually matters. This statement is what really shows what’s happening in a business. As humans, we tend to be emotionally connected to the debt on a balance sheet.

But your statement of cash flow can be solvent. It’s what makes leverage out of debt, and debt is what separates the billionaires.

The data provided in the Financial Statements is based on an average from the clients of Naden/Lean, LLC. These reports were provided by Tim Lott who is a partner with Naden/Lean, LLC, a professional services and CPA firm with a specific concentration in the dental industry. He has been working with dental professional for thirty years and w e appreciate his contribution. Timothy D. Lott, CPA, CV A; Naden/ Lean, LLC; tlott@dentalcpas.com; (410) 453-5500 Local; ( 800) 772-1065 National; www.dentalcpas.com

In memory of Dr. Rou’aa Diab

Dr. Rou’aa Diab, a female dentist, was arrested by the Islamic State on August 22, 2014. She was arrested with four others in Al-Mayadeen, a city on the border of Iraq. Without proper trial, Diab was charged with the crime of “treating male patients,” and was executed.
As fellow dentists, Dr. Diab was a colleague to each of us. She was beheaded for helping prevent and treat dental disease. She should be recognized for her bravery and dedication. And her name should never be forgotten.

See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=372&aid=5079#sthash.OfKFTcgi.dpuf

How to Successfully Integrate CAD/CAM

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I had active Townie Dr. Sameer Puri come to my practice to train my staff on a new CAD/CAM software last month. Why? Because I wanted my assistants to know how to use the system just as well, if not better, than I do. I know that 90 percent of the questions asked by patients are fielded by the front desk and the assistants, not me or the other doctors. And because of this, I want all my staff to know what they’re doing!

So many doctors go to CE courses or conferences alone. They’ll do in-office training alone. They’ll never teach their staff the software or systems or procedures. This doesn’t make any sense. You don’t work alone. You don’t run your practice alone. Why would you attend a conference to learn how to better your practice and then not bring your staff along? That just doesn’t make sense.

I sat down with Sam to ask him about CAD/CAM implementation. Our office has it already, but not all offices do. I wanted to see what he had to say about the technology and how he helps doctors successfully implement the machine into their offices. Here are some of his tips:

Train Your Team

The key with any office utilizing CAD/CAM is getting your team on board. At one point, there was a lot of debate about whether the technology worked or was worth it. I think that’s over. There have been offices—single doctor, one assistant, one front desk—that have been successful and there have been multi-doctor, multi-staff offices that have integrated it efficiently.

Once you get your team trained with how to use CAD/CAM properly, the dentist really just needs to do what he or she has been doing with a lab. The dentist should numb the patient, prep the tooth and then leave. With CAD/CAM, the team can take over (depending on the laws of the state) and nearly the entire process can be done without the supervision of the dentist. The dentist can be in the other room being productive. And when the restoration is done, come back in to check the work and cement it. If the team member takes the impression, designs the restoration, mills it and either polishes or glazes it, it saves the doctor a lot of time he or she can spend in another operatory. The key is that you have to have your team trained. You have to help them learn how to utilize the machine.

Don’t Let it Be Disruptive

Introducing a new piece of equipment into the office can be huge. Change doesn’t have to be overwhelming. I hear from dentists all the time, “We’re really busy. I don’t know if we have the time for it.” Well, it’s no different whether you have a well-functioning office using CAD/CAM or if you’re sending your restorations to a lab. The doctor does not have to be heavily involved in the design of the restoration…if you train your team.

Integrating CAD/CAM doesn’t have to be disruptive. You should adapt the system to your practice, not adapt your practice to the system. No matter how big or small your practice, you have a certain flow in your office that obviously works for you. Make the machine accommodate the flow of your office. Things don’t have to change drastically.

Yes, you’ll have to learn how to take a good digital impression. But that’s easy with the current generation of CAD/CAM systems. The impression gives you a lot of feedback. You instantly know whether you have a good prep or not, whether you’ve reduced enough, whether you need to do a reduction coping or spot the opposing. You know instantly whether you’ve captured the margins and whether you’ve prepared the tooth properly.

If the team member is doing all that work for you and they say, “I can’t quite see the margins.” He or she simply calls the dentist back, the dentist makes the appropriate modifications and you proceed.

Recognize the Need for Same-day Dentistry

When it comes to implementing the technology, the biggest mistake that offices make is they forget that there is a person attached to those teeth. They’ll say, “My lab is great. My temporaries fit well. My patients don’t mind coming back for a second visit.” This is utter nonsense. I have never met a patient who would prefer to have a restoration done in two visits instead of one. It’s crazy to believe that your patients have all this free time and can come back for multiple appointments.

Discover CAD/CAM’s Potential

When CAD/CAM first entered the mainstream market, many offices bought a CAD/CAM but they didn’t know how to use it to its full potential. This was common because the learning curve was significant. Twenty years ago you had to spend time doing 50 to 100 restorations just to learn how to do a simple inlay. You had 2D software. You had to manipulate a bunch of lines on the screen and imagine that would be a restoration. Today, with proper training, a dentist can do 30 restorations his first month. The learning curve is significantly reduced. The return rate (those who buy the machine and say it doesn’t work out) has dropped exponentially too, because the machine, the software and the results are so good.

In the past, dentists were limited by the materials they could use. We only had one material: feldspathic porcelain, which is a relatively weak porcelain. We had to use that everywhere. Today, a dentist has anywhere from six to ten different types of blocks they can mill—from composite to zirconia to lithium disilicate to feldspathic porcelain. We can do inlays, onlays, implant abutments, bridges…we’re not talking about just a simple little machine anymore. We’re talking about a robust piece of equipment that can serve as a center of the practice doing many different types of restorations.

What’s your experience with CAD/CAM? Have you integrated it? Are you ready to do so? Let’s continue to talk about this massive evolution of technology at Dentaltown.com. – See more at: http://www.dentaltown.com/MessageBoard/thread.aspx?s=2&f=2680&t=233712#sthash.teltjuS7.dpuf

Howard Speaks: And the Band Played On…Again

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Howard Speaks: And the Band Played On…Again
Dentaltown Magazine
August 2014
by Howard Farran, DDS, MBA

When you’re young, everything is black and white. When you’re half a century old, everything is 50 shades of gray. And as you get older, you see patterns.

I remember my senior year of high school when two men were dying of something called Kaposi’s Sarcoma in a hospital in California. This was strange because the two men were young and the cancer was something typically only found in the older population.

Then researchers found out both men were gay. When they crunched the odds of this, it caught the attention of the Center for Disease Control and Prevention (CDC). Soon the numbers grew to prompt a medical investigation.

A New York Times article dated July 1981, reported: In the United States, [Kaposi’s Sarcoma] has primarily affected men older than 50 years. But in the recent cases, doctors at nine medical centers in New York and seven hospitals in California have been diagnosing the condition among younger men, all of whom said in the course of standard diagnostic interviews that they were homosexual. Although the ages of the patients have ranged from 26 to 51 years, many have been under 40, with the mean at 39.
This was, of course, the start of the AIDS epidemic of the 1980s. The CDC just hadn’t quite realized yet how widespread and destructive it would be.

In 1987 Randy Shilts published a book titled And the Band Played On: Politics, People and the AIDS Epidemic. A movie stemmed from the book, which premiered in 1993.

The synopsis: Don Francis, epidemiologist and main character, questions the escalating number of unexplained deaths among gay males, particularly in large cities like New York and San Francisco. He starts to investigate the possible causes and keeps tally of those affected by the disease. This list is nicknamed “The Butcher’s Bill.” He talks with politicians, professionals within the medical community and activists and eventually theorizes that AIDS might be sexually transmitted.

Now, we’re more than 30 years beyond this public health nightmare. And hindsight is 20/20. We might have high awareness now but at the time, it flew under the radar for years. And part of the problem was that people refused to talk about it.

In the past, oral and oropharyngeal cancer—or “mouth cancer,” as they call it in the U.K.—have most often been linked to drinking and smoking. And even more specifically, the cancer has been linear—someone who had smoked two packs a day for four decades was more likely to get cancer than someone who had smoked one pack a day for one decade. Chewing tobacco didn’t follow this model. It was less predictable and didn’t get a lot of attention, though still a cancer risk.

Now, the tides have turned. Today we’re seeing an explosion of oral cancer in young girls! Girls who have never had a cigarette in their lives and don’t have a drinking problem. They’re showing up at the doctor with lesions and screening positive for cancer. It’s HPV and it’s hitting us all by surprise. But nobody is talking about it.

You can’t talk about HPV without talking about oral sex… so let’s just get that out of the way. It’s awkward, but you’re an adult, so buck up. Last year the U.K.-based newspaper The Guardian published an article about Michael Douglas, who opened up the conversation about HPV’s ties to oral sex, attributing his own cancer to it.

I get it; you’re not a sex ed teacher, but if we’re going to call ourselves doctors, we need to be asking some tough questions. When I lecture I ask dentists if they talk to their patients about HPV. It’s not even on dentists’ radar.

You should be asking every patient who comes in if they’ve been vaccinated for HPV. Many dentists give excuses. “That’s not my area. Their family physician should do that.” No! We are all on the frontlines of health. If we’re not talking about this, let’s just say we’re not doctors. We’re just molar mechanics.

We have a serious biological problem here: a virus. We’re knowledgeable about AIDS—possibly one of the only positive outcomes of the epidemic—but we’re missing the new problem right in front of us.

I talked to a mother of a patient in my office who refused to talk to her daughter about HPV. And the mother thought that vaccinating her daughter against the virus would be the same as sending her off to college with a box of condoms. She didn’t want her daughter to feel protected. These are huge moral, ethical, religious questions. We need to talk about this stuff, even if it is uncomfortable or controversial.

In 2007, Texas Governor Rick Perry worked to mandate the HPV vaccine among middle-school girls. Though it was controversial and was overridden in the months after, it was one of the only big-time public actions taken against the virus. All 50 states in the U.S. have a Department of Health and Human Services, and nearly every state has a dental division. Have you ever called yours to talk about HPV? Ask for resources. See what the division is doing in your state.

HPV is a topic that makes people squirm in their seats. We don’t want to talk about it. No one wanted to talk about AIDS either. It made people uncomfortable. But the epidemic happened right in front of us anyway. And in a way, we were blindsided! This is what’s going on right now with HPV. The fact is, we don’t know how serious it is or isn’t. And it’s our job— as dentists—to talk to patients and parents about the risks of the disease.

Not only are we not talking to patients, but we’re not talking to each other about it either. I’m on Dentaltown all the time and there is hardly any discussion at all about HPV. Let’s talk about how to educate patients and parents! Let’s converse about the public health risk and our part in the big picture. Americans see a dentist twice as often as they see a physician. We have 125,000 dental offices in America. That’s manpower! We have a massive ability to get out in front of this.

We don’t want to look back at an HPV Butcher’s Bill and ask ourselves what we could have done about it. I’d love for dentists to stand up and become physicians of the mouth. We’ve got a problem on our hands right now.

References

  1. Rare cancer seen in 41 Homosexuals: by Lawrence K Altman; July 3, 1981; The New York Times http://www.nytimes.com/1981/07/03/us/rare-cancer-seen-in-41-homosexuals.html
  2. National Conference of State Legislatures http://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx
  3. Michael Douglas: oral sex caused my cancer”; June 2, 2013; The Guardian http://www.theguardian.com/film/2013/jun/02/michael-douglas-oral-sex-cancer?CMP=twtgu

– See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=365&aid=4974#sthash.utdmJeBH.dpuf

Why Two Out of Three Cavities Go Untreated

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Every year, since 1991, there have been more cavities diagnosed than the year before. That’s a terrible statistic.

What would happen if the fire chief of a city reported that in the 23 years he had been in the position, more houses had burned down each year than the year before?

Legendary, successful mayors are the ones who substantially lower the crime rate while they’re in office. “I’m so proud of the fact that there were more murders than last year! We’re hoping and expecting even more next year!” said no one ever.

On average, for every three cavities a dentist diagnoses, he only removes the decay on one. One! He doesn’t remove the decay two out of three times! That’s below average dentistry! We all claim to be good dentists, but on average, we can’t all be.

I always hear clinicians say they’re 20/20/20 dentists—“My fillings are bonded with greater than 20 megapascals.” “All my indirects fit within 20 microns.” “All the materials I use wear less than 20 microns a year.” They use their fancy adhesive bonding agents and their fancy CAD/CAM machines on one-third and do squat on the other two-thirds.

You are a dentist because you got A’s in science and math, and because you (hopefully) genuinely care about removing decay and disease. But part of the problem is that dentists typically aren’t good at sales. And to fix patients’ cavities, and in turn, prevent the spread of disease and decay, you’ve got to convince them they have a problem that needs fixing.

Say you have a patient in the dental chair and you are presenting treatment after an exam. You might say something really technical and clinical. “You have an interproximal legion on the distal of three. It’s causing irreversible pulpitis. You’ll need endodontic therapy, a post-build up and a full-cast restoration.” The patient just stares at you like a deer in headlights. She doesn’t understand what you just told her, doesn’t realize the importance of fixing the issue and because she, like most people, doesn’t buy based on information, she walks out to the front desk, says she’ll call later to schedule her treatment and then leaves. Two out of three cavities are walking right out your front door!

Let’s look at this same situation by putting ourselves in different shoes. Say a dentist was selling real estate. He’d walk in the house with the client and say something like: “The altitude of this house is 368 meters above sea level. This side of the street gets direct sunlight in the morning. The climate of the area is mostly rainy…” Boring! It would be all technical information.

A good real estate agent, on the other hand, would present a house much differently. She would walk you into the living room and help you imagine the big parties with family and friends that you could have. She’d sit with you around the fire pit and talk about how fun it would be to BBQ on the patio during the summer. She’d make it relatable. She’d make it an emotional decision rather than an informational one.

There is a biological science to selling. There are only two things humans can love. It’s not ice cream or cookies or dogs or cats or family. It’s dopamine and serotonin.

Your dog sees you walk in the front door from work. His tail wags and he jumps up, excited to see you. You think you love each other but you actually love the two chemicals. The real estate agent is secreting dopamine and serotonin too.

What on your résumé makes you think you’ll be good at sales? Sometimes dentists are their own worst enemies. Patients are already on edge when they visit the dentist, so it doesn’t take much to (even unintentionally) put them in fight or flight mode. Looking back to the patient in the dental office, it’s no wonder she wasn’t compelled to schedule her treatment. You weren’t giving off any dopamine or serotonin. In fact, you were secreting norepinephrine and adrenaline, which have the opposite effect.

We’re putting patients in fight or flight mode because of the clinical information we’re spouting off and because many dentists feel compelled to comment on previous dental work. If you’re not impressed, keep it to yourself. In 1997, William Ecenbarger published an article in Reader’s Digest called “How Dentists Rip Us Off.” The investigative journalist went to 50 different dentists for consultations. He received 50 different treatment plans. Dentistry is as much an art as it is a science. It’s inexact. So unless you see shoddy dentistry worthy of malpractice accusations, don’t badmouth! What if the patient was a family friend with her previous dentist? What if their kids played sports together? If you’re badmouthing her previous dentistry, you’re telling the patient that her decision to have treatment years ago was a bad one, but now you’re asking her to make the decision for treatment again with you.

The point is we need help selling treatment. Most of us are just not biologically good at it. I’ve had the same dental assistant for 25 years. She is great at presenting treatment because she gives off serotonin and dopamine. She’ll present treatment like this: “You have two cavities, but I wouldn’t fix them just yet because if the doctor puts those fillings in there, he’s going to match them to the existing teeth. So, what I would do is bleach them first. But before you do that you need to have them cleaned. So let’s get you in the hygiene department and we’ll get all the plaque and tartar off your teeth, then we’ll bleach them in the office and send you home with bleaching trays. Then we’ll remove those cavities and match the fillings to the pretty white teeth. It’s going to look great.” The patient gets excited about what her new smile will look like!

I lucked out having an assistant who is so good at selling dentistry. But the fact is, I still have a treatment coordinator. This is something that orthodontists figure out two years into practicing and nine out of ten dentists never figure out. Treatment coordinators have been known to triple treatment production! By hiring a TC we can lower the rates of decay and disease, and maybe clean out two of three or three of three cavities that come into our offices! – See more at: http://www.dentaltown.com/MessageBoard/thread.aspx?s=2&f=2669&t=230414#sthash.47OLzMj8.dpuf

What Dentists Can Learn From the Downfall of Sears

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In February 2014, Forbes published an article titled “Sears Still Missing the Boat: 6 Ways the Brand Can Be Saved.” Sears has been on a painful decline for the last decade. When I was a kid, Sears was the be-all end-all. It was all things great. I can still remember sitting around with my five sisters looking at the Sears Catalog. We’d circle things. We’d make Christmas lists. It was fantastic.

Sears was one of the first department stores to carry exclusive product lines including DieHard Batteries, Kenmore appliances and Craftsman tools. But now, it’s had its lunch handed to it by Lowes and Home Depot. But why?

The smartest economic gurus in the U.S. and Canadian market insist the market is split in two—half shop on price and half shop on service. But companies, department stores and even dental offices have to have one of the two. They can’t cater to both markets successfully.

For Sears, it used to be all about the service. You knew when you walked into Sears that its product lines were good quality and that you would receive great service if you had any questions or needed help. Now, you walk into Sears and nobody can explain anything about a battery or a tool or an appliance. Its service has taken a plunge but it hasn’t made up for it in price. Other stores, like Wal-Mart for example, have the same products but offer them at a better price.

On the other side of the coin, every time I go into Home Depot and have a question, I get it answered immediately (and of course, realize I need more equipment and tools). I end up being led by the sales associate to four other aisles to find things. It’s good business. That store is staffed with a bunch of people who know what they’re talking about.

This is interesting to me on the dental side of things because I go into dental offices all the time. Nine out of 10 dentists don’t let their staff talk intelligently to patients. Hygienists are afraid to show patients a cavity on an X-ray because they’re “not the doctor.” This is absurd.

The patient is sitting in the chair and the dental assistant is taking a PA and a bitewing for an emergency. The tooth is completely bombed out. It’s obvious that the tooth has to be extracted. The patient asks the dental assistant, who has been working for the practice for years, what the verdict is. She doesn’t answer because she’s afraid of her own doctor. She’s afraid of being knowledgeable staff member. So basically, the doctor wants to be Sears.

I often hear dentists use the excuse: “It’s illegal for a dental hygienist or an assistant to read an X-ray.” Can you name one hygienist, dental assistant or receptionist in America who is serving time in prison for reading an X-ray? It’s not like you, the doctor, are going to go in there and take the hygienist’s reading on the X-ray and just start doing a root canal blindly. No! You are going to evaluate it for yourself. You’re going to ask her to clarify if her handwriting is messy. You’re going to discuss what she saw versus what you’re seeing. This is why the “it’s illegal” excuse is just crazy. It’s crazy for the patient’s questions to be put off and it’s not fair for the staff. They’re knowledgeable, so let them show it in the work they do. The same way the knowledgeable employees at Home Depot take pride in their work, your assistant’s knowledge in the work she does is one of qualities that make her proud to work in your office. And it’s what keeps staff turnover low.

The best thing about having knowledgeable staff is that they’re empowered to do well, which means they’re often the longest-retained employees. Mary at the front desk might not be able to say for sure whether a tooth needs a root canal, but between a little knowledge about what might be causing the patients pain and the fact that she’s been sitting by the doctor’s side for 20 years… patients trust that. It’s selling the invisible.

I continue to hear dentists talk about how they want to operate on service not price. They want to develop a high-end practice. They want to do implants and veneers. It’s interesting to note that these are the same doctors who often come to meetings alone rather than bringing their staff. All I can say is “Where is your team!?” Where is the person answering the phone at your practice? The person who answers the phone should be sitting in a class on ortho or perio or root canals or gum disease. That person is going to be fielding 90 percent of the questions. That incoming call is one of the most powerful things in dentistry.

The greatest stores (those that are continuing to be successful in this economy) are all adding new services. Nordstrom added Topshop. Macy’s expanded their shoe department and partnered with Finish Line. They’re also continuing to train long-term staff to be knowledgeable. The workers know the brands inside and out. They offer specialty services like tailoring and personal shopping. Or in Home Depot’s case, tool rental and installation offerings. They’re differentiating themselves through staff as well as product and service offerings.

You need knowledgeable workers. Our team has busted our butts for 15 years to develop our online CE program. All you need to do is spring for a pizza or sandwiches and you can sit around a table for an hour at lunchtime with your team and watch a CE on Dentaltown. Right now we have about 215 courses online. You could watch one a week for four years and still not finish them! These courses are particularly great because they’re only an hour long (which is about how long our attention spans work effectively). You need knowledgeable workers. You shouldn’t be watching these courses alone. You shouldn’t be learning alone!

There is a lot to be learned from Sears. The failing department store and the stores that are thriving have one big difference—knowledgeable staff. So, which model are you going to follow?

See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=360&aid=4903#sthash.i3uf3H4E.dpuf

Google Reviews are the Only Ones that Matter

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Everyone’s buzzing about online reviews as if they’re something new and different. The fact is, we’ve always had reviews. They just haven’t always been posted online for everyone to see. Online reviews are a digital version of an analog voice, and everyone reacts to them differently.

Here are some facts about online reviews:

  • 92 percent of people have confidence in online reviews (Wall Street Journal, January 2009).
  • 70 percent of people consult reviews or ratings before purchasing (Businessweek, October 2008).
  • 61 percent of reviewers are motivated to write reviews to give recognition to a company, versus only 25 percent who write them to punish a business (Nielsen 2011).
  • Women are more likely than men to write online reviews (Nielsen 2011).

Humans don’t like transparency, but when humans aren’t transparent, bad things happen. I raised four boys. Whenever they all went into one of the bedrooms and shut the door, I knew something bad was going to happen. It was a red flag that definitely made me go check out what was going on.

Online reviews facilitate transparency. They’re a digital platform for checks and balances, and reviews can be your best ally if you handle them right.

Sometimes patients will make a comment about how great their experience in our office has been. Ask patients who you know are happy to write an online review for your practice! Most of the time, they love to be asked. Don’t show them how to do it from your office computer. Google is watching and if they see your reviews coming from your IP address, it might affect your SEO optimization. The patients can, however, post a review from their cell phones.

There are hundreds of review sites out there—Yelp, HealthGrades, Yahoo—but don’t waste your time on these; Google drives the whole industry. Google and YouTube (which is owned by Google) are the two most-used search engines. If you Google a dentist and they have a website of any kind, he or she will come up on Google’s search results. This means the doc’s reviews also come up (Fig. 2).

In my practice, we give out “Review us on Google” cards (Fig. 1). These cards are included with new patient gifts, in recall goodie bags and are also available in all the operatories. The card not only reminds patients to write a review after they leave the office but it also guides them through the process of writing one.

Occasionally patients might have a bad experience and surprise you with a nasty online review. Say this happens. You’ve made a woman so mad that she’s gone home and registered on Google+ (which she might have had to read instructions or watch a YouTube video to learn to set up) and she’s gone through the process of writing several paragraphs about her practice experience. This probably took her the better part of an hour start to finish.

For many dentists, their first response is to hire a lawyer or try to get Google to take down the review. But you should be going the opposite way! This is an awesome opportunity. First of all, how many patients who don’t come back take the time to write a letter telling you what you can do better? Not too many!

Second of all, can you imagine if this woman, with the amount of energy and determination she has, was rallying for your practice instead of working against it? If you can rectify her bad experience, she’s a walking marketing campaign for your practice.

The best way to deal with a bad online review, whether it’s a minor complaint or an absolute disaster, is to call the patient. There are often posters on Dentaltown who will ask what to do about bad reviews. The initial answer seems to always be to show it to your malpractice carrier. Really?

This patient is already in confrontation mode. Why isn’t your first response to call the patient? Say: “Hey Sally. You are mad. Can you come down to the office and we can go to lunch and talk about it?” Most the time, the bad reviewer just wants to be heard. And by doing whatever you can to fix the situation, you’re not only addressing that patient’s complaint but also creating good rapport for your practice overall.

In addition to online reviews, I’ve found exit interviews to be very effective for getting feedback. Call all the people who haven’t been in to the office in 24 months. See why. It’s important to keep track of why patients leave. Do you really think they all died or moved? Who are you kidding? You’ll find some of them have moved, some of them changed because of insurance policies or better scheduling. But what if you find out that a substantial number of patients decided not to return because they hate one of your hygienists? What if you find out a front office person is unwelcoming?

Most of your new patients are just old patients from the dentist across the street, which means you need to ask them why they left their old dentist. When a new patient comes in to the office, the person fills out a health history. Why don’t you include a question about why they left their last dental office?

Sometimes you’ll get answers like: They didn’t take my insurance or they didn’t provide nitrous oxide as an option or they weren’t open on evenings or Saturdays. You might learn their previous dentist was unapproachable or talked down to patients or created a culture of “don’t ask questions.”

How do you get feedback in your office? Sign on to Dentaltown.com and visit the Howard Speaks article for this issue. I’d love to hear about what you do to receive and track feedback. – See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=357&aid=4863#sthash.pqxdvVBG.dpuf

The Changing Landscape of Dentistry

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When I was a kid, pharmacists had their own pharmacies and optometrists had their own eye clinics. Now these models have been replaced by Walgreens and CVS, with EyeMasters and Pearle Vision.

In France they actually have ATM machines for prescriptions. A physician loads the prescription onto a medical card and a patient can pick it up anywhere there is one of these machines. The machine dispenses however many pills the electronic script is written for, puts a sticker on the bottle and drops it into a drawer, the same way you’d grab chips from a vending machine. Prescriptions are now a commodity.

When we go get glasses, most of us don’t care if we look into a machine to tell us we have 20/80 vision because that number goes to a lab tech who crafts the lenses. Most of us are more worried about how the frames look. Glasses are now a commodity.

It’s like “The Jetsons” where a mechanized robot brushes George Jetson’s teeth, shaves his face and dresses him based on a scanner view of his body. What we once thought was futuristic and unattainable is here and now!

All this has me thinking about dentistry’s model and how it’s changing. What will the dental landscape look like in 2050? Will dentistry go the way of Walgreens and EyeMasters? I asked several of my colleagues this question and they shared their opinions, which we feature in this issue (page 64).

Let’s talk about the reality. Dentistry’s unique selling proposition is surgery. We work in an operatory. Our hands and fingers are in someone’s mouth. It’s not the same as a pharmacy or an eye clinic. It takes human hands and human eyeballs to perform dentistry.

Commodities are things you buy on price. When you buy corn, you don’t care if it’s from Iowa or Nebraska. The silliest ad campaign I’ve ever seen is the Florida orange juice one. Have you ever heard anyone at the grocery store asking for Florida oranges because they don’t want the ones from Arizona?

My practice is 25 years old. I have a lot of contacts from Dentaltown who have significant roles in the business to consumer (B to C) marketplace, and we all agree: half of America buys dentistry on price. Some of these people do perceive dentistry as a commodity and some buy on price simply because they don’t have money. If they have bad dental insurance and their insurance says they can only go to one doctor in town, they’ll go to that one doctor in town. This phenomenon is going to be around forever. There are people who are poor who really do value dentistry and there are rich people who don’t value it.

The other half of America has strong opinions about who gets to work in their mouths. The relationship with their provider has a huge impact on their choice of dentist. Have you ever once based whether you want a prescription filled at Walgreens on which pharmacist is going to be there? No! You just want to know when Walgreens is opened and if it has a drive-thru!

The argument is that corporate dentistry fuels the side that says dentistry is a commodity. These companies are representing a brand instead of an individual dentist. They’re often marketing on price, rather than procedure or specialty or dentist. So, yes, there are real-live dentists, not robots, performing the procedures, but it seems to be the beginning of taking the relationship out of the process.

Once you’re 50, you’ve seen everything at least twice, particularly in economics. This is the second time I’ve seen the idea of corporate dentistry come around. Black Monday in 1987 was just months after I graduated dental school. I was practicing during the stock market crash in 2000 and Lehman Brothers fall in 2008. When everyone thinks it’s the end of the world, it’s not. It’s a cycle. We create an economic bubble and then it explodes. It’s just economics.

Corporate dentistry chains have a good grasp on sophisticated marketing and management. When I got out of dental school, not a single dentist I knew, including myself, could use QuickBooks to make payroll. I hadn’t taken one class on management or communication with staff. For some, the answer is: let someone else do it. So if you hate dealing with all things social media and Excel, corporate might be the way to go.

For those who would rather learn it for themselves, check out all the practice management courses on Dentaltown.com. They’re only $18 each. Or, if you want more than a few hour-long classes, maybe you’re interested in going back to school. I went back to school in my 40s! I took two business classes each semester. I attended class on Monday and Wednesday evenings from 6-10 p.m. every week for two years. And I about cried when it was over because I loved it and learned so much! Another solution is to hire street-smart staff—an office manager, specifically. Recognize your limits and delegate!

The other advantages to corporate dentistry are better access to capital and better patient financing. It’s nice not to have to worry about these things. The CAD/CAM unit and other equipment is part of the package and there is no third-party when it comes to financing treatment.

It’s nice to have access to capital and to have patient financing, but you can have these things in a group practice, too. You can split the cost of the rent and the CAD/CAM and the payroll with other partners. You can work with CareCredit for patient financing. So in these ways, I don’t see how a corporate chain in all 50 states is any more competitive than an independent group practice.

I’m not opposed to corporate dentistry. I think it provides needed services for many Americans who need treatment. But unless corporate chains can preserve the one-on-one relationship that a patient gets when he or she visits her independent dentist, I don’t see corporate taking over the dental landscape or dentistry going the way of Walgreens. I think they’ll always be a spot in the marketplace for both private offices and corporate chains. – See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=354&aid=4817#sthash.L80fMs9A.dpuf

“Ethical Dilemma” – A Series Kickoff

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When the 2013 Townie Choice Awards was in full swing this summer, and dentists and hygienists were voting for all their favorite products and services, we asked all the voters to answer the question “what’s the biggest crime in dentistry?” We got some interesting answers – overtreatment, managed care, insurance reimbursement, indifference, embezzlement – just to name a few.

Dentists deal with all sorts of ethical dilemmas on a daily basis, and the Dentaltown the ethics forum on our message boards are filled with debate. This month we’re starting a series called “Ethical Dilemma” that will address some of the stickier, less black and white, 50- shades-of-gray areas in dentistry. These articles will run throughout the duration of 2014. I’m kicking off the series with the topic of managed care.

There are some ethical issues the majority of us can agree on. Right now most of the world agrees we shouldn’t eat cats, dogs and dolphins even though I bet they all taste like chicken anyway. But sometimes the lines are more blurred, or aren’t universal. I once lectured at a dental school in India. A dental student came up to me and said she couldn’t listen to my talk because I eat cows. When you go to McDonalds in India, there is no Big Mac on the menu. It’s a McVeggie Burger or a fish sandwich.

Everyone sees everything differently. It’s hard to get 150,000 dentists (that’s about how many are on Dentaltown.com) to even agree what day of the week it is, let alone about how managed care should or shouldn’t work.

When it comes to ethics, most people, dentists included, fall within a midrange. This middle is the silent majority. A normal distribution curve (Fig. 1) says 68.5 percent of people make up the middle ground. The further out from the middle, the fewer the people, but the more extreme. I envision this Ethical Dilemma series sparking conversation on the boards, but chances are only the extreme outliers will argue. This series is meant to start a conversation, not be the world according to Howie! It’s meant to get you thinking and discussing your views and experiences from what you see going on in your practice and in what ways you deal with the ethical issues that arise everyday. Can’t we just have an honest conversation?

About Half the U.S. Market is Focused on Price.

If someone asks you “What’s the best car?” you’re going to say something like Lamborghini or Maserati or Ferrari, or some luxury car that costs an absorbent amount of money. While this is ideal, a $200,000 car isn’t realistic for the average buyer.

Jay Leno might throw these numbers off, but the most popular cars, according to Forbes are: Ford Focus, Toyota Corolla and Volkswagen Jetta—all midsize, reasonably priced sedans. These are the top cars because they are what most of us can afford. No, they’re not the best cars, per se, but they are the most practical based on cost, safety and mileage.

This same idea can be applied to dentistry. Sure, you could have a high-end boutique style practice in a lower economic area, but it would be like setting up a Mercedes-Benz dealership in Parsons, Kansas. It could work, and would depend entirely on the dentist being exceptional in many areas, but a Ford dealership would probably do a lot better, and would be a lot easier of a sale. Demographics act like gravity, they’re hard to deny. In business we call this market segmentation and markets are usually carved up by price, quality and service.

Americans basically divide the dental market in half meaning half are primarily focused on cost and will go wherever their dental insurance, employer, Medicare or Medicaid tells them to go while the other half sees dentistry as a relationship and they absolutely want to pick their dentist. They have a special relationship with their dentists and do not want to go to another dentist just because a third party told them to, and they will pay more for this privilege.

I hear so many dentists say that the problem with third-party insurance fees is they can’t do the treatment a patient really needs, and they’re only willing to do treatment that they’d do for themselves. I personally think this view is a little extreme, especially having traveled the world over.

If someone has a cavity, the decay needs to be removed and you need to fill it. If you’re getting $300 for the filling, then get out your fanciest materials from 3M and Ivoclar, do your tooth-colored adhesive restorations, and make some money. That’s basic; Cost + Profit = Price. But when managed care comes in and sets an exact price, you’ve got to switch to Price – Profit = Budget. A budget means you will need to have a plan. Why are you doing a tooth-colored restoration when bonding agents cost nearly $1 million a barrel? Is it because it’s the only thing you would have in your mouth? Why is it that you don’t place amalgams when research says they’re lasting 30-35 years and 3 billion earthlings live off of $3 a day? This was the only material available when I was a kid and at least a few people would say I turned out just fine!

You might have very different values and priorities than the patients you are treating. Your patient has the right to have different values than you, the dentist. I heard a speaker once say how horrible a parent was because he didn’t have money for his kid’s braces but he took his whole family to Disneyland. I’m good with that. I still remember driving from Kansas to California with five sisters in a green station wagon playing Monopoly in the back the whole way to Disneyland, without seatbelts, I might add, and it still is an awesome memory.

If you’re doing low-cost dentistry then treatment plan accordingly. Be aware of all the upgrades that are not covered like ortho, implants, bleaching, bonding and veneers. And if a patient only has enough resources or dental values for an amalgam, then place one.

I’m not a firm believer that the highest price is always the highest quality. Southwest Airlines is a testament to this. Southwest is the lowest cost airline and no one has ever died in one of its planes. If the plane doesn’t fall out of the sky, and it takes off and lands on time (and preferably doesn’t lose my luggage), it passes my test. High-cost dentistry isn’t necessarily the best quality or what’s best for the patient anyway. Which lasts longer, amalgam or composite?

You can never afford to get complacent and ignore your own unique dental marketplace. You must cultivate relationships and provide exceptional service at a fair price. The case of low cost dental offices and those who don’t participate is not about the quality of dentistry. It’s perceived value. Managed care fills a necessary market. For a free enterprise system to successfully exist, you must have different market providers for different price points. If this does not happen it is called a market failure and this almost always invites the government in to correct the failure. Do you want government-owned dental offices? If the answer is no, then start treating the low end providers with more respect.

Don’t try to dictate what people can choose or afford. That’s not your decision to make. They’re the consumers. They’ll make their own decisions as to how to spend their money based on what they want and how much they have to spend. It’s our decision as to how we deal with their choices. – See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=351&aid=4778#sthash.v4VaGYlH.dpuf

Go West, Young Man

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Made popular by author Horace Greeley in the mid-1800s, the quote, “go west, young man,” was a proclamation to embrace new opportunity in the new western country. Granted, today I’d personally have to travel 1,457 miles east to get to St. Louis – the gateway to the west – from where I live in Phoenix, negating any literal meaning of the quote, but even so, it still has significance today. If you want to take advantage of new opportunities and possibilities, it might be necessary for you to move to an entirely new area or change your practice to accommodate a certain demographic.

In late November 2013, I started a message board thread on Dentaltown.com, which links to an article in The Denver Post titled, “Flood of new dental patients in Colorado meets trickle of caregivers” (Editor’s note: To view the thread, please visit www.dentaltown.com/ColoradoPatients). The article explains the new dental benefits Coloradans will receive via Obamacare and Medicaid, but that dentists are concerned that they won’t get paid enough to treat these new patients and keep their doors open. Also in the article, nine Colorado counties are listed as having no dentists in them whatsoever. In just a few days, this thread generated more than 130 posts from Townies. I invite you to check out this particular message board. It’s a pretty touchy issue, but I feel the concerns of some dentists surrounding this issue aren’t correct.

One of the arguments I hear is that those nine counties in Colorado have no money, hence, no reason for a dentist to open up a practice there. That’s ridiculous. Were that true, there wouldn’t be any Wal-Marts or McDonald’s in those counties either (and there are). If Wal-Mart and McDonald’s are in those counties, why can’t there exist a dental practice? For 25 years I’ve said all major businesses start with this equation:

Price – Profit = Budget
And I’ve always said that dentists seem to arrive at their price backwards:
Cost + Profit = Price

Ford Motor Co. has no problem starting with the average price of a Ford Taurus (at around $26,000 minimum average), from which they will subtract their profit, and from which the engineers will work off of the budget. Similarly, if they are designing a lower cost Ford Escort, they will say, “Here is what we are selling a Ford Escort for, we will subtract the profit we need to remain healthy, and then we will arrive at a budget.” Dentists don’t do that. Dentists don’t think they have two distinct markets. They will go into an area that has less income, taking HMOs and PPOs, but they won’t do amalgam. They’ll insist on doing composite. They won’t use a lowcost lab – they’ll go with some high-end cosmetic lab. They’ll insist on providing high-cost dentistry that much of the poulation of that town cannot afford.

These are the dentists who say, “I refuse to do dentistry on my patients that I wouldn’t do on myself.” That’s very altruistic of you, doc, but let’s get real here. The dentistry you would do on yourself is high-cost, high-quality dentistry only the upper class could afford. If that’s the way you think, you have to stay in the upper-half of the market and only that section of the market. You can’t be everything to anyone because eventually you will become nothing to no one. If you cannot figure out that there is lowcost dentistry, and that some people get amalgams and extractions and flippers and partials and dentures, and you need to use a low-cost lab, then you need to stay away from that geographic zone and let another dentist in who will make a killing offering low-cost dentistry. If all you offer is high-end dentistry, you’re going to make money on some patients and lose money on others – it will be a wash. You might as well pick low or high, run off half of your patients and only focus on the demographic you want to treat.

Also, consider the underserved areas themselves. No, they are not San Diego, Manhattan, Florida or Arizona where everyone seems to want to practice these days, but you have to remember those areas are already oversaturated with dentists. If it was always your goal to become a dentist and practice somewhere warm, you’re going to need to do something major to differentiate yourself from the rest of the pack. It takes a lot of work to practice in a saturated area. On the other hand, if you’re the only dentist in an entire county, people are going to flock to your practice in droves. When you serve the masses you dine with the classes, and that’s what will happen if you practice in an underserved area of the country. Do you really want to practice in San Francisco now, when you can make a killer living in a part of the country with no dentists and visit San Fran any time you want? Think about it.

There are already practices that are moving into underserved areas – corporate practices like Aspen or Heartland – and they’re doing it the right way. You know, the scariest question being asked around the dental profession is, “Is dentistry going to go the way of Walgreens and CVS the way pharmacies did?” Mom-and-Pop pharmacies collapsed because all the profit margin came from the buying power to purchase the pills. Group purchasing of drugs by Walgreens and CVS was everything that the small independent pharmacist couldn’t do. Secondly, there was not a single continuing education class pharmacists could take that would differentiate them from other pharmacists. We all know what happens when a dentist goes through Pankey or LVI or the Misch institute; we all know how dentists who take tons of CE each year for a decade can differentiate themselves from their competitors so much they’re almost playing a different game.

Corporate dental practices like Aspen and Heartland are making some very smart moves. They’re opening up practices in rural, underserved areas where there are few or even zero dental practices, and they’re making a killing. We’ve all heard why corporate dentistry is dominating – buying power for supplies and lab costs, and better marketing. But its Achilles Heel will always be staff turnover. How many dentists who sell their practices to corporate chains are still there three, four or even five years later? In my backyard, they are all gone. And when the dentist leaves, the patients stand around wondering what happened, and they become a lot less loyal. Staff turnover trumps brand name every time. While writing this column, I asked my office manager Sandy how big a blow it would be to our practice if we let Jan, my assistant of 25 years, go, and Sandy literally gasped. It would have a devastating impact on our patients and our practice.

There is a lot of opportunity out there, doc. You don’t have to sit in an oversaturated area spinning your wheels trying to figure out how you’re going to get your next new patient. Take a look at demographics in your own state or states around you. Figure out where the underserved live. “Go west!” – See more at: http://www.dentaltown.com/MessageBoard/thread.aspx?s=2&f=2606&t=219440#sthash.ba2IC3ce.dpuf

Best Practices, 2013

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At the end of my September 2013 column, I asked readers to visit www.dentaltown.com/besttips2013 and post what they did this year to make their dental practice the best it can be. I really love the responses this thread generated. For the sake of this column, and for the health of your business, I’m going to share with you my favorite posts from this thread and my thoughts about them.  First of all, for this thread to be kicked off by a first-time poster on Dentaltown.com – and that the advice drkinnarshah provided was spot on – thrilled me to no end. When we look at patterns of a successful dental office, practices that have morning huddles do infinitely better in any way you want to measure, whether it’s stress reduction, or increases in productivity and net income. The only thing I want to add to drkinnarshah’s post is to remember, after the morning huddle, it’s imperative to keep in constant contact with the team via walkie-talkies throughout the day.

Dr M’s post is spot on. Everyday since the economy tanked on September 15, 2008, (aka, “Lehman Day”), when asked “If you could have just one magic bullet to improve your practice, what would it be?” four out of every five dentists would say, “I need new patients.” I’m personally proud to say that October 2013 was the best month my practice, Today’s Dental, has ever had in terms of production, collection and new patient intake; I attribute this to two things. The first thing we did was begin nurturing online reviews; this is very powerful. In my neck of the woods, Internet marketing is very strong. We know nine out of 10 appointments are made by women, and more women post online reviews than men do. At my practice, our staff outright asks our patients to post reviews about their positive experiences online. We know that we might receive a negative review from time to time (you can’t please everyone all the time), but if you can drown out any negative review with a ton of positive reviews, you’re doing something right. Our staff hands our patients a card prompting them to say something nice about us, and it’s been a great success.

The second thing we did in order to obtain more new patients was handing our current patients a referral card. I know pretty much every practice management consultant on the lecture circuit and just about all of them have told me when they do in-office consulting, the first day is always observation. They want to go in there and see what the team is doing and not doing. In almost every instance, on the day of observation consultants never hear a single employee – whether it be the dentist, assistant, receptionist or hygienist – ask for a referral of a friend or a loved one. This is the number-one most powerful form of marketing, and it’s never done. When we hand out our referral cards, our patients refer a friend to our practice and when their friend becomes a patient of ours, our patients and their friends will receive a $20 Visa gift card. These cards aren’t validated unless a member of our staff signs it. Also, we incentivize our staff to hand these cards out; whomever on the team has the most referral cards with their initials turned in at the end of the month receives $100.

Also in this thread, Jen Butler wrote…  For years, I’ve said all leaders are readers, and I’m glad Jen made this recommendation. In my practice, we all read a book a quarter (we’d love to do a book a month, but it is hard to try to find the time to fit a book in each month). I highly recommend getting your team to all read the same business book once a quarter, and discuss it – but, for non-readers, instead of reading the book, you might consider the audio version of it. All non-readers can knock an audiobook out in the same amount of time it takes to do three loads of laundry and mow the lawn. It’s team building and total enrichment for the entire practice.

 I applaud dave27 for implementing new procedures into his practice (it already seems to be paying off for him), and for streamlining his processes to do dentistry faster, cheaper, higher in quality and lower in cost. If you’re burning out in dentistry, start learning new procedures like short-term ortho, or implants, or CAD/CAM.

 Dr. Duke talks about how she set up a private Facebook group for her team and in the thread, Sandy Pardue quotes that as saying that this is the top pick of this entire thread. I have to agree with Sandy, but I am going to have to one-up it a bit. You have to have a communication platform for your team, at Today’s Dental we’ve had our own e-mail platform that has been very effective. The Facebook group Dr. Duke refers to is very interesting; I like that a lot. It’s also why we set up the same kind of platform on Dentaltown.com. Dentaltown’s private groups are far more robust than the Facebook private groups, however, because you can organize them by subjects. I mean you can set something up for hygienists, something for the entire office, something just for insurance or marketing, etc. It’s more organized. But here’s what I like even more: If the dental office staff members are on Facebook in the private Facebook group, they are extremely tempted to hop off that page and go see what all their nieces and nephews and girlfriends are doing. When they are on the Dentaltown.com private group, now when your hygienist, receptionist, assistant or office manager leaves that group she sees three-million other posts by thousands of other dental assistants. And if she gets caught up and lost and distracted in that, she’s still learning about dentistry.

I want to thank everyone who participated in this thread, and I invite everyone to read what’s been posted already, and continue to contribute their best practices from 2013 as we move into the new year. Best of luck to you in 2014, and I’ll see you on Dentaltown.com! – See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=343&aid=4683#sthash.tTzSBN8t.dpuf