Interviews with Dr. Carter and Dr. Unthank
John Jameson, DDS
This month, Dr. John Jameson interviews Dr. Jeff Carter and Dr. Michael Unthank, two of the most respected names in dental office design.
Dr. Jameson: We have seen many changes in dentistry in recent years. In terms of office design, what philosophical changes have you seen in the last 10 years?
Dr. Unthank: Generally, the biggest change has been the integration of technology. The same technological revolution that has taken place in business also has taken place in dentistry. The offices have not changed much other than the introduction of new technology and the transfer of some of the work from the front end of the practice to the treatment area. Another change has been in the image of the office in terms of cosmetics and esthetics. The image of the practice needs to be conveyed so that those two are one and the same. We need to let patients know that through our interior design and architecture the dentistry provided to them is of the highest quality.
Dr. Carter: This may surprise you, but the more things that come along that would seem to change the facility, the more we're finding that some of the well-established principles of the last 30 to 40 years are still very much in play.
Three of four years, people would tell us at T.H.E. Design that we would have to make their operatories much bigger. They knew of 10 new things that they just had to squeeze into the operatory. Were we going to expand the room? Were we going to surround the chair with every piece of available equipment? It was a major challenge, and people were running in circles trying to figure out the solution. But the more we examined it, the more it brought us back to human dimensions - the proper seating position, how far people can reach, etc. Once you look at these factors, it really limits - from an ergonomic standpoint - where you can put pieces of equipment.
At some point, you can have a 20-by-20 operatory, but you're still not going to be able to reach very far. You have to decide what you can ergonomically reach. It's really a combination of ergonomics, functional utilization, and prioritization of what pieces of equipment you use the most. One of the main considerations is to produce efficiently, but you also have to look at how to lengthen the careers and the life spans of those people working in that operatory. If we create operatories just to display equipment, we're shooting ourselves in the foot.
You may have some pieces of mobile equipment, but they can clutter the operatory. If you're not going to use a piece of equipment all of the time, it's going to clutter the operatory. Some people have created a central alcove or sterilization area where these items are stored and kept when not in use.
There's a definite logic that can be used to determine what stays in the operatory and what doesn't. You may have 10 or 15 smaller pieces of equipment that won't be used with every procedure. Prioritizing is the key.
Dr. Jameson: During the last 10 years, what kind of bottom-line impact to the practice have you seen in the changes in design?
Dr. Unthank: Ten years ago, very few of us had a practice-management monitor or an intraoral screen for patient-education purposes in our treatment rooms.
Dr. Carter: It's really a concept. We combine highly functional offices with an esthetic element. All of the operatories in the office are identical, so that no matter what room the doctor is in, if he or she reaches for something, it can be found in the same place. It's like if you went into your garage every morning and there was a different car and you were running late, it would be very stressful. You would fumble around to find the right key and get the mirrors and seat in the right position. If every operatory has something different in it, that's stressful. Delivery units, chairs, and even cabinets have to be the same in all operatories.
There's an esthetic element when people walk into a dental office. People equate high quality with the facility they see. It's a subliminal thing. People walk in and think, "Wow! These people must know what they're doing!" When you propose more comprehensive, higher-quality treatment, there's a huge increase in acceptance based solely on the appearance of the facility.
We've tracked numbers for 20 years. Over the last three-year period, the typical office went from four operatories to five-and-a-half, and moved from seeing 20 new patients per month to 35. In the old office, the average production was $51,000; it increased to $71,000 in the new office. The average production increase is around 36 to 40 percent, and the average new-patient increase is roughly 35 percent. We've found that dentists who build a new building generally have their debt service covered within a three- to four-month span.
It's funny that some bankers will ask a dentist why he or she would want to invest so much in a dental office. Yet, when you walk into the bank, it has marble countertops, a four-story atrium, and architecture that tells the customer that there is validity in this institution. Customers think, "If I put my money here, it will be here tomorrow."
When you walk into a dental office and there's faded carpeting, miter corners that don't fit together, and mismatched posters, people aren't going to request veneers on six upper teeth.
My best friend in dental school had a practice in Aurora, Colo. He was producing in the low-30s. He had a couple of financing plans, but could never talk a patient into accepting a comprehensive treatment plan. From 1996 until 1998, his income went down. We did a mid-range design level for him on a beautiful lease space that overlooks the Rocky Mountains. By his fourth month, he was averaging $51,000. A lady who went to her physician in the same building walked into his office and asked for 10 crown and bridge units. Another woman walked in off the street and asked for six veneers for her upcoming wedding. Neither one of these women was referred by anyone. They didn't know anything about this dentist or his practice. They just saw his facility, and they were impressed.
A person's perception is very important to a dental practice, as is the marriage of function and esthetics.
Dr. Jameson: What percentage of practices have gone through a technological and physical metamorphosis to have these types of products?
Dr. Unthank: Every office that we design is designed with clinical workstations in mind. That marks a large paradigm shift from 10 years ago.
Dr. Jameson: What kind of changes are being reflected in today's office design?
Dr. Unthank: From an ergonomic standpoint, there haven't been a lot of changes in design. That's very frustrating. The design of the treatment needs to be based on logic that we all should have followed forever, but it's not part of the logic taught in dental school. If we incorporate technology and use four-handed dentistry, we are positioned properly. The incorporation of that technology needs to be flexible enough that everyone - the doctor, hygienist, assistant, etc. - who is using it is taken into account. The workstation needs to be in a logical location so that all three primary staff members can access it. The assistant needs her primary focus on instrument delivery, so she'll be at the 12 o'clock position, whereas the dentist could be at the 11 o'clock position. The workstation must be able to help them both. Flexibility is the most important thing. The workstation must be fully articulating.
Screens are big in today's office design. Offices should have screens that the patient and dentist can view.
Dr. Jameson: If you look in your crystal ball for the future of our practices, what would you see?
Dr. Unthank: We will all have practice-management monitors, workstations located in our treatment rooms, and the evolution will continue with our CPUs, with flat screens and flat computers becoming a big part of the office. At the Chicago Midwinter Meeting, we saw more and more devoted to the "flat" concept. You're seeing all of this within one box, which also contains the screen. That screen will soon be activated by touch or pen, and total-recognition voice technology is just down the road.
Dr. Carter: I have definite technology ideas, but I don't know that they would change the operatories that much. A lot of the talk at the Chicago Midwinter Meeting was on magnification and headlights. We tested a lot of them, and they have some wonderful benefits. But, at some point, we have to have cameras where I can watch on the monitor what I'm doing. I'll have a 20" monitor right in front of me, and I'll be able to see more than I ever could with direct vision.
One thing that I saw at the Midwinter was the Gendex 765, an updated version of the Gendex 770, which is probably in half of the dental offices in the United States. It has a lot of the "bells and whistles" that dentists are looking for, and the makers put controls on the head so you can extend that unit and manipulate it at the head where you're standing as opposed to going back to the box. That cuts down on duplication of effort. You don't have to run to the hallway to use the control box.
I think you'll see controls on wands in the future as well. If I can control air abrasion using the wand instead of maneuvering to find the box, that's an ergonomic function that will help me and my practice.
A lot of talk has centered on offices being "front deskless" in the future. There's a perception that you can put computers in all of the operatories and cut down on the load on the front desk. The most efficient thing you can do is to design a room for what actually goes on in there. Yes, you can schedule in an operatory, but you really don't want to conduct business in there. That's mismanaging your space.
Anything brought into the operatory or the practice should make us more productive, increase the quality of care provided to the patient, and not disrupt the inner ergonomic principles. If you can't meet those three criteria with a new piece of equipment, why are you bringing it into the practice?
Dr. John Jameson is chairman of the board of Jameson Management, Inc., an international consulting firm. Dr. Jameson lectures internationally on high-tech dentistry and its integration into the dental practice. He provides research for manufacturers and marketing companies. Dr. Jameson may be reached at (580) 369-5555 or by e-mail at [email protected].