More is More

by George Salem, DMD, FAGD

When I ask dentists what they believe is most essential in developing a thriving, successful practice, they will almost unanimously recite the doctrine of "quality dental care combined with excellent service." But what is "excellent service" anyway?

It may just be me, but it seems that many dentists and consultants seem to have espoused the "less is more" philosophy as a strategy to build a successful practice. This philosophy rears its head in many forms and convolutions with the general premise being that by offering "excellent service" to patients, the dentist gets to work less and earn more. Here is a good example of a dental practice with such a philosophy: The practice becomes a "high tech, high touch" boutique delivering only aesthetic dentistry during regular business hours (no evening or Saturday appointments). This practice also does not accept assignment of insurance benefits. Fees for dental procedures are in the top 0.1 percent in the nation. The practice offers 15 different beverages and fresh-baked cookies every hour on the hour in the reception area. Additionally, it offers a shoe-shine machine and 10 varieties of cologne and moisturizing cream in the restrooms. As a result of this "excellent service," patients will give up conveniences such as evening and Saturday appointments, assignment of insurance benefits, and the array of dental services beyond cosmetic dentistry.

Unfortunately, this practice model also reduces patient convenience, offers a narrower range of services, and does all of this with higher costs to the patient. The unavoidable effect of this philosophy is a reduction in the patient population with the time and financial resources to do business with this practice. The notion that this practice model is a way to grow any and all practices is unrealistic.

Common sense would dictate that no professional service business in a competitive, capitalistic economy could prosper by offering less service and less convenience while charging more. Yet, the above practice model asks us to do exactly that. Well, I will embrace common sense. It has served me well in my years in practice.

Let me begin by sharing one of the questions I have asked every new patient for the past 15 years: "Why did you leave your previous dentist?" You'll find their most common responses listed in the box on the right.

Although we may take solace that the first four responses do not describe any disappointments with the dentist or the practice, all of the other responses are clear descriptions of a lack of service. Today's patients are more pressed for time than ever before. They also are becoming increasingly familiar with excellent customer service due to the efforts of many companies to secure customers, both inside and outside of health care.

Successful companies recognize the changing needs of today's consumer. The modern consumer seeks more convenience and more flexibility, not less. Customers require it and successful companies provide it at a price the market will bear while factoring in a handsome profit. A basic law of consumerism promises that if you do not provide what the consumer needs or wants, some other business will.

That said, we must now distinguish those conveniences that really matter to patients from those that either have very little impact upon them or are not appropriate from a return-on-investment standpoint. Some years ago, I watched an interview of the then president of American Airlines. The interviewer badgered the executive on items such as more leg room, better food, more convenient routes, etc. Finally, the president of American Airlines responded by stating, "We can provide all of that and more, but very few American consumers are willing or able to pay for it." His response could not have been more astute. To engage our staff's time and our financial resources in activities and expenses that are unimportant to patients or do not return more revenues than they consume is financially irresponsible.

Every practice is different and so, too, the service mix that each will deliver. Let me share with you those conveniences and services my patients find desirable and have allowed me to build a healthy suburban fee-for-service private practice. Think about how these services and conveniences correlate with the reasons patients leave their dentists.

Our practice offers evening and Saturday appointments. I do not delegate the responsibility of seeing patients during evening and Saturday hours to my associates so that I may have Saturdays off. In fact, even my periodontist provides Saturday appointments along with me and my general dentist associate. As successful as our practice is, eliminating either evening or Saturday appointments would impede our growth and long-term profitability. Indeed, in this retracting economy, our new-patient flow has been increasing and, with it, growth in production, collections, and profitability numbers. In a slow economy, when patients are concerned about job security, they are not likely to take time off from work to make a dental appointment. Thus, our evening and Saturday hours are an important and timely strategy for continued practice growth, regardless of the economy. Similarly, we do not engage in block scheduling because this further reduces our ability to offer convenient appointments. If a patient requires a crown at 6 p.m., that is when I will do it. A new patient for an initial oral examination at 8 a.m.? That's just fine with me. More convenience, more patients, more profitability. More is more!

Over the years, I have listened to many patient complaints that their previous dentist performed procedures at a cost that far exceeded their yearly insurance maximums and their out-of-pocket budget. Dentists need to understand that most of our patients are employees on fixed salaries. They can't spend one dollar more than their budget allows without spending less in some other area of their lives. Unexpected large costs can mean not meeting their savings goals or actually taking money from their savings to pay the bill. Unlike us, they cannot simply work more hours or sell more products whenever necessary to make ends meet. When patients tell me that they do not wish to exceed their insurance maximum, I honor their request without hesitation and ask my front-desk staff to precisely monitor their insurance usage throughout the year. Any modern computer system will easily track this. It does not benefit anyone to lock horns with these patients and try to prevail upon them to disregard their budget plans.

Many dentists believe they cannot provide ideal care if they are restrained by insurance plan limits. It is simplistic to recommend only ideal dentistry and a rigid up front payment policy to every new patient. Providing ideal dental treatment results, while honoring the patient's fiscally responsible budget, calls for excellent treatment-planning skills, proper sequencing of specialty treatment, a highly intelligent and responsible front-office staff, and effective communication. Although certain cases demand an "all-at-once or no-treatment-at-all" approach, most cases — including complex ones — can be completed in sequential phases the patient can afford. More skill and insight from the practice results in more patients able to engage in dental treatment. Once again, more is more.

When a new patient or a patient-of-record has an emergency, he or she must be seen immediately (during normal business hours). The absolute bedrock philosophy I try to consistently project to every patient is: "My practice is comprised of kind and caring people with the patient's best interest at heart. We exist to serve our patients and our community."

Not seeing a patient with a real or perceived emergency immediately destroys the very image I am so diligently trying to uphold. Learn to build some flexibility into your schedules and your personnel, and your practice will receive greater numbers of respectful patients who, in turn, will refer others. Keep in mind these emergency patients usually need considerable treatment. They also are highly motivated to proceed with care. More flexibility and more compassion equals more patients arriving at your practice in need of your services. Again, more is more!

More than a few patients over the years have complained to me that their previous dentist was not able to anesthetize them adequately. They will then usually go on to say that they informed their dentist of the problem, but the dentist ignored their concerns. There is no need for even one patient to feel this way.

Everyone can agree that the lower molars are the most unpredictable teeth to anesthetize. I use Septocaine regularly in my practice, and I have observed that enhanced anesthesia was achieved. When standard injections fail, intraosseous injections usually are 100 percent effective. Doctors, please learn and become proficient in this technique, and you will be able to handle mandibular molars predictably and efficiently. The more skills you can master, the larger the pool of patients you can successfully treat.

These services may not seem "sexy" or novel, but I am convinced they are the core services that have contributed to the success of my practice. Dare I say that I do not offer five kinds of fruit juice and freshly baked cookies every hour in the reception area or a shoe-shine machine and 10 different moisturizers and colognes in the rest rooms? These amenities may have a place in some practices, but they would not have the desired impact on my patients or my practice. Instead, the following amenities, in addition to the above-mentioned core services, have secured a generous and consistent new-patient flow, a near perfect treatment-acceptance rate, and a handsome bottom line.

We seat our patients on time and finish their treatment on time. This is the most appreciated luxury for today's busy consumer. If you like to treat the affluent, successful crowd, it is extremely important to be time-efficient. These people did not become successful by meandering through life. For them and just about everyone else, assorted beverages and cookies in the reception area will not make up for a doctor who consistently runs late. If you are consistently on time and seat your patients as soon as they arrive, your patients will have very little opportunity to utilize the beverages and the cookies anyway.

We offer Virtual IO®•; headsets in each of our six operatories. We have a library of over 300 movies for patients to view through these headsets during their dental treatment. Once patients use this device, they will use it for every visit thereafter. They also cannot wait to tell their friends and coworkers that they watched a movie during their dental treatment. This immediately makes me the "high-tech dentist" in the area. From a patient comfort point of view, this single service has had a tremendously positive effect on stress levels and the number of word-of-mouth referrals.

Other services that have the proper impact for the time, money, and effort involved include:

• Personal CD players
• Hot towels for every patient
• Post-treatment phone calls
• Reminder phone calls on the day of the appointment for patients who must premedicate
• Multiple specialists available within my practice (orthodontist, periodontist, oral surgeon)
• Dentist on call 24 hours a day, seven days a week, 365 days a year
• Nitrous oxide
• Intravenous sedation
• Consistent and generous use of the intraoral video camera during the initial oral examination, as well as before, during, and after dental procedures.

This list is by no means exhaustive, since I have not tried everything out there. Nevertheless, I can state with confidence that these services and amenities have had a profound effect on my practice and my patients for a minimum investment in cost and time expenditure by my staff.

To reinvent your practice by transforming it into the narrowly-focused, aesthetics-only boutique model is a difficult task indeed, requiring tremendous time and effort from dentists, their families, and their staff. Furthermore, these types of practices are extremely sensitive to the health of the economy. Although this type of practice can prove lucrative and provide great personal satisfaction and fulfillment, most of these practices fail to live up to their intended goals. I know several dentists who took this plunge and now regret it because they did not realize the tremendous commitment that was necessary, or the realities of chasing a few prospective patients with the desire and financial resources to undergo this type of dentistry.

My advice to dentists who wish to incrementally improve their practices rather than reinvent it is to add those services that make it easier for patients to access your practice. Then, implement strategies that make it easy for those patients to stay with you. Next, provide strategies that allow you to quickly and easily enhance the patient's dental I.Q. Then, utilize the intraoral camera to develop patient trust by taking before, during, and after pictures of the first operative procedure on every new patient. Finally, rather than invest your financial resources and staff time in amenities that make the patient's waiting time more pleasant, devote these resources to amenities such as the Virtual IO glasses and effective anesthetic techniques that make their actual treatment more pleasant.

As I said at the beginning of this article, this advice is not exotic or new, but it is effective for every practice, in every region of the country, for patients of every socio-economic level, during all economic climates. What advice could have more impact than that?