Less is more (or how bigger is not necessarily better)

July 1, 1998
In the four basic levels of dental practice, more is more in two levels. For the other two, it`s less is more. Here`s how it works...

In the four basic levels of dental practice, more is more in two levels. For the other two, it`s less is more. Here`s how it works...

Michael Schuster, DDS

The prevailing belief in America today - which, of course, includes the dental profession - is that more is better: more production, more patients, more volume, larger office, more money, more material accumulation. There are no words that can change an individual`s belief system, commonly referred to as a mental model or paradigm. In the second and third years of my practice, I learned that, for me, more was less. That was when I ended up in the hospital for two weeks from exhaustion and then found out I had developed an ulcer.

My three daughters - ages 6, 7, and 8 - were at my side in the hospital. At age 30, I knew for sure that something was very, very wrong. I was busier than my body could take, caught up in a quantity vs. quality trap. I wanted to do high-quality dentistry, but I was seeing too many patients and working too much to really achieve either. I wasn`t totally quantity- and high-volume-oriented, but I sure wasn`t doing the quality of care that I knew was in my patients` best interests. So, I crashed ... and, as a result of that low point in my life, I started looking for something different, a different way to proceed with the rest of my life.

Since that time, I have had the good fortune to practice dentistry for 26 years in what is commonly referred to as a low-volume, patient-centered, less-is-more practice. As little as two months ago, while lecturing to a small group in Atlanta, an accountant attending my course stated that he had worked with dentists and physicians for more than 40 years. He related that in the mid-1950s, the average gross income of a dentist was $2,500 per month and the ads for practice-management courses read, "How To Gross $5,000 per Month!" It wasn`t too many years later that the ads read, "How To Gross $10,000 per Month!" This was followed, in quick succession, by ads for courses that would teach you how to gross $20,000 and, later, $100,000 per month!

Now I read brochures coming across my desk in which dentists are offering courses to teach other dentists how to gross $3,000,000 per year and to see 200 new patients per month. I ask myself what in God`s name are those dentists doing to people? I sometimes wonder if it will ever end. Will the pursuit of money and material accumulation ever end? Of course, the answer is no!

* When money is your goal, you will never have enough!

* When money is your goal, you always will want more!

* When production is your goal, you always will want more!

So, naturally, when I was asked to write about "less" is "more," I approached it with a great deal of trepidation, because less is more is not the prevailing attitude in our culture. In fact, I realize that less is more is not for everybody. In reality, it is for the minority. For the majority, "more" is "more." For the minority, the quiet minority, less is more.

I have met wonderful, happy, fulfilled dentists grossing $31,000 per month and netting $22,000. I have met happy, high-quality dentists working 36 weeks a year, seeing 30 patients weekly, grossing $350,000 and netting $180,000 annually. I also have met dentists preparing and seating 25 crowns a day! Certainly, in our culture and in our profession, there must be and is room for all these dentists.

In my work, I have come to understand (with the help of others) that there are four basic levels of dental practice. For two of these levels, more is more, and for the other two, less is more. Let me share what I have learned with you.

The Level I dentist

One of my students aptly named this kind of dentist the patch and push dentist. Little or no exam is done and no treatment plan is completed. Patients come in, get patched, and are pushed out the door.

This is a high-volume practice and gross incomes are high. Many times, this kind of practice will have 3,000 to 10,000 patient charts. This kind of dental practice definitely needs more.

Managed-care practices seem to fit into this category. In this model of practice, more is better. In fact, in this level of practice, there always will be a constant push to get more and more patients into the practice.

The Level II dentist

This is the most common type of practice that I have seen, and it also has the greatest number of variations. This was my practice when I began. This is the prevailing model, with many variations on the same theme. This is a very busy practice with 2,000 to 3,000 patient charts. This type of practice has perhaps two or more hygienists and the dentist working out of two or three treatment rooms at the same time.

New patients do receive a thorough examination and treatment plan. They definitely get more than the Level I practice, but the primary thrust in this type of practice still is disease-oriented, as evidenced by the delivery of mechanical treatment as the treatment of choice. The quality of the mechanical treatment may be very high or mediocre, but still the primary thrust is to fix people. This is the way we were taught in dental school.

We estimate that 70 to 80 percent of dental practices in the U.S. are Level II. Level II normally is - though not always - a high-volume practice. Many dentists have learned how to turn this kind of practice into a high-production practice. Time is the constant in this kind of practice, and quality is the variable. Though good technical care is rendered, it usually is incomplete by high-quality standards and the dentist is playing doctor, fixing the mechanical needs of his/her patients.

Yes, preventive programs exist, but generally, lip service is given to these programs and they are used primarily to get the patient in to do the mechanical treatment. Many highly manipulative and confrontational sales techniques are used to get the patient to move ahead with treatment, which turns into high-production dollars. Like the Level I practice, more is better. No question about it. Let me also say that since it is the prevailing model not only in dentistry, but also in American business, the influence against a dentist wanting to move into a lower-volume, higher-quality model is extreme.

In his or her heart, the dentist may believe that treating fewer patients with greater respect and high levels of dignity and compassion is correct. But the prevailing insurance models, as well as prevailing beliefs of the American culture, are the opposite. We go to church and learn one way to live on the weekend and then we are pressured to go against our spiritual values on Monday.

Maybe this is why I got sick. Maybe this is why 26 percent of sudden deaths are on Monday and another 25 percent of sudden deaths are on Saturday. Since dental insurance drives so many practices today, we find ourselves getting paid by insurance companies (whoever is writing out my checks is who I am working for). We frequently find ourselves sending what I term "predenials" - i.e., asking an insurance company for permission for some procedure that is in the patient`s best interest and finding ourselves in constant conflict as a result. In many instances, the patient trusts the insurance company more than he or she trusts the dentist.

There is much internal stress in this kind of practice. Many dentists give up on their dream and resent the loss of control in their practices and in their personal lives.

The Level III dentist

We call the Level III dentist the "biologic dentist." These dentists spend a great deal of their time remaking dentistry that has not lived up to its promise. That is, they remake defective and deficient dentistry. This is an entirely different kind of practice. The attitudes are different, and the office layout is different. The purpose of the practice itself is different. It is in the movement from a Level II practice to a Level III practice that less becomes more. In the Level III and IV practices, the cardinal difference is that the dentist is at least as concerned about the cause of dental disease as he/she is about mechanical treatment of the disease.

Many practices are a combination of Level II and III, especially when the dentist is moving upward to a more patient-centered practice. A more comprehensive periodontal charting, evaluation of the state of the patient`s existing dentistry, and occlusal and muscle-related examination are completed in the patient-centered practice. The skills and capabilities learned in dental school - not only technically, but also in communication, listening, and organization - do not prepare us for this type of practice.

Partnership formed

In a true Level III practice, each patient has a comprehensive examination, diagnosis, and master plan for prevention and treatment of disease. This is the single, highest-leverage activity that differentiates the Level III or Level IV dentists from the Level I and II dentists.

Of course, far more than advanced technical skills are required to move up to a Level III and Level IV practice. We understand that to achieve health, a partnership relationship must be developed. The dentist needs to understand behavioral-change models and models of effective listening and communication if he/she is going to help patients move toward greater responsibility for their own health.

Less is more is the emphasis in this type of practice. When the dentist`s attitude truly changes to become more concerned about the cause of disease, the tempo and the flow of the practice begin to change. We find that it takes about three years of coaching effort with dentists to move into a lower volume, more patient-centered practice. As part of this transition, money and time need to be understood and controlled in order for the dentist to move into a less is more model.

A delicate issue is that there is no exact formula for any of us, but when the quality of care (and I mean total patient care here) and the importance of significant relationships become the focal point of the practice, the dentist must slow down. How much slower and how many fewer patients are dependent upon the dentist`s objectives, temperament, skills, and abilities.

For less is more, dentists cannot simply see fewer patients and do the same quality of care as they would do in the Level II practice. Dentists must learn and apply correct principles of money and time management that will serve as the foundation for this new model. If money and time are out of control, they will control the dentist and all decisions made relative to patient care.

The fear of not having enough money will prevent the dentist from ever moving into this model. Based upon my experience, living in fear is the greatest roadblock to dentists moving into higher levels of dentistry.

Understanding is key

We mistakenly believe that the majority of patients do not accept the dentistry they need because of money. My experience is that when patients understand the disease process, they accept more responsibility for their own health and, as a result, ask for more complete and comprehensive care. Until this happens, a greater volume of dentistry will have to be done. The failure to understand this process has caused more heartaches and pain for dentists trying to improve their practices than any other factor.

Many dentists believe that when they learn to do higher levels of technical care, patients are going to want that care. My experience and the experiences of hundreds of my colleagues suggest that we must slow down and create meaningful relationships with each patient. When the understanding, trust, and belief on the part of the patient increases, so will the acceptance of more complete dentistry. But more than the acceptance of the dentistry, the key issue is the patient accepting the dentist.

My experience over the past 20 years of actively helping dentists pursue this path is that a transformation occurs. Once a professional makes the commitment to a Oless is moreO type of practice, there is peace of mind, fulfillment, enjoyment, and satisfaction. You will feel better about yourself, your purpose in life will become clearer, and you will be motivated to go to your office each day.

When you work with grateful patients who understand the causes of dental disease and you then decide to take an active role in the prevention of their problems, your life changes. Less creates more fun, more time with family and friends, a more meaningful and purposeful life and practice and, in most cases, it also creates more net profits.

Each of us has to ask ourselves these all-encompassing life questions:

. Is it nobler to serve each person completely than to labor diligently for the masses?

. Will it be the primary thrust of my professional life to treat each individual with as much dignity and respect as I am capable of or will I continue to seek more and more for myself?

I believe the answer to these questions will determine if you are living your life out of fear or living your life growing in love. I hope you enjoy the journey; it is your life. You deserve to have the best life and the best practice you can create.

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