The many HATS of dentistry--Part 1 of 4

May 1, 2003
As small-business owners, dentists must wear many hats: those of clinician, entrepreneur, marketing executive, staff coach, manager, and sometimes diplomat.

by James R. Pride, DDS, and Amy Morgan

As small-business owners, dentists must wear many hats: those of clinician, entrepreneur, marketing executive, staff coach, manager, and sometimes diplomat. In our travels, we consistently hear from dentists about their struggles:

Juggling all of the hats necessary to be successful in business

Feeling the pressure of wanting to wear the clinical hat vs. the need to wear the managerial/business hat

Lacking time-management skills to be "multi-hatted" and yet maintain personal and professional balance

Since this is a major source of frustration and stress in our profession, we at Pride Institute decided to write a series featuring important hats that every successful dentist must wear. For each article, we have selected one dentist studying with us who excels in wearing the "hat of the month" and who uses other hats to support it. We hope you will gain insight into how to wear your various hats and balance them effectively so that you can run your practice instead of letting it run you.

This month we will discuss every dentist's favorite — the clinical hat. We will consider this hat from the perspective of how it requires the business hats in order to flourish. We will take you through the experiences of an actual dentist in the Midwest, whom we will call Dr. Smithwood to preserve her privacy. This dentist accomplished her dream of establishing an advanced clinical practice. We selected Dr. Smithwood because she fully implemented management and business systems beforehand, which allowed her to reach her clinical potential. She, like all dentists, needed to deal with the business aspects of her practice first to be free to do what she loves — dentistry!

Establishing a solid practice-management base

After completing dental school, a residency program, and a few years as an associate, Dr. Smithwood bought her own practice in the late 1990s. Unlike many young dentists who wait a decade or more to obtain formal practice-management training, Dr. Smithwood began immediately.

"I didn't know what I was doing business-wise, so just a few months after I bought the practice, I joined Pride Institute. I strongly believed that I needed to focus on practice management prior to establishing a specific clinical philosophy and direction."

Although Dr. Smithwood had purchased a well-run, profitable practice, she wanted to improve it. She believes that "excellence is expected here; anything less shortchanges our patients." She goes on to say, "We implemented everything we learned without ifs, ands, or buts. As a result, we developed sound business plans, budgets, and tracking programs, which transformed our scheduling practices and other operational systems to make us more profitable."

After three years of intense focus on practice management, Dr. Smithwood developed and implemented a sophisticated practice supporting quadrant dentistry and a strong soft-tissue-management program. At this point, the practice was ready to support advanced aesthetics.

This one-dentist, five-operatory practice enlarged its staff to 12 full-time employees and one part-timer — more than double the number of staff in an average dental office. Dr. Smithwood works with three clinical chairside assistants and one lab assistant. Three hygienists, aided by a hygiene assistant, deliver a strong soft-tissue-management program encompassing 11 hygiene days per week. The front-desk staff is comprised of three appointment coordinators, one treatment/financial administrator, and one part-time insurance coordinator. Most importantly, everyone is busy and happy!

One crucial factor that distinguishes Dr. Smithwood's practice from many others is her total commitment to her staff. "I know that I can't implement things by myself, so I involve the staff in every reasonable way. They accompany me in the training I take, whether it's practice management or clinical. If a course doesn't allow my staff to attend, I call the sponsor and ask if I can bring my team. After every course, the staff and I together develop a detailed action plan on how to implement the training."

The practice makes an unusually large investment of time and money in training, which typically involves a half-dozen or more out-of-town trips to attend courses for several days. As a result, the practice instills its employees with a spirit of excellence. "No one just punches a time card here. Our staff members are professionals with a career interest in dentistry," says Dr. Smithwood.

Of course, because the practice employs an unusually large staff, the cost of payroll is higher than it would be in an average practice; however, due to the increased production made possible by the well-trained staff, the actual percentage of payroll and employee benefits remains at a fiscally responsible 23 percent.

Advanced clinical training

In mid-2000, with her infrastructure, staff, and philosophy of comprehensive care already in place, Dr. Smithwood embarked on advanced clinical training. She selected a well-known program delivered in the West and applied her typical enthusiasm and intensity to the curriculum. Within the brief span of 18 months, Dr. Smithwood and her staff completed a considerable number of clinical courses including advanced aesthetics, masters' aesthetics, full-mouth reconstruction, posterior aesthetics, occlusion, and some ancillary programs to support the clinical training. All along, Dr. Smithwood's clinical practice continued and even surpassed the goals set in her annual plan.

"The staff was excited about the clinical training and very proud to be able to offer such high-quality care," comments Dr. Smithwood. "However, it's one thing to be able to do comprehensive dentistry and quite another to be able to present it, have the patient accept it, schedule it, finance it, ensure that the patient completes it, and do all of this within what is already a very busy practice."


After putting into practice much of what they learned in their management training, the doctor and team worked with their consultant to develop a master plan, setting specific goals, responsibilities, and completion dates. The following are highlights of their powerful effort to introduce comprehensive dentistry successfully:

Set goals. Dr. Smithwood and her staff set a goal of performing five comprehensive care cases per month involving more than one quadrant of dentistry and accounting for an additional 20 percent of production.

Profile the ideal patient. They identified the characteristics of patients most likely to accept and benefit from new treatment. They defined conditions related to age, wear on existing restorations, risk of tooth breakage, and the patient's motivation toward oral health and aesthetics. The patients needed to be periodontally sound prior to reconstruction. Through their prior practice-management training, the dentist and team already had a system in place for recording their patients' dental motivators and concerns. This information proved invaluable in identifying the patients they would broach on advanced clinical treatment. They intentionally did not diagnose the patient's pocketbook, only his or her clinical condition and interest in quality care.

Select patients to approach. Effective morning huddles were vital to achieving their goal. At each meeting, the doctor and staff strategized on which of the patients scheduled that day would be approached, which clinical person would assist the doctor in educating the patient on new treatment, and how the case would be presented based on the patient's motivators and concerns. The patient educator is the chairside assistant or hygienist who takes care of the patient. This person assists the doctor by explaining, educating, and clarifying the diagnosed treatment. Having worked on management first, the providers and assistants already had developed systems and verbal skills to help patients make treatment choices.

Debrief on the results. At the following day's huddle and at each departmental meeting, the staff talked about which techniques and verbal skills worked well and which did not, and they strategized on how to improve their approach.

Define and refine the strategies. The doctor and clinical staff developed a procedure for introducing the selected patients to aesthetic dentistry, as well as for doing a clinical work-up (radiographs, study models, or whatever was needed) and a consultation for those patients who reacted positively. The doctor and staff use the computers in each operatory to present a digital slide show of before-and-after shots and intraoral pictures. Again, they already had the practice-management systems, verbal skills, and tools for case presentation and patient education prior to their advanced clinical training.

These key operational tools support their goal of offering more comprehensive cases. Doctor and team choreograph patient education and case presentation, answer clinical questions, close the patient clinically, and transfer the patient to the financial coordinator for financial arrangements.

Financial arrangements are handled through outside credit sources. The doctor indicates the price range early on so as not to surprise the patient. The financial coordinator assists the patient in completing and processing the credit application on the spot. These systems were already in place as a result of the high degree of management and organization developed prior to the clinical training.

Unexpected mini-projects arose during this attempt to implement comprehensive dentistry. For example, the team needed more before-and-after shots in their presentations, so they devised a way for patients to return to the office after their treatment was completed and the swelling subsided to take pictures and gain permission to use them.

The team did this through value-added services, such as a final inspection of the treatment by the doctor, a smoothie (also provided during the treatment sessions), and a gift.

The practice had a system to obtain and record information about the patient's hobbies, occupation, and family, which proves useful in providing customized gifts.

Schedule treatment. The schedule is preblocked to accommodate advanced clinical cases. An extra day is set aside for these appointments so as not to interfere with the practice's busy schedule. The dentist has chosen to work the additional day for the present time to launch the new program.

Track results. Already in place are patient monitors to track treatment presentation, case acceptance, and completion. These systems were essential to measure how successful the practice was in introducing advanced aesthetics.


The practice has been averaging 4.2 comprehensive care cases (i.e., cases involving more than one quadrant of dentistry) per month in almost two years of the program, an excellent result and close to the doctor's goal of five such cases per month. The practice is currently using outside marketing to attract more targeted patients to the practice and to reach the goal of five cases per month. Dr. Smithwood's comprehensive case-acceptance rate rose from 50 percent the first year to 65 percent currently.

It is significant that their completion rate is almost 100 percent. This indicates that the staff and dentist are doing an outstanding job of educating and motivating patients. The procedure mix in the practice is now approximately 20 percent comprehensive-care dentistry and 60 to 70 percent quadrant care.

"There is no 'watching' of decaying teeth in this practice," says Dr. Smithwood. "We don't have that word in any of our literature. Most of our patients present with existing restorations that are breaking down. I'd say the treatment they are receiving is as much or more functional as it is aesthetic."

Dr. Smithwood and her team used all of their practice-management tools, including an action plan, goals, scheduling, financial arrangements, marketing, treatment presentation, morning huddles, and patient education, precisely and effectively to enhance their clinical offerings.

For those dentists who say, "I think I'll put off practice-management training and take advanced clinical courses instead," we say that's like trying to fly with only one wing!

Through this example, you see the seamless integration of the dentist's management hat with her clinical hat. Do yourself a favor and get your practice-management hat fully comfortable on your head. Then the freedom of clinical advancement will be yours for the taking.

For more information on how to improve your practice and to implement the management systems described in this article, call Pride Institute at (800) 925-2600.

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