Three-quarters of human brain growth takes place in the first three years of life.

And that represents almost everything except the prefrontal cortex, which does not fully mature until around the age of twenty-five. This means that our ability to cognitively process…our ability to understand and respond appropriately to lower brain functioning, and particularly our emotional system, is quite limited early-on. Yet that is exactly when most of our beliefs about the world and how it works are formed and rarely challenged. So, when a person comes into the office claiming that “When I was a kid, the dentist put both feet on my chest to extract the tooth. It was horrible. I hate going to the dentist,” we are actually dealing with a belief and not a fact.

Responding to “When I was a kid…”

It is counterproductive to begin a new relationship with a person by telling them that they are wrong and don’t know what they are talking about. So, we have to begin someplace else, with the goal of facilitating a change in belief over time, and not with a goal of convincing others how much we know and that they should surrender to our intellectual prowess. Start with the understanding that we humans don’t like to be challenged as wrong. Also understand that we’d often rather be wrong than right, simply because it feels better to our ego.

It turns out that the only way beliefs change is through an inside-out process of self-reflection, re-assessment, new realizations, and new assumptions repeatedly confirmed by new experience. Before there is a commitment to action, your patient with negative beliefs about dentistry must go through this. And, I’ll bet you weren’t thinking all of that was going on in your patients’ brains, but it is…every single day. That is why relationship-based dentistry holds so much power and potential.

Truly helping relationships are the only vehicle through which significant personal change occurs in dentistry. L.D. Pankey said, “Know your patient,” not because you can use the knowledge strategically to defeat them on an intellectual level, but rather to help pave the way toward significant change and therefore better decision-making.

We can’t manipulate our patients toward becoming healthier.

In fact, the more we try to manipulate people, the more their lower brain recognizes something is wrong. It doesn’t know what, but at least it’s smart enough to stop listening, and focus on self-preservation—like staying away from people who will likely put “both feet on their chest.”

Theresa Duncan from Odyssey Management has been one of the top 25 women in Dentistry, and for over 20 years, she has advised dental offices on how to correctly use insurance to their advantage and how to carry out a conversation about insurance.

Why? Because one of the biggest barriers to patient conversion is fear about how much it is going to cost.

Her book, ‘Moving Patients To YES!‘, doesn’t help only insurance dependent dental offices. It also helps insurance independent or blended practices have easier conversations about nonparticipation and out-of-network services.

The latest trends she is reporting will set you on the edge of your seat, because just when you thought it couldn’t get any worse, it has. And, this brings us back to the consideration that nonparticipation or getting off of plans might be best for you.

In a recent conversation, Duncan reported there are big changes being made in plan designs and how patients are getting their information. The plans are so difficult to understand that the front office of the dental practice is put in the spot of having to translate them. Patients get their plans and don’t understand what they mean. The plans are confusing even to professional insurance coordinators.

Patients are paying more for their benefits, so they are expecting to get more, which is unfortunate because dentists can’t deliver more. Duncan is seeing a lot more deductibles. The upshot is that more employees are opting out of dental benefits.

Dental practices, especially solo practices, now have less power to negotiate with insurance plans.

In the last twenty years, dentists have gone from “laughing at plans to getting on plans,” even rushing to get on them. And then, reimbursement got pushed down. The average dentist (according to the last ADA numbers) will participate in 8 to 10 plans, but Duncan sees the trend is now swinging back towards being selective and getting off of plans. Many dental offices are happy being in 3 to 4 plans. They don’t want to deal with plans that are costing them too much in revenue and time.

If you drop plans (or have never participated in plans), it doesn’t mean you lose patients, says Duncan. It means your team needs to be highly skilled at having conversations with patients when the topic of insurance arises.

It seems that “empathy” has become one of the most popular buzzwords in dentistry, and in spite of the popularity of its use, few people understand what it is and why it is so important.
Confusion may be rooted in dictionary definitions such as “the ability to understand and share the feelings of another.”

Can we really understand and share the feelings of another?

Avrom King used to say, “There is no such thing as a second-hand feeling.” It’s impossible for us to fully understand the feelings of another person. In truth, the best we can do is contemplate intellectually what a person MIGHT be feeling and then project our feelings upon our thinking.

Our feelings, and our patients’ feelings are unique to us and them. They cannot be fully explained or understood by others. Yet, they are valid because what we feel is our reality.
Our brains function based on mental models or “thought constructions.” These thought constructions may be fairly accurate, total fabrication, or something in-between. But in all cases, they are still our reality. And the only way for us to square the inaccuracy of our thought constructions with reality is to test them against what we perceive to be reality.

Perceptions are open to review. They change.

And, there is another problem. Our perception of reality is a thought construction as well. In other words, our brains function by testing our thought constructions against our thought constructions, and then we call the most successful ones “beliefs.”

Because a belief is still a thought construction, it is always up for review with regard to accuracy, unless of course, we don’t want to do that. And in that case, we choose to become dogmatic instead of continuously being open to refining our version of reality.

So, why is understanding this important?  Because beliefs, dogma, and empathy all fully infuse the relationship we have with ourselves as well as our patients.

What we think they think influences how we think.

Let me say that again. What we think they think influences how we think. So, if we come into a new relationship with beliefs about ourselves and other people which are rigid and dogmatic, then it is very unlikely that we will find the whole truth, and most certainly, we will never even come close to understanding our patient’s perspective. Yet, our patient’s perspective is the complete source of their motivation to act or change their perspective.

Empathy is an attempt to understand another’s thoughts and feelings.

Giving others quality attention signals we are interested in understanding what they think and feel. It signals that their thoughts and feelings are important to us. Empathizing is an act of caring about another person. When we give others this kind and quality of attention, it allows them to feel safe and accepted. And in that space, they are more likely to re-assess their beliefs about dentistry, dentists, and what dentistry might be able to do for them. Consequently empathy, non-judgmental acceptance, and behaving in a transparent authentic fashion is the pathway towards facilitating change in others. This is what Carl Rogers called “congruence.”

When patients feel supported and risk committing to change, we call it trust.

Change in attitudes, beliefs, and perspectives is what causes patients to commit to significant change, which at the end of the day is a risk…a risk taken because they feel like the people around them will support and care for them along their journey toward new understandings, perspectives, and experiences. And when that happens, we call it “trust,” which is at the foundation of every enduring and meaningful relationship.

As I lay here and reflect on the last 30 years of my life, I cannot help but wonder and imagine what my life would be like had I not been given the gift of being a part of The Pankey Institute. Today marks my 30 year anniversary of walking through the doors of what was then called The L.D. Pankey Institute for Advanced Dental Education. I was seven weeks shy of my 27th birthday, and I had nothing but a lot of debt and dreams of doing great dentistry.

Back Then and Now

I am no different than many, if not most, of the students of today, who are saddled with what seems to be an insurmountable amount of debt. At the time, we were charging about $300 for a crown and paying a $70-$90 lab fee, a percentage of over 20%. I never even considered that percentage high, because I was just happy to be taking care of people.

Many people say, “It was different back then,” but was it? People were waking up with mouth or jaw pain. They were seeking an individual that could take care of their needs. Some wanted to feel better. Some wanted to look better. Some were willing to lose teeth. Some wanted to keep teeth. It is the same now as it was then, and it will continue to be this way for decades to come.

The fact that people will need or want to be taken care of will never change. The fact that some will have money to pay for your services and some won’t will never change. The question is “What type of dentist will you want to be?”

The Road Less Travelled

Thirty years ago, I wanted to be the best. Having been given the book The Philosophy of The Practice of Dentistry by L. D. Pankey, in dental school, I felt this was the way to care for patients that needed us. You see, it is all about the choices we make. I wasn’t going to be guaranteed a salary by a corporation, but I was going to have the opportunity to keep a portion of all I earned. It was up to me to make the decision about how I wanted to care for people, and this philosophy became my driving force.

The office I was in and peers in my area at the time did not seem to have the desire to take this path, as no one else had been to The Institute. I guess you could say I took “the road less traveled.”

The choice of committing to this philosophy has impacted my life beyond measure. For 30 years I have been able to learn from some of the greatest educators this profession has to offer, who have given their time, treasure, and talents to the 30,000 students who either have flown or driven to the beautiful island of Key Biscayne, Florida. I have established lifelong friendships with individuals from all over the world, who had and still have aspirations and dreams just like me. I have made mistakes, and I have done great things. All along the way, I had a group of individuals I could count on to get me through the ups and downs of the practice of dentistry, as well as life itself.

The Pankey Institute Community Is There for You

As you finish reading this, whether you are 26 or 56, realize there are people willing to help you get to where you want to be. I am glad it was The Pankey Institute for me. The Institute has now been here for over 50 years, and I feel immensely grateful for the 30 years that have been mine.

I want to thank all of those individuals who have given me so unselfishly their gift of priceless knowledge. And, if you have just begun your journey with The Pankey Institute or thinking you might like to, let me assure you that The Pankey Institute community is there for you.

Enabling Your Team to Bring Their Best to Collaborative Problem Solving

One day, several years ago, our dental practice was facing an imminent snowstorm. We could see that the storm would play havoc with our professional and personal schedules. Decisions had to be made about our response. Should our plan be the same as the last time the office had been closed by weather? People were beginning to get nervous about how this was going to play out. A clear decision and well thought out plan were called for, but there was no one right answer. We needed to quickly make a collaborative plan (an agreement) to distribute power and communicate with our patients.

Planning for Contingencies

As in the case of the imminent snowstorm, I believe there are frequently practice decisions to be made for which there is no one right answer – no one strict plan that we can establish ahead of time and not expect to modify. Many variables need to be considered each time as the circumstances of owners, team members and patients change.

Collaborative planning takes “high engagement,” insight and practice. If you have preplanned team agreement on how to handle special events, you are ahead of the curve, but you will find it helpful to visit these agreements periodically, and you can anticipate you may need to collaborate “on your feet” when contingencies arise.

Role-Playing

Last year, at “Inspired Team Facilitation” with Joan Unterschuetz, we did role-playing that helped the team develop a collaborative plan for which every member of the team had buy-in and agreement. Role-playing has helped our team huddle in an emergency to clarify what needs to be done, who can best take the lead on each task, and acknowledge the compelling reasons why we are doing this as a team. It also has been helpful to prepare each department leader to motivate team members who will help them make sure we effectively communicate with patients, assure patients, and shut down if we need to do this swiftly; then in reverse, open up the practice and zero in on what needs to be done to open the schedule and reschedule patients as priority dictates.

Agreeing to Agree

From the earliest time possible, work on building a culture of agreement around:

• Team meetings with high-engagement of all stakeholders
• Understanding problems to be solved and why they must be solved
• Respecting all team members who would be affected by giving them a voice in the planning
• Understanding that department team leaders will be accountable for execution
• Coming to joint agreement and celebrating that fact at the time the agreement is made

The goal of these “coming to agreement” exercises (even about the small stuff) is to set a standard of collaboration that is in alignment with your practice philosophy. When an emergency arises, the team knows from experience that they can quickly collaborate and come to agreement on a plan of action…even when there is no one right answer and you need to kick start action immediately. If your collaborative meeting goes off track, the dentist as practice leader needs to remind everyone of the compelling reasons why they need to come to agreement now.

Can’t Involve Everyone?

Sometimes involving everyone is not possible in a crisis, but the goal is still the same. The goal is to be on the same page and united in decisions. All team members need to be informed of decisions, so if you and your department leads need to quickly create an agreement, the leaders will report back to other team members for implementation and keep them in the loop. Keeping everyone in the loop honors them and combats the human response of making false assumptions and experiencing energy-consuming emotions. In a culture of agreement, there is less opportunity for negative energy to accumulate—less “drama.”

When we identify patients, whose dental esthetics has been negatively impacted by altered passive eruption, our treatment plans are apt to include altering the gingival esthetics. One of the things we are tasked with is determining where we want the tissue to be.

We start by determining if the incisal edge is correctly positioned in the face.

For example, by looking at a lips at rest photograph and a full face image for my patient with altered passive eruption, we can see that the patient’s incisal edges are correctly positioned. If they were not properly positioned, we would next plan the position for the incisal edges.

Tooth proportion becomes the next building block in the planning puzzle. We know that beautiful anterior teeth are usually between 70-80% width to length ratio. This variability allows us to accommodate other clinical considerations, as well as patient preference. As a starting point, I begin with 75% and then look at the other parameters.

If the patient has excessive gingival display, and one of the hoped for outcomes is to minimize the amount of gingiva, we can alter the drawing to increase the length and then evaluate the esthetic result.  On the other hand, if there is excessive sulcus depth, we can place the proposed gingival margin within the confines of the sulcus and assess the esthetic result.

Patient Involvement

I create template drawings, like the one below, in Keynote on my Mac computer, but drawings also can be done in PowerPoint. I then sit down with my patient, insert a retracted teeth apart patient photo behind the drawing, and together we move the lines until the patient is happy with where the pink will be.

Once we have the final proposal, the next step is to determine the possible treatment options to gain the intended result. The information can easily be transferred to a wax-up or used to create a snap on trial smile.

How to Create and Use Templates

In Keynote or PowerPoint, take a retracted teeth apart photo of a beautiful, near perfect smile. Put it into the presentation software. Blow the image up to 200%. Using the free form drawing tool, trace the outline of the upper six anteriors. Take the photo out and save the presentation as a named template.key or template.ppt file.

When you want to do proposal drawings with your patient, open up the template, insert the patient’s photo and save the file with the patient’s name. You can copy and paste the tooth outlines onto any of the patient’s photos to propose gingival changes. If you pre-draw and save outline templates for various tooth sizes (ratios), you can quickly show options to your patient.

One of the hardest things in dentistry is to know when to keep pressing onward or deeply reconsider a situation and move on in a new direction.

Everyone knows that perseverance and “grit” are key to success. Anyone who has worked their way to the top can tell you about their moments of doubt, horror stories and wounds acquired along the way. But never re-assessing, never changing course is problematic as well, as it is analogous to sailing with a fixed rudder. It is only a matter of time before you run your boat aground.

Do you have both a plan and a strategic planning process?

Successful management of the direction and functionality of a practice requires the use of both approaches, and that is why every practice needs to not only have a plan but also a strategic planning process. A strategic planning process is an iterative process of self-reflection. It is constant and not just an event. Because it is a “process” of constant reassessment, you can discover when to reimagine and change course. Dwight D. Eisenhower spoke to this truth when he said, “Planning is essential, but plans are useless.”

Where are things breaking down?

An objective way to arrive at an answer is to begin to analyze where things are breaking down. The work of Simon Sinek is helpful in making this analysis. He says we can have breakdowns in the areas of HOW, WHAT and WHY.

Breakdowns in specific areas of a practice are often breakdowns in HOW. This is when people are not executing well-designed and well thought through processes and procedures. This may be driven by a lack of knowledge, understanding, ability and/or desire. And these represent objectively correctable problems. For example, if the margins of our crowns are consistently substandard, we need to go back and figure out where our processes and thinking are breaking down. If a team member is failing to execute their responsibilities in an appropriate fashion, the same approach holds true.

Are you climbing fast in the wrong direction?

Failures can also occur at what I would call a “strategy level.” This is a more global level above execution, because it involves more of why we are attempting to do what we are attempting to do. Simply put, poor strategies will lead practices in the wrong direction. Steven Covey’s metaphor of having our life ladder up against the wrong wall applies here. We can be climbing fast, while simultaneously climbing in the wrong direction.

Does your work feed your soul?

Failures can and do originate on a WHY level. An example of this would be a person working hard and making bank, while hating being a dentist. This represents a failure on the visionary or philosophical level. Failures on this level represent spiritual depravation. In this case, we are going through the motions, yet very little of what we are doing feeds our soul. As a consequence, people often attempt to fill this void in a dysfunctional way, perhaps, with alcohol, drugs, sports, extreme exercise regimens—or something else that easily becomes an addiction.

If we have HOW and WHAT breakdowns in a practice and still have our WHY worked out, staying focused and working through issues and problems is appropriate. However, if the reason things are not being executed well and the reason our strategies aren’t effective is really because our heart isn’t in it, then we have a spiritual crisis on our hands.

Without first addressing our inner nature and our inner truths, we will never be successful at addressing more downstream challenges such as HOW and WHAT. L.D. Pankey was speaking to the essential nature of this truth when he said, “Know yourself.”

When asked about The Pankey Philosophy, L.D. Pankey famously responded, “What do you mean when you ask me about The Pankey Philosophy? I am not familiar with the document, although I do recall writing an essay entitled A Philosophy of Dentistry by L.D. Pankey.”

Most dentists are comfortable acknowledging that L.D. Pankey was a great philosopher and that he was the first well-known philosopher in dentistry, but most dentists don’t think of themselves in a similar fashion; rather they like to think of themselves as being prototypes of practicality. This is why most dentists never even think about the value of writing a Philosophy Statement.

Just what is a philosophy statement?

A philosophy statement is a statement of core beliefs, and a validated philosophy is a philosophy statement which has been affirmed through its frequent use, reference, and revision. It is, therefore, a living creed around which a person or group of people live their lives.

A great example of a validated philosophy statement was how Wilson Southam and the Group at Cox operated a number of years ago. Cox was a progressive dental equipment designer and manufacturer located in Stony Creek, Ontario. Wilson Southam was an investor, a co-owner, as well as the philosophical leader of the company. Cox had developed a philosophy around which all of its equipment would be designed – a concept is called, “the computerized dental cockpit,” fashioned similarly to how a fighter pilot might operate. And Cox preferred to sell its equipment to only those who understood its philosophy…only to those who understood the “why” behind the “how” and the “what.” Cox believed in this so strongly that it held workshops centered around its philosophy at Stony Creek.

A philosophy statement can also be called a “core beliefs statement.” A good example of a philosophy statement is the Nicene Creed, co-authored after the center of the Roman Catholic Empire was moved from Rome to Constantinople. At that time, Christianity was in a fractured state, with many different sects, and with many different belief systems. The Nicene Creed was co-created by the Roman Catholic leadership with the intention of having it function as a unifying document around which everyone could agree, so that the church could again move forward.  It states, “We believe…. We believe.”

It’s a well thought out basis for behavior.

So, a philosophy statement represents a statement of beliefs, which is so basic and so fundamental that it provides a rational and comfortable basis for you and your care team to determine what it is that each member of a care team should do, as well as what they should choose not to do.

William James was a physician who lectured at Harvard in the late 1800s on Philosophy and Psychology. He is considered to be America’s first psychologist and was thought of as a “pragmatic philosopher.”  In this regard, James said, “There is nothing more practical than having a personal philosophy.” In the case of dentistry, an applied philosophy (validated philosophy) is practical as well, as it naturally leads to an organically-driven team, deep in mission, and high levels of personal autonomy and interpersonal trust.

A philosophically-aligned team is essential for the creation of a philosophically-driven community.

Barkley a year or so before his untimely death in 1977, said during an interview with Avrom King said: “If I had one wish that could be granted, it would be that every dentist would take the time to create a written philosophy statement.” Let’s talk about why Bob would make such a statement.

The creation of a relationship-based/health-centered practice is a perfect example of the creation of a philosophically-driven community, with the word community being used as a reference not only to the creation of a care team, but also to the patients of a practice, its associated suppliers, mentors, and facilitators. All of the members of this community are philosophically aligned through either careful selection, development, or both.

A community of this type begins with the creation of a care team which has co-authored a written statement of philosophy. This is because you cannot have a true health-centered dental practice without a philosophically-aligned care team which listens well, are true helpers, and who facilitate healing in each other, as well in those with whom they come in contact. One or two people acting alone, simply cannot apply a practice philosophy as others, who are in contact with patients, will create too much confusion and mixed messages in the minds of the patients.

A personal philosophy statement starts the ball rolling.

The dentist might begin the process of thinking through a personal philosophy statement by answering these questions:

1. Who am I? (What are my values and core beliefs?)
2. Who do I want to become? (How do I want to see my life unfold?)
3. Why do I feel this way? (What is my personal purpose in this life?)

To develop your philosophy-driven community (care team, patients, suppliers, mentors and facilitators) the dentist next shares his or her personal philosophy with care team members and leads them in co-authoring a practice philosophy statement.

Remember: A philosophy statement is a statement of core beliefs, and a validated philosophy is a philosophy statement which has been affirmed through its frequent use, reference, and revision. It is, therefore, a living creed around which a person or group of people live their lives.

A co-authored and applied practice philosophy statement produces multiple benefits.

Here are four concrete benefits of co-creating a written group philosophy statement with your care team:

1. It will establish a standard of behavior for everyone to live up to and aspire towards.
2. It will allow for that standard of behavior to be used in a situationally appropriate fashion, and therefore not be used dogmatically, as everyone recognizes that every person and every situation is unique.
3. It will function as a centripetal force…as a kind of principle-centered psycho-social glue which will hold the care team together during times of change and challenge.
4. It will function as the foundational document out of which a practice vision (where are we going long-term) and a mission statement (how we will get it done) can evolve.