The Gray Areas of Dentistry: No one talks about this...

This generations dentist will be tested more than any generation before. When I say "this generations dentist"; I'm talking about dentists <15 years in practice. This generation is standing witness to HUGE shifts in the structure of dental care is delivered. And, It is my opinion (as well as many others), that it is going to get harder and harder for a solo private practice dentist to thrive. The growth of corporate dentistry (low cost - high volume locations), the dominance of PPO dental plans (which can take a HUGE chunk out of what you actually collect) and the escalation of overall costs (especially technology) and regulation are going to squeeze dentists more and more each year. It is more important than ever for young dentists to be trained in dental business...because gone are the days of the 'easy money' for owner dentists. You can not thrive if you simply plan to open/buy a practice, hang up a sign with your name on it and focus only on clinical dentistry. These simple facts are becoming more and more apparent to me each year: 1) marketing is VITAL to your success and survival 2) efficient, streamlined - patient experience focused practices will prevail 3) multi doctor practices are going to offer owner dentists a lot more flexibility/income and quality of life.

Many graduates expect to make $150,000 yearly income during their first couple years...but many will find that target difficult to hit while working for corporate dentistry. The level of production you need to create in order to reach the level of income you dreamed of (early on in your career) is difficult  to reach...because of PPO's your writing off more of each bill...and because we are under trained in endo/oral surgery - we are referring (or in the case of corporate dentistry) - told to refer cases to specialists. Many dentists are be groomed to become solely drill and fill - operative dentists. And, because of this they will have to learn to work FASTER with more VOLUME to pay the bills...

New dentists WILL (and do) feel the financial crunch. And, because THIS generation is facing more financial pressures than any generation before...the "gray areas" of dentistry become a big issue. What are the "gray areas"? They are the obvious reality that, despite our "standardized" dental education...dental treatment planning can be VERY difficult, and each dentist will come to adopt their own "treatment philosophy". This philosophy will dictate things like - how aggressive they'll be to treatment plan borderline caries lesions - when to recommend a crown vs a new filling? How you view the promotion of "elective" dental procedures... and when to recommend endo and periodontal treatments.

TRUTH = Dentistry is a business ( You BETTER Believe it)

Coming out of dental school you'd think that it would be much more black and white - but each patients case is unique, and real world dentists are always battling the dichotomy of "entrepreneur/business owner (make a living/pay the bills) vs doctor/clinical (care for the patient)...Are we recommending a more aggressive and profitable course of treatment because it is REALLY in the the patients best interest? Or rather, because we will make more vs an alternative procedure...is it something that we seem to be able to justify in our minds and on paper? These pressures are real...every practicing dentist that has been out a few years can attest to it. I'm just the one calling it what it is...being honest with our profession.  It seems like we all know the dynamic exists but refuse to talk about it or discuss it...I believe that most dentists out there really believe they are making decisions in the patients best interest, but all of us who have been practicing a while know that we've come across cases and patients that make us wonder. And, the unprecedented financial pressures now facing our generation only compounds the problem.

The spectrum is across the board: dentists too conservative they are borderline neglectful,...all the way to the other side...dentists so aggressive they are over treating patients. It boggles the mind sometimes when I see what other dentists have recommended...but the truth is this: the real world is NOT black and white. Yes, the right thing to do is to put the patients health and interest first...and as I said, I think that MOST ALL dentists do believe that they are doing the 'right' thing for their patients. But, the more I practice the more I see that gray areas really do exist inside each practitioners treatment philosophy and inside the profession itself. Does that crack line mean the tooth automatically needs a crown? Does a sensitive tooth need to go right to a root canal treatment? Do all those little lesions on the radiograph mean we HAVE to do fillings on all those teeth right now? We see it all. Does this old amalgam really need a crown vs a new composite? Does what we've justified in our minds ACTUALLY line up with clinical evidence?

I'm talking about this because my generation faces increased pressure financially and we live in a world where we hear so many consultants (many NOT dentists) who state that we just need to "SELL" more dentistry to get ahead...we need to make more money per patient...get more patients to sell to... we simply need to offer and push more new services. 

What is RIGHT? What I've learned from great mentors and my experience is this: great quality treatment planning that is profitable AND in the patients best interest is closely tied to marketing. Sounds weird right? But what I've found is that if I carefully develop my treatment philosophies ( when to remove caries, how to assess caries risk and when to recommend surgical treatment of lesions, a protocol for cracked teeth, teeth with large lesions and crack line) with empathy/compassion and the goal of becoming the patients trusted dental adviser and caretaker; great relationships result. We must think about, create and examine our reasons for WHY we do what we do, and weight it against the best evidence that is available. 

The truth is that I also believe that in TODAY'S dental world, dentists MUST think about "sales" (in an ethical way), and MUST expand their services through quality training. Because we need to be more skilled, more efficient and more marketing savvy than ever before. By training myself and offering to keep a #12 endo in house - the patient is impressed by your "advanced training" and abilities, as well as happy that they don't have to leave your practice to visit and "unknown" dentist. You will fill your schedule with profitable procedures and less single tooth operative. Training yourself in cosmetic 'elective' procedures also offer great opportunities for your patients smile, self esteem as well as your bottom line. Market your practice for success, be efficient and profitable, train yourself and build a trusted lifelong relationship with patients. Resist the temptation of "treatment sales". Invest in the relationship and it will pay dividends over the life of your practice. Patients will trust you when you DEMONSTRATE a reason to be trusted (explaining that a crown is an option - but the tooth has adequate tooth structure to support a new filling - which will slow the 'restorative life cycle' of the tooth as well as save the patient some money) The more patients trust you, the easier it is for them to respond (say yes) to treatment plans you present...treatment that is, of course in their best interest. You should be recommending dentistry that you really feel is a) the best investment the patient could make and b) will really have a positive impact on their LIFE. 

Offer patients more: more compassion, better service, better communication and a better experience than they've had elsewhere. View your ability to go 'above and beyond' for your patient as an investment in your practice (a marketing opportunity). Sometimes you'll look at the holes in your schedules 1-2 weeks out and feel a pit in your stomach...will treatment present itself? Will I have enough to pay the bills this month? You'll be tempted to compromise by crossing into more of the "gray areas of dentistry"...So, lets keep the conversation going, and figure out how we can tackle the challenges that face this generation. Train yourselves, learn the business of dentistry, be profitable/tactical and efficient; serve your patients, create raving fans and build a practice you love.

~ Cole Brenny DDS