Orthodontics … the Ideal Life

By Dr. Dean C. Bellavia

In this article, we will sum up how it feels to work in an exceptional practice, from the orthodontist’s point of view. If you have not fully reached your exceptional practice goals, this “typical day with a doctor from such a practice”, should help you to understand what your practice would be like once you have. If you have already reached your goals, you already know how it feels.

Orthodontics is a wonderful life, filled with creativity and personal fulfillment, which is derived through discovery and change. It is a journey that begins each morning and ends each evening, after a day of growth and accomplishment, with hopeful thoughts towards tomorrow. I awake each, morning after a restful sleep, and look forward to being with my family before going to my office. I eat a healthy breakfast, which enables me to meet the physical challenges of the morning.

As I drive to my office today I reflect back to when I was in orthodontic school, completing the final steps in my education. Upon graduating, I had many paths to choose from and knew that there was a right path for me. I have always been independent and considered the solo practitioner path alluring but difficult, especially with $185,000 in school debt. I looked around for practices that were for sale and found a few that were promising. Unfortunately, to have a practice large enough to pay off my loans, pay off the orthodontist I purchase it from, and have enough left over to have a decent lifestyle, required an initial payment that was much too large for me to handle. I then looked into a partnership. This was better than buying a solo practice outright, but it would have been about seven to ten years before I would make a decent living. Having exhausted my options, I then decided to do some creative financing and marketing of my own and start a solo practice in my spouse's hometown. I had a friend from dental school that was practicing in town and I knew I could talk a few more local dentists into referring their orthodontic patients to me. I got my father-in-law, a successful businessman in town, to co-sign on a bank loan to start my practice in a two-chair office that a general dentist sold me for a reasonable price when he retired. I was able to fix up that tiny office and make it functional and attractive. I loved that old office, but I love my beautiful new office even more. Back then I hired only one staff member to help me with the work. To this day, I don't know how we did it all, just the two of us, but we eventually hired more staff as we grew. I can remember how difficult it was to choose our team members. Once or twice, we experienced the pain of not hiring the ideal person the first time, but we eventually ended up with the great staff we have now. We worked very hard to build our practice, but it just wouldn’t grow to the level that I wanted until I made my final decision about how to practice the rest of my orthodontic life. I decided to build the exceptional practice, with help. I realized that I couldn’t do it alone and accepted the help of others, even though it goes against my personality.

As I pull into the ample parking lot of my beautiful new state-of-the-art orthodontic office I am reminded of that point in my journey when we were building it. I remember all of the hassles with the city, contractors and suppliers, and appreciated the help I received in making decisions and getting it done. As I enter and look about my office I notice and appreciate how wonderful an office it really is. It is large enough, but not too large, to treat the maximum number of patients that I can treat, using the treatment philosophies that work best for me. My office is ideally laid out to maximize every movement I or my orthodontic team makes. It is also a pleasant atmosphere to work in, with warm color schemes, textures, and designs, and with sufficient equipment and furniture to make the daily work as efficient and effective as possible. The patients love the warm office atmosphere, which they compliment us on all the time. The flow of patients throughout the office is smooth and the treatment area is well organized for maximizing the effectiveness of our every move, reducing stress and allowing us to enjoy being in relationship with our patients.

As the rest of the staff arrive with adequate time to get settled in, they chat about what went on the night before as they prepare for our patients, with enough time left over for our short morning get-together to discuss what we have to accomplish this day. As the patients arrive, I can't help but be proud of the fact that the patient is our focus, and indeed, the practice is an ideal referral-based, patient-centered, fee-for-service practice. Others may choose to practice in other ways, but I can't. I refuse to treat managed care patients or patients at a reduced fee; it isn't fair to my other patients to pay a much higher price for receiving the same high-quality service. Also, II don't see why we should work harder treating more patients for less. I consider our treatment and service to be exceptional and know that this is the reason we now have enough patients to keep us productive and profitable. It wasn’t that way in the past, before I learned how to properly manage my practice.

As I watch our team prepare for the day I can't help but appreciate them for who they are and how well they work together. We have truly organized and hired the ideal staff to serve our patients; they are a well-balanced, service-oriented team. We have taken great care to make sure that our well-selected team is mentally, financially, and emotionally cared for. We make sure that they are well trained in their positions and retrained as needed. We pay our staff very well and give benefits that fit their personal needs through a cafeteria type benefits program. We also use bonus programs, not because the team isn’t highly motivated to promote the practice, but because it is a way for them to share in our growth and prosperity. We also make sure that our team stays in relationship with each other by immediately resolving “issues” that gets us out of relationship. But sometimes we go out of relationship with each other without realizing it. For example, I sometimes focus too much on the result instead of the person helping me get the result and unintentionally belittle them in the process. To resolve this, we have one-hour weekly team meetings that allow us to address any friction-causing issues between us and get back in relationship. When done, we share our warm feelings for each other by acknowledging what we appreciate about each other.

This appreciation is transferred over to our patients, who we are also in relationship with, and when not, we meet privately with them and get back into relationship. Yes, each patient is a joy to behold, recognized for his or her strengths and weaknesses, and dealt with based on that understanding. Thus, there are no bad treatment days, instigated by seemingly uncooperative patients. Why? Because each patient and family knows what their treatment outcome is ideal for them based on the level of their cooperation. I know that an ideal result is not intrinsic in nature, but is instead relative to the abilities of the patient to assist us. We do our best with what we have to work with and cast no blame. At first, I found this difficult to deal with, thinking that we should always seek intrinsic perfection, but nothing is intrinsically perfect! How well I treat patients improves daily, but each patient is a part of the definition of perfection for that patient. I don't take it personally when the result is not as good as I think it could be, but I am satisfied that I, my team, and the patient did their best to get that optimal result.

From the operatory, I can see the TC indicating that she is about to bring a new patient into the exam/conference room. That tells me that I have about twenty minutes before she needs me in the exam, so I get the clinical staff together and we decide all that we must do to get me into the exam on time, yet keep the treatment flowing in the operatory. This is also supported by our ideal-day schedule that accounts for every minute of my time throughout the day. Each productive team member has specific patients that she sees on time, as I effectively interweave my time with theirs. Sometimes we get a little behind, but we all know what to do and pitch in to get back on schedule. Our focus is on the treatment of all of the patients and thus, we make decisions from time to time that inconveniences the uncooperative patient for the good of the other cooperative patients. We repair broken appliances as we find them, but when not possible we have appointments available the next day to complete the work. Our wonderful schedule is well managed by our people-oriented receptionist who knows how to use the schedule and how to get the patients to accept the appointments as programmed in the schedule. We usually have the exact number of appointments we need per day, but sometimes we have demands for certain appointments over others, which our schedule easily accounts for with its automatic substitutions. All in all, we have a wonderful schedule that keeps us productive and values the patient's time, by getting them treated and out the door as we promised.

As we work on our patients, I stay aware that I must be in the new patient exam on time. The TC conducts a patient-centered exam that makes the family aware that the patient is all-important. This is just one of the steps in our patient-centered approach. Initially, when they call us for an exam appointment, they are courteously handled by our receptionist who obtains their initial data, makes their appointment and after a pleasant conversation hangs up and sends out a Health History Questionnaire and brochure about our practice. When time permits, she sets up the patient's exam folder, enters all of the pertinent data in the computer and checks on their insurance and any possible siblings. Another step is to help prepare the patient and family for the exam visit by having the TC call them the day before, to introduce herself, have a pleasant chat with the patient, and give directions to the office if needed. The patient and family appreciate this, as it is difficult for people to get involved with something new.

When the patient and family arrive at the exam, they are pleasantly greeted by our receptionist who notifies the TC of their presence. The TC has the exam room clean, tidy and prepared for the patient. It is a lovely room with natural light from windows that look out on a pleasant natural scene. The room is comfortable, efficiently laid out for ease of communication, with a relaxed yet professional decor. The TC has the patient and family sit around the conference table so that the patient is the focus of their attention. She makes the family aware that we work hand-in-hand with the patients to achieve excellent results, while having fun achieving them. The TC's interview of the patient is structured in such a way as to not require input from the parents, allowing the patient to respond to all of her questions. As the TC and patient interact, the TC makes the patient feel important by validating what the patient feels is important through genuine interested. The TC is the ideal person for her job, having a strong relator personality style that establishes rapport and a strong socializer personality style that makes the patient excited and enthusiastic about wearing braces. After she has obtained all the data from the patient, the TC thanks the patient for their help and asks the family a few specific questions. The patient feels good about the positive, validating interaction with the TC and is enthusiastic about his or her treatment. This transfers over to the family who share in the patient's joy and who are excited about proceeding with treatment. When done with her information gathering the TC takes imaging photos of the patient and one photo with the patient and family. The patient and family enjoy the imaging, which our TC makes a fun experience. When done they are ready for me to do their clinical examination. But before getting me, the TC gives the family a set of before and after pink and white acrylic models of a case similar to theirs. She explains that this is an example of the excellent kind of work we and our patients achieve here and that we are very proud of it.

While all this is going on, I am in the operatory, doing some final checkouts before going into the exam. Oh, it’s time, as I notice the TC obtaining a printout of the imaging photos. My clinical team and I are all set for me to spend the next 15 minutes in the exam thanks to our productive schedule. Before going into the exam, I look over the patient information that the TC hands me and I listen as she tells me about pertinent information I need to know about this patient. It is important for me to know what to say and what not say about issues that the patient or family are sensitive to, such as divorce, perceived attitudes about their appearance, and the like. I follow the TC into the exam room, which is a short distance away, and she introduces me to the patient and family. The TC then returns to her seat and I sit on my short stool to be at eye level with the patient. We discuss the kinds of things that the patient likes as noted on their TC interview form and I acknowledge the patient for his or her accomplishments. When done, I review their health history, after which I'm ready to put the patient in the exam chair and do our comprehensive dictated exam. The TC and I have worked out a very impressive dictated exam that is choreographed perfectly. It puts on a good show and gives me all of the clinical information I need to evaluate the case. When done, I invite the family to the chair to explain my findings. The TC gives me a printout of the imaging photos and I proceed to explain my findings. Certain findings are described best using the patient, who follows with a mirror, and some are best explained using the imaging photos. When done, I answer any other questions they have and then have them re-seated at the conference table as I position myself between them and the door, ready to leave after my exiting comments. I have learned from the past that sitting down at the conference table to discuss treatment did not further the patient's understanding nor fulfill their need to get started with treatment in this office—it also wasted a lot of my time. The patients are more relaxed and learn much more from my TC than they do from me. I do my doctor tasks and I have well-qualified people to do the communications work I have neither the time nor the skills to do as well as they can. After the exam, I return to the operatory where the clinical team coordinator (traffic cop) makes me aware of which patients I should see in order. I pick up where I left off with the clinic patients as the TC finishes with the new patient.

Back in the exam room, the TC reviews my findings with the family in writing and gives them the fees and possible financial arrangements. Should a particular financial arrangement best meet the family's financial needs, the TC obtains an initial payment if the family is prepared to pay it at this visit. Whether settled or not, the TC calls in the records tech to take the patient to our well-equipped records room. As the records are taken by our warm and supportive records tech, which makes records taking more of a fun experience than an ordeal, the TC and family make the necessary appointments to get started with treatment. The TC gives the family an exam summary card on which we print a picture of the patient and their family as a pleasant remembrance of the visit. We also give them the imaging photos printout to help them explain the findings to other family members who could not attend the exam. All in all, we provide a wonderful, comprehensive, uplifting exam experience that makes the patient want their orthodontic treatment done here.

About two weeks after the exam and records visit, we have our case presentation. Although it isn't necessary to have a case presentation to sell the case, which is aptly done at the new-patient exam, I have found that when I didn't do case presentations I had a major problem with cooperation, because the patient/family didn't fully understand what to do. We incorporate the case presentation into our separation visit to further the patient's understanding of how they can help us to achieve the kind of result they desire. The case presentation also gives us a chance to clear up incomplete financial arrangements and pay unpaid initial payments, which was a problem in the past, before we did case presentations. Our three-step procedure for getting the patient started (exam & records, case presentation & separation, and the braces insertion) is acceptable to us and our patients who now cooperate to their maximum capability. I spend little time in the case presentation, typically two to three minutes, although the TC requires about 45 minutes to educate the patient, resolve finances and get them started with their separation or impressions. The TC conducts a patient-centered consult and focuses her attention on the patient, but has a pleasant way of including the rest of the family. She is very effective at educating them with a problem-oriented case presentation, focusing on just one problem and its resolution at a time. This is so much better than my old records-oriented presentation in which I showed a record and described all of the problems in that record, which confused the patient, even after I re-explained it, wasting a lot of my time and frustrating them. But now they understand implicitly and know what they must do to help us attain an ideal result for them.

In the clinic, I continue to work on my patients, knowing that the financial stability of the practice is in the capable hands of the TC. She knows what the treatment is and thus, the fee and acceptable financial arrangements. The TC is given a broad spectrum of financial arrangements, but most families take the average 25 percent initial payment with the balance over the months of treatment. If they want to pay in full, we give them a 5 percent courtesy. This 5 percent loss in income to us is offset by a 10 percent gain in income from the $15 per month we charge for our extended payment plan, for patients who can't afford an initial payment, but have a good credit rating. Patients are given a full spectrum of initial payment options, based on their credit rating, and choose one that best fits their family budget. We do a credit check in case we need to limit our financial arrangement options, for we wouldn’t want a patient to start treatment and be burdened with payments that would cause them hardship. Oh, I notice that the TC is coming out of the exam room and is waving to me indicating that the patient has had their spacers placed and are on their way. I wave to the patient and family as they leave and they wave back, smiling.

It’s about 9:30 and I am needed, as per my schedule, at an initial banding. The clinical team is a wonderful group of well-trained individuals who work as a team to serve our patients. They do such a good job that I rarely have to refit a band or appliance, re-bend a wire or re-ligate a complicated tie. The brackets are ideally aligned since we have a great lab tech that does an excellent job setting up indirect bonding trays, which I review before they leave the lab. Although well aligned, we sometimes have to reposition one or two difficult-to-place brackets before we place the ideal archwires, which reduces many second and third order bend appointments once the ideal archwires are place. Yes, our treatment proceeds very smoothly, and although some cases are more challenging than others, we attain as ideal an occlusion as possible for every patient. This evening I will call a patient to make sure that all is well with his new braces. I will expect everything to be all right, make comforting comments as needed, but in general, it will be a pleasant conversation about the office and staff and how wonderfully the patient assisted us in placing their braces. The assistants who help me place the initial appliances today will send our child starts a letter welcoming them to treatment. The kids get a big kick out of receiving this letter and we get a kick out of sending it.

As I see each patient, as scheduled, I am proud of the fact that I know all that is planned and done for him or her on our complete, easy-to-use treatment chart. Everything I want to know about each completed visit and what I plan to do at the next visit is noted on the chart in detail. At first, I was apprehensive about stating exactly what the patient needed at the next visit, but over the years, I have become extremely proficient at it. We rarely change what we plan to do and the cooperation of our patients helps to make my next treatment predictions accurate. This ability makes it easy to productively schedule and not waste my time or the time of my clinical team. They get started on the patient's treatment before I see the patient and if there seems to be a problem, they usually know what to do. Thus, by the time I get to the chair, look at the chart, and examine the patient, I know what was done, what I must do and what to do the next visit - it's all very effective and efficient. This approach allows us to stay on schedule and get our patients in and out on time. And, due to their great cooperation and our six-month progress reviews, our well-planned treatment is completed on time.

Every six months, after the patient starts, we do a comprehensive review of the patient's progress. At the review, we explain our findings to the patient and family and give them a written report. A copy of this report is sent to the family dentist as a treatment request for a cleaning and oral exam. In fact, as the patient leaves at the end of a six-month review, our receptionist calls the family dentist's office and sets up an appointment, if they have not had one in the past six months. Our personable receptionist knows the receptionists at the family dentist's offices and they speak throughout the week about patient-related matters and have periodic get-togethers. Each month our entire team has a luncheon with one of our family dentist's staff. Sometimes it is in a restaurant and sometimes here in our office. They all enjoy the luncheon on us and the interaction, and enjoy learning about how we treat their patients. Of course, it doesn't hurt when it comes to referring new patients back and forth, since we want our patients to share in the best of both our and their practices. I also have a good rapport with the referring dentists and have made it a point to determine how I can best serve their patients. I know what type of treatment that each dentist prefers to do and to whom he or she likes to refer out their specialist treatment to. The TC and I make it a point to comply with their wishes and support their practice in any way we can. This symbiotic relationship best serves our mutual patients and thus, we are all happy with the arrangements. We have learned a lot from our consultants about operating a patient-centered, high-quality practice and share our knowledge with our referring dentists in any way we can.

As I look over to the sign-in area, I notice Bobby Smith, whose treatment result may not be as ideal as I would like it to be, but who will get as good a result as he is capable of helping us attain. We started him on a headgear, but he found it impossible to wear. We worked with our patient trainer to help him establish a daily routine to wear the headgear, but to no avail. The TC even had a conference with him and his mom to set up a program to remind him daily when to put it on and take it off, but he took it off in his sleep. He's not a bad kid; he just finds it difficult to make the kind of changes in his life that will help his treatment along. Out patient training program is successful about 95 percent of the time, but nothing's perfect and we have to do what we have to, to get the best result we can. Thus, we had to do an upper four's extraction for Bobby to get his severe class-II under control. He is, though, almost finished and is wearing his elastics well and we are expecting to finish on time. In general, Bobby represents about two percent of our patients who end up with a result they are happy with, but which I would rather had been better, but nothing's perfect and I know it.

I finish up with my initial banding and move over to another chair where Mary Jones is having a debanding. We had done a retention evaluation on her at the last visit and sent a written copy of it to her family dentist to make him aware that she will be debanded. At this visit, we will remove all of her braces and take impressions for removable retainers. I used to use a lot of fixed retainers, which were cumbersome to install, although they did require little patient cooperation. Today I only use removable retainers, mostly those clear occlusal retainers that are easy for the patient to put in and wear. And since our patients are so cooperative, they have almost no problems wearing them the required hours per day. We do our debandings and occlusal retainer insertions all in the same visit; we deband and take impressions, and while the lab tech makes the retainers, we take final records. The occlusal retainers are then inserted and the patient and family have a retention conference to explain what will happen in retention and how they need to help us stabilize the result we all worked so hard to attain. The patient and our entire team take a Polaroid picture at the end of the visit and we give it to the patient along with two tickets and a coupon for jumbo popcorn at a local theater. This visit is a very positive uplifting experience for all.

As I move around the operatory, choreographed by my excellent schedule, I have a bittersweet moment with Billy Johnson who is to be dismissed from retention treatment today. It has been about four years since we started with him and we have all become great friends since, enjoying our visits together and the results we have attained. I do a final evaluation of the case in a written report and give a copy to the patient, indicating the success of retention, what comes next, and the prognosis of the stability of the overall treatment, which is usually positive since we have received so much assistance from the patient. I also send a copy to the family dentist so that they know what is going on with the patients, especially the prognosis and what the family dentist needs to do at this time. This well-established communication link we have with the family dentist is very well received and keeps the dentist abreast of the patient's case. With this information in hand the family dentist feels that they can support the patient's orthodontic treatment by answering questions that orthodontic patients ask their dentist, like how the dentist feels the treatment is going and what the prognosis of the treatment might be during active and retention treatment or thereafter. Some dentists may feel that we send too much information, which is fine and they can do what they will with it, but most feel it is important to know so that they don't look foolish when orthodontic patients ask them questions that they couldn't answer had they not had that information. I say good-by to Billy and we shake and show a true appreciation for each other, me for having such a wonderful patient and Billy for having such a wonderful, healthy smile.

I look around the operatory and notice that all of the clinical patients are gone. I look up at the clock and realize that the treatment day is almost over - where has the time flown, it seems like we just got started. As I reflect back on the day, I appreciate my wonderful staff and patients who made such a day possible. I have welcomed new patients, had a joyful tear for those who were dismissed and enjoyed the progress achieved on the rest. I really love being an orthodontist! The rest of the team is completing their daily clean-up tasks as I go into a case presentation to say hello and inspire the patient to be a part of our orthodontic team. When the consultation patient has gone we chat about what a great day it was, and dwell on some of its highlights. We say goodbye to each other, appreciating our time together, but anxious to get on with our private lives. As I drive home, I reflect on my patients and my team and how well we all get along. When I arrive at my home, it makes me think about and anticipate being with my family. Because my day was fulfilling and stress-free, I have the attitude and energy to fully participate in, and share the joys of being with my family. I get great joy just seeing them, sharing their love, hugs, and kisses. They tell me of their great day and I understand and appreciate what they have to say, making it as important to me as it is to them. I share in their joys and woes, supporting them in any way I can. I think of nothing but them when we are together, for my practice does not have to impose on my personal life. We are in relationship with each other, but realize that we are not perfect and will do or say something from time to time that will get us out of relationship. We thus practice the same techniques for getting ourselves back into relationship as we do in the office. We immediately repair the damage when we are aware of it, and have monthly family meetings to make sure that we are still in relationship. This provides us with a happy, low-stress home life, which we carry on to our friends and relations. In reflection, I remind myself of a truth: I am either in relationship with everyone important in my life or else I am out of relationship with all of them. I think back of times that I had issues with others I cared about, issues that kept us out of relationship, and I realize that I was also out of relationship with everyone else at that time, because I found it difficult to appreciate them and share in their joys. When I realize that I am not in relationship with everyone, I know that I am out of relationship with someone and that I must seek out and repair my relationship with that one person to get back into relationship with all. Once back in relationship with all, I am one with the universe and it showers its physical and spiritual gifts upon me. I have come a long way on my orthodontic journey, both in personal and practice growth.

You might ask how I accomplished all of this. The answer is, I did it through systems and relationships, which I truly believe is the basis of a happy, well-organized, patient-centered, traditional referral-based practice. But I didn’t do it alone; I had help. I was good at producing wonderful smiles, but was never taught how to manage the kind of practice that I could only dream of. So, I got help from reputable consultants. I couldn’t market my practice and make it grow, but they showed me how. I couldn’t set up a proper communications (TC) program, but they showed me how. I couldn’t design a productive schedule, but they showed me how. I couldn’t get my team and family in relationship, but they showed me how. Now I know how to practice in the best possible way and I wouldn’t change - the funny thing is, I can’t remember how we use to operate our practice, before we got organized.