JABA FOUR
SEASONS
OF
DENTISTRY
Spring: commencement and chaos Jim Pride,
DDS
Whether the first season o f dentistry is chaos or commencement depends on the young dentist’s operational systems, sound management, and effective leadership. W ithout these critical components, the dentist’s house m ay collapse at any time.
he four seasons of dentistry—spring, summer, fall, and winter—are as distinct as the seasons in nature. I think of these seasons as stages of development—commence ment, growth, maturity, and transition—corresponding to four developmental levels of business outlined by the Pride Institute: chaos, organization, management, and leadership (Fig 1). This article examines commencement—spring—the first season of the dentist’s career, and relates it to the first developmental level of the business of dentistry—chaos. Commencement is a prom ising time. A community is chosen, the young graduate joins a practice, or starts a solo practice. In time, relationships are established with financial institutions, governmental agencies, and community groups. T he average new doctor is 27 or 28 years old,1 and anticipates everything new, fears the unknown, and hopes to make dreams into reality. In the spring, the new dentist expects an abundance of patients, a top-notch team of employees committed to the practice and to long-term contribution, and financial success. Transcending all other expectations is the dentist’s desire to provide the finest dental care to p atien ts, regardless of circumstances. True happiness comes when our job performances meet our own high standards. Expectations of the young dentist also include community acceptance. As do other community members, dentists want to be m utually respected as educated, concerned individuals whose thoughts and opinions merit consideration. Responsibilities weigh heavily on the new dentist’s m ind and are more complex than simple repayment of school loans. The pressure to meet expectations of parents and others who provided both emotional and financial support is intense. T he new dentist comes face to face with the “bottom line,” and an obligation to make the business perform. At the same time, rigid new professional standards must be met. T he family or social life can take second place on the list of priorities as a result of these extraordinary professional responsibilities. Extraordinary pressure is felt by the beginning dentist with an average $39,300 in educational debt.2 Of the 76.5% of graduates who go into private practice, 30% are owners.1 For them, paying the rent and other practice expenses are “added heat under the pressure cooker.” For the 38% of those who associate with existing practices, there is the concern of fitting into a functioning organization directed by another professional.1 Spring is the stim ulating season of every dentist’s professional life. T h e unk n o w n is ch allen g in g , and there are m any
T
unanswered questions: How many patients will I have in six months? Will I be able to perform those wonderfully advanced procedures I studied? When will I show a profit from my services? How much profit will I make? After students’ graduation, parents usually stop helping with expenses. Teachers no longer provide inform ation and education. Patients no longer “magically” appear as they did in the dental school clinic. A thriving dental practice is not the “pot of gold” at the end of every student’s rainbow. W hether the dentist is starting anew, purchasing, or associating, no practice is secure until the dentist earns the right to keep it. In the first years of practice, dentists often have difficulty accepting this reality. We hear: “They didn’t teach me practice management in dental school,” or “T he schools are graduating too many dentists,” or “Why doesn’t the profession do something about insurance companies?,” or “Why doesn’t someone do something to improve patients’ dental IQ?” Blameful language is evidence that the dentist expects results
The Four Seasons of Dentistry B usiness developm ent
D entist/practice developm ent
JADA, Vol. 120, May 1990 ■ 513
FOUR
SEASONS
OF
D E N T IS T R Y
not from himself or herself, but from others. Doctors who enjoy the commencement stage of their business and are successful from the start accept full responsibility for the condition of their professional life. Rather than blam ing others, they know “if it’s going to be, it’s up to me.” The duration of a dentist’s spring time is different for each dentist. From m onths to an entire lifetime—time spent in this first season of dentistry corresponds directly to the manner in which the dentist deals w ith the first developmental level of the business of the practice. Chaos, or extreme confusion or disorder, is a natural state when any practice starts (Fig 1). Fueled by a lack of clarity and direction, chaos is characterized by frequent patient misunder standings, high cancellation rates, low treatment acceptance, and poor collection levels. T he dentist has difficulty hiring quality staff, and the current staff feels overworked and underpaid. Consequently, staff turnover is an ongoing problem. Because operating systems are not in place or are not managed, the practice constantly functions in a “survival mode.” Staff members don’t really understand what is expected and everyone is relieved just to make it through the day. Staff meetings are rarely held with a real sense of teamwork. In chaos, both doctor and staff members perform tasks without understanding why. Chaos is not know ing why patients cancel at the last m inute or just d on’t show up for appointm ents. Chaos is attem pting to do a thorough new patient examination in 20 minutes. Chaos is m aking a perfect treatment presentation w ithout discussing the fee. Chaos is thinking that quality dentistry can be performed w ithout profit. Chaos is believing that a salary increase alone is the answer to motivated, committed employees. Chaos occurs when the dentist fails to inspect what is expected. The doctor who has yet to identify goals and communicate them to staff is entrenched in chaos. Goals encompass the dentist’s long-range vision for the practice, quality standards, ethical conduct, as well as specific financial goals such as hourly, m onthly, and annual production. Chaos is also indicated when specific goals are not managed. Harold Geneen, former CEO of International Telephone and Telegraph, has said that “management must manage.” In his book, Managing, he wrote: “T o want to achieve certain yearend results is not enough. M anaging means that once you set your business plan and budget for the year, you must achieve the sales, the market share, the earnings, and whatever to which you committed yourself. If you don’t achieve those results, you’re not a m anager Oh, you may have the title and it may say M anaging Director or Vice-President or Sales Manager on the door, but in my book, you’re still not a manager . . . It’s not that you’re a mediocre manager. You’re not a m anager.” T o move through chaos into higher levels of business development, the dentist m ust first understand the importance of “process” versus “event” management. "Event” management exists when numerous, isolated, nonrelated activities have little interrelated effect on each other. Event managers act first and consider the im pact later. Spending time and money on a prom otional brochure will undoubtedly be a poor investment if the receptionist lacks verbal skills to influence new patients. “ Process” refers to a series of interrelated parts that have a synergistic effect. If one is omitted, the others are inefficient. Dentists are taught to restore a tooth or perform surgery as a process. T he cement for the crown is mixed at the end of the procedure, never at the beginning. If the procedure is to be successful, every step m ust be included. 514 ■ JADA, Vol. 120, May 1990
The same is true for the business aspects of dentistry. The successful practice does more than offer a quality product or service. It is a body of interdependent supporting parts. Imagine a house: a strong house is built on a firm foundation, with beams, framework, and walls that support the roof. Similarly, the foundation of a successful dental business consists of the doctor’s values and commitment to quality. As written in the Pride Institute curriculum , efficient operational systems, sound entrepreneurial management, and effective leadership provide the necessary support, the walls, for the practice’s roof—the doctor’s goals (Fig 2). W ithout these critical components, the dentist’s "house” may collapse at any time.
Treatm ent acceptance by the patient; performance in a friendly, comfortable environment; accurate, comprehensive comm unica tion am ong team members and between patient and team; and assured, satisfied patients are just a few interconnecting parts needed to succeed through the chaotic springtime. T he manager who understands “process” meets both the professional and personal needs of staff members. He or she also realizes w hat a healthy practice represents to the business and to the committed staff. Success is not achieved at 65% or 70%, but only when the business process is complete. A lthough commencement and chaos run neck and neck at the start, they rarely meet at the finish line. Fifty-five percent of dentists in a Pride Institute study that spanned 8 years were still in chaos, although they were practicing in the mature portion of their careers. For them and many others, chaos never ends. Stress and burnout accompany chaos. The longer the practice remains in chaos, the more blameful, negative, and unhappy the dentist becomes. A happy commencement and positive attitude toward dentistry are the rewards of a swift passage through chaos. Accepting responsibility and becoming a young leader in dentistry is the key to a speedy journey through the chaotic times. As Max DePree, form er CEO of H erm an M iller, noted: “Participative management is not democratic. Having a say differs from having a vote.”3 In the practice of dentistry, dentists have the all-im portant vote. Dentists make the choice to accept ultim ate responsibility for the outcome of their practices. ------------------------------------ JÜ O A --------------------------------------Dr. Pride is head of the Pride Institute. Address requests for reprints to the Pride Institute, 900 Larkspur Landing Circle, Larkspur, CA 94939. 1. Bureau of Economic and Behavioral Research. T he 1989 survey of recent dental graduates. Chicago: American Dental Association, 1989. 2. American Association of Dental Schools. Survey of senior dental students. W ashington, DC: American Association of Dental Schools, 1989. 3. DePree M. Leadership is an art. East Lansing: Michigan State University Press, 1987.
SEASONS
OF
DENTISTRY
Spring: commencement and chaos Jim Pride,
DDS
Whether the first season o f dentistry is chaos or commencement depends on the young dentist’s operational systems, sound management, and effective leadership. W ithout these critical components, the dentist’s house m ay collapse at any time.
he four seasons of dentistry—spring, summer, fall, and winter—are as distinct as the seasons in nature. I think of these seasons as stages of development—commence ment, growth, maturity, and transition—corresponding to four developmental levels of business outlined by the Pride Institute: chaos, organization, management, and leadership (Fig 1). This article examines commencement—spring—the first season of the dentist’s career, and relates it to the first developmental level of the business of dentistry—chaos. Commencement is a prom ising time. A community is chosen, the young graduate joins a practice, or starts a solo practice. In time, relationships are established with financial institutions, governmental agencies, and community groups. T he average new doctor is 27 or 28 years old,1 and anticipates everything new, fears the unknown, and hopes to make dreams into reality. In the spring, the new dentist expects an abundance of patients, a top-notch team of employees committed to the practice and to long-term contribution, and financial success. Transcending all other expectations is the dentist’s desire to provide the finest dental care to p atien ts, regardless of circumstances. True happiness comes when our job performances meet our own high standards. Expectations of the young dentist also include community acceptance. As do other community members, dentists want to be m utually respected as educated, concerned individuals whose thoughts and opinions merit consideration. Responsibilities weigh heavily on the new dentist’s m ind and are more complex than simple repayment of school loans. The pressure to meet expectations of parents and others who provided both emotional and financial support is intense. T he new dentist comes face to face with the “bottom line,” and an obligation to make the business perform. At the same time, rigid new professional standards must be met. T he family or social life can take second place on the list of priorities as a result of these extraordinary professional responsibilities. Extraordinary pressure is felt by the beginning dentist with an average $39,300 in educational debt.2 Of the 76.5% of graduates who go into private practice, 30% are owners.1 For them, paying the rent and other practice expenses are “added heat under the pressure cooker.” For the 38% of those who associate with existing practices, there is the concern of fitting into a functioning organization directed by another professional.1 Spring is the stim ulating season of every dentist’s professional life. T h e unk n o w n is ch allen g in g , and there are m any
T
unanswered questions: How many patients will I have in six months? Will I be able to perform those wonderfully advanced procedures I studied? When will I show a profit from my services? How much profit will I make? After students’ graduation, parents usually stop helping with expenses. Teachers no longer provide inform ation and education. Patients no longer “magically” appear as they did in the dental school clinic. A thriving dental practice is not the “pot of gold” at the end of every student’s rainbow. W hether the dentist is starting anew, purchasing, or associating, no practice is secure until the dentist earns the right to keep it. In the first years of practice, dentists often have difficulty accepting this reality. We hear: “They didn’t teach me practice management in dental school,” or “T he schools are graduating too many dentists,” or “Why doesn’t the profession do something about insurance companies?,” or “Why doesn’t someone do something to improve patients’ dental IQ?” Blameful language is evidence that the dentist expects results
The Four Seasons of Dentistry B usiness developm ent
D entist/practice developm ent
JADA, Vol. 120, May 1990 ■ 513
FOUR
SEASONS
OF
D E N T IS T R Y
not from himself or herself, but from others. Doctors who enjoy the commencement stage of their business and are successful from the start accept full responsibility for the condition of their professional life. Rather than blam ing others, they know “if it’s going to be, it’s up to me.” The duration of a dentist’s spring time is different for each dentist. From m onths to an entire lifetime—time spent in this first season of dentistry corresponds directly to the manner in which the dentist deals w ith the first developmental level of the business of the practice. Chaos, or extreme confusion or disorder, is a natural state when any practice starts (Fig 1). Fueled by a lack of clarity and direction, chaos is characterized by frequent patient misunder standings, high cancellation rates, low treatment acceptance, and poor collection levels. T he dentist has difficulty hiring quality staff, and the current staff feels overworked and underpaid. Consequently, staff turnover is an ongoing problem. Because operating systems are not in place or are not managed, the practice constantly functions in a “survival mode.” Staff members don’t really understand what is expected and everyone is relieved just to make it through the day. Staff meetings are rarely held with a real sense of teamwork. In chaos, both doctor and staff members perform tasks without understanding why. Chaos is not know ing why patients cancel at the last m inute or just d on’t show up for appointm ents. Chaos is attem pting to do a thorough new patient examination in 20 minutes. Chaos is m aking a perfect treatment presentation w ithout discussing the fee. Chaos is thinking that quality dentistry can be performed w ithout profit. Chaos is believing that a salary increase alone is the answer to motivated, committed employees. Chaos occurs when the dentist fails to inspect what is expected. The doctor who has yet to identify goals and communicate them to staff is entrenched in chaos. Goals encompass the dentist’s long-range vision for the practice, quality standards, ethical conduct, as well as specific financial goals such as hourly, m onthly, and annual production. Chaos is also indicated when specific goals are not managed. Harold Geneen, former CEO of International Telephone and Telegraph, has said that “management must manage.” In his book, Managing, he wrote: “T o want to achieve certain yearend results is not enough. M anaging means that once you set your business plan and budget for the year, you must achieve the sales, the market share, the earnings, and whatever to which you committed yourself. If you don’t achieve those results, you’re not a m anager Oh, you may have the title and it may say M anaging Director or Vice-President or Sales Manager on the door, but in my book, you’re still not a manager . . . It’s not that you’re a mediocre manager. You’re not a m anager.” T o move through chaos into higher levels of business development, the dentist m ust first understand the importance of “process” versus “event” management. "Event” management exists when numerous, isolated, nonrelated activities have little interrelated effect on each other. Event managers act first and consider the im pact later. Spending time and money on a prom otional brochure will undoubtedly be a poor investment if the receptionist lacks verbal skills to influence new patients. “ Process” refers to a series of interrelated parts that have a synergistic effect. If one is omitted, the others are inefficient. Dentists are taught to restore a tooth or perform surgery as a process. T he cement for the crown is mixed at the end of the procedure, never at the beginning. If the procedure is to be successful, every step m ust be included. 514 ■ JADA, Vol. 120, May 1990
The same is true for the business aspects of dentistry. The successful practice does more than offer a quality product or service. It is a body of interdependent supporting parts. Imagine a house: a strong house is built on a firm foundation, with beams, framework, and walls that support the roof. Similarly, the foundation of a successful dental business consists of the doctor’s values and commitment to quality. As written in the Pride Institute curriculum , efficient operational systems, sound entrepreneurial management, and effective leadership provide the necessary support, the walls, for the practice’s roof—the doctor’s goals (Fig 2). W ithout these critical components, the dentist’s "house” may collapse at any time.
Treatm ent acceptance by the patient; performance in a friendly, comfortable environment; accurate, comprehensive comm unica tion am ong team members and between patient and team; and assured, satisfied patients are just a few interconnecting parts needed to succeed through the chaotic springtime. T he manager who understands “process” meets both the professional and personal needs of staff members. He or she also realizes w hat a healthy practice represents to the business and to the committed staff. Success is not achieved at 65% or 70%, but only when the business process is complete. A lthough commencement and chaos run neck and neck at the start, they rarely meet at the finish line. Fifty-five percent of dentists in a Pride Institute study that spanned 8 years were still in chaos, although they were practicing in the mature portion of their careers. For them and many others, chaos never ends. Stress and burnout accompany chaos. The longer the practice remains in chaos, the more blameful, negative, and unhappy the dentist becomes. A happy commencement and positive attitude toward dentistry are the rewards of a swift passage through chaos. Accepting responsibility and becoming a young leader in dentistry is the key to a speedy journey through the chaotic times. As Max DePree, form er CEO of H erm an M iller, noted: “Participative management is not democratic. Having a say differs from having a vote.”3 In the practice of dentistry, dentists have the all-im portant vote. Dentists make the choice to accept ultim ate responsibility for the outcome of their practices. ------------------------------------ JÜ O A --------------------------------------Dr. Pride is head of the Pride Institute. Address requests for reprints to the Pride Institute, 900 Larkspur Landing Circle, Larkspur, CA 94939. 1. Bureau of Economic and Behavioral Research. T he 1989 survey of recent dental graduates. Chicago: American Dental Association, 1989. 2. American Association of Dental Schools. Survey of senior dental students. W ashington, DC: American Association of Dental Schools, 1989. 3. DePree M. Leadership is an art. East Lansing: Michigan State University Press, 1987.
