Dr. Michael DiTolla: Hello, Mark! I know you have lectured at nearly every major dental meeting, but for the dentists who haven’t had a chance to see you before, I want you to explain a little bit about your past. Just kind of take me through that and how you got to where you are today, because you’ve got a fantastic practice, and I’ve always liked the fact that you’re not doing it in Beverly Hills or some rich suburb in Florida. You’re doing it in Greensboro, North Carolina. So walk our readers through it, if you would.
Dr. Mark Hyman: I’d be glad to, Mike. Again, it’s a pleasure talking to you and reconnecting.
My journey through dentistry was checkered to say the least. I started dental school at UNC School of Dentistry in 1980. I was president of my freshman dental class, while coaching intramural football, and playing basketball and soccer. Midterms came and I got creamed. The first week back, spring semester of freshman year of dental school, I quit school because I knew I was a failure and I would never be a dentist. And I was walking through the halls of the UNC School of Dentistry and ran into a young professor, Dr. Ron Strauss, who saved my life. He said: “It’s OK, Mark. Being a dental student is nothing like being a dentist. So give it another hour. Give it a day. See how you do.” I’d gone to the dean to tell him I was going to quit, and he said, “Great!”
The first week back, spring semester of freshman year of dental school, I quit school because I knew I was a failure and I would never be a dentist.
MD: (laughs) He didn’t put up a fight? He didn’t try to talk you out of it?
MH: Not even a bit. He told me to go back to class, come back at halftime, and he’d sign me out. Then I ran into Dr. Strauss, had a decent morning, went back to tell the dean I wasn’t going to quit, and he acted disappointed. And I muddled my way through the spring of my first year of dental school, started in patient care that summer, and caught fire! So I basically went from worst to first. I finished dental school in three-and-a-half years. By the end of my junior year, I’d finished basically all of my requirements.
MD: So was it coming in contact with patients that lit your fire? Was it the book classes you didn’t like? Or how do you explain that kind of sudden metamorphosis?
MH: You know, I think the pure basic science — anatomy, histology, physiology, biochemistry — wasn’t my passion. It was the people part of dentistry. And there were a lot of people, a lot of classmates of mine, who were certainly more talented. There were many of them that had a superior academic background. But my big turn-on was the people part. Once I got one-on-one with patients, things exploded.
MD: That’s funny, because that is the exact opposite of my story. I went to University of the Pacific, and when we started with all the academic classes, I did really well because I’m able to memorize and spit out facts. And I thought: Dental school is easy. I can’t believe everybody thinks this is hard. In fact, this is easier than college. And then when we got to the clinical classes, that’s where my grades plummeted in a disastrous fashion. I ended up in remedial operative and it took a long time for me to come around to that part of dentistry. So it turns out you and I had kind of exactly opposite experiences in dental school.
MH: But we both ended up doing well, so that’s kind of cool.
MD: Thankfully when you go to dental school, 99 percent of your classmates end up being dentists. Of the people I know who went to film school, 99 percent aren’t doing anything related to making films! So dental school got better for you after that point?
MH: Yeah, and having graduated dental school in three-and-a-half years, I went over to Israel to work on a kibbutz from January to April in 1984, prior to my classmates’ graduation in May. I grew a beard and grew my hair long. You know, I did more dentistry in my first week there than I’d done in three-and-a-half years of dental school. And I loved it. It was a very profitable trip, Mike, because my last week there I met my wife.
MD: Wow, hold on. I was raised Catholic, so you’re going to have to define “kibbutz” for me.
MH: A kibbutz is a cooperative farming community. It was how the land of Israel was settled back at the turn of the century. Little cooperative farms were placed around the borders of the country. It was a way to settle the wilderness. The children all lived in the children’s house, and the men protected them at night. And the kids were taught together. The kibbutz movement was really a wonderful thing at the time.
MD: So you went over there and became …
MH: The kibbutz dentist.
MD: The dentist. Did they have a dentist before you?
MH: They had a one-room dental chair where people would rotate through, and I worked there three days a week. And then I worked up at the Lebanese border, in a development town with North African immigrants, a couple days a week. That was during 1984. I worked at a children’s dental clinic. I walked out of the clinic one day and there were tanks rolling by my dental office as they were heading into Lebanon. I was this kid — I’d lovingly call myself a redneck Jew in Greensboro, North Carolina — and to look out of my dental clinic one day and see tanks rolling by was distinctive.
MD: So while the other students were finishing up their clinical requirements at school, it sounds like you crammed about a year’s worth of private practice into those four months.
MH: It was pretty unbelievable, Mike. And then I came back and did the two-year oral medicine general practice residency program at UNC Hospital at Chapel Hill. So June 30, 1986, I finished my residency, and July 1, I bought a private practice in Greensboro and got started. I bought a 10-year-old practice from a wonderful man who was just not enjoying private practice. At the time, we had two-and-a-half employees. The receptionist quit six weeks after I started. I had to fire the hygienist. And I was left with one employee. It was one of those classic “don’t-you-just-love-it-when-this-happens” moments.
And then I lovingly say God smiled upon me, because I stumbled into a Linda Miles seminar. Linda took me under her wing and was amazing, and she has been a dear friend ever since. So I had people looking after me early on. Drs. Cathy and John Jameson have been tremendous influences on my life.
I started going to the Pankey Institute in 1990. I went every January for six years until I finished the curriculum at Pankey. And that was one of the most liberating things I ever did in my education dentally, because I stopped doing single-tooth dentistry. Basically when I bought my practice, it kind of doubled and doubled, and doubled and doubled. And I had no clue what I was doing. Patients were saying yes to me for whatever I was suggesting to them, but I didn’t know how to treatment plan, and didn’t really know how to do a complete comprehensive exam. I didn’t know how to study a panorex or a full-mouth series or study models, and then deliver to the patient what they really wanted for their health. So Pankey got me to slow down and work comprehensively. It was the single most important thing I did in my dental education to that point.
MD: So you mentioned that list, and it sounds like it includes clinical and practice management mentors that really are in a large way responsible for the success that you’ve had. But the point I want to bring up is, it sounds like you went and sought these people out and really kind of attached yourself to them.
MH: I did. I sought them. And they were very gracious in their caring for me. At my sixth Pankey course, Dr. Irwin Becker asked me to be a teaching assistant at Pankey. And when I got called to his office, I felt like I was being called to the principal’s office. I thought I had really screwed something up. And he said I certainly had a long way to go, but he thought I had potential to help teach there. So that was a great experience for me. Dr. Strauss, who saved my life in dental school in 1980, asked me to come speak to the freshman class and tell my story. And that’s really when my seminar career started. I was so nervous, Mike. I had diarrhea and nausea and vomiting for the month before I was going back to teach at Chapel Hill.
I bought a 10-year-old practice from a wonderful man who was just not enjoying private practice. At the time, we had two-and-a-half employees. The receptionist quit six weeks after I started. I had to fire the hygienist. And I was left with one employee.
MD: Wow, that’s quite the weight-loss plan! At least your suit would fit well.
MH: The funny part of that is, I worked the morning of the lecture. I was supposed to speak in the afternoon. I was out of gas, ran to the gas station, filled up my car, jumped back in my car, and my pants split from bellybutton to tush. And I’m like, what do you do? I’m already late, and I would be later if I went home and changed. I figured there was going to be a podium I could hide behind with my ripped pants. But instead I ran home, changed, got back to Chapel Hill, and there was a little metal folding chair on the stage — and nothing else! I would have been mooning Miami. But I was so nervous, and the moment I started, it was like an out-of-body experience. I just told my story and the crowd went wild. Afterward, Dr. Strauss said: “You had a magic moment there. You don’t get many of those.” And I thought, I don’t know what that was, but I want more of that.
So now I’m an adjunct professor at Chapel Hill. I teach the freshman Intro to Private Practice class, and have for the past 21 years. I also teach at the Advanced Education in General Dentistry residence. I did a talk for the seniors for many years. I’m a keynote speaker at Parents’ Day. I teach at Bowman Gray School of Medicine, their dental residence. So I got to do little talks. Dr. Keith Phillips, who is one of my heroes in dentistry, gave me some of his time at a couple of major dental meetings.
But my big break was in 1999. I had the opportunity to speak at the CDA (California Dental Association). In preparation for that, I got involved with the Dale Carnegie Training® organization, which was transformational. I took the 12-week How to Win Friends and Influence People course, which I think is the finest thing I did post-dental school in my life — education wise, outside of dentistry. Along with that I took their two-day High-Impact Presentations course, where they do eight three-minute videos of you. They film you, and you look at yourself, and your hands are in your pockets, and you’re scratching your head on the first video. And by the eighth one, you’re outside yourself — really bringing it! So then I went to speak in Anaheim, and from that one two-hour gig, the next year I went from five seminars a year to 20. So from that one seminar I got ADA, AGD, Chicago Midwinter, Yankee, Hinman, Greater New York, FNDC — everybody. So it was amazing, just transformational.
I got involved with the Dale Carnegie Training organization, which was transformational. I took the 12-week How to Win Friends and Influence People course, which I think is the finest thing I did post-dental school in my life — education wise, outside of dentistry.
MD: You have a real gift for speaking. Our readers should bring their teams to hear you speak the next time you are in their town. It’s a real treat. How was your practice doing during those years?
MH: So I started in private practice in 1986. And in 1998, another thing happened. I got really angry that I couldn’t figure out how to solve people’s problems more effectively. One of my favorite patients was in. I did a quadrant of partial crowns, and the provisionals broke three times. His wife came in not long after that — they’ve always said yes to any treatment I recommended — and the wife looks at me and says she couldn’t get her work done because she couldn’t come in five or six times like her husband did. It was heartbreaking. And that’s when I looked into CEREC® (Sirona Dental Systems; Charlotte, N.C.). So I was probably the second CEREC user in North Carolina. I was the first one in my area. Everybody told me not to do it. They told me not to buy CEREC, that it’s too expensive. No one believed in it. This was the CEREC 2. My accountant told me not to do it. My colleagues told me not to do it. The staff was upset. And I told my father about it and he, in his wonderful wisdom, said: “Son, why would you do it that way? People are used to coming in for two visits.” So I thanked him, and I bought it.
MD: Well, at least you had the decency to ask them for their advice before you ignored it!
MH: So I probably did a couple thousand units with the CEREC 2. I got the CEREC 3D in 1994 — did a couple thousand units with that. And now we have the CEREC AC unit. I’ve also worked with CEREC Connect. I think it should be whatever is appropriate for a practice. I don’t think CAD/CAM dentistry is for every practice. I think CAD/CAM dentistry is an idea whose time has come. And if someone chooses not to mill in their office, if there’s a lab that has an expertise in receiving digital impressions and returning quality dentistry, I think everybody wins. My understanding from some of the top labs that I know of is that they can deliver that care cheaper, and their remakes tumble. Does that sound correct?
MD: Yes, absolutely. It’s one of the things that we’ve noticed as well. And the other thing I’m excited about is hopefully being able to shrink the amount of time between the prep appointment and the delivery appointment. Because certainly I’ve noticed — we’ve got many CEREC units here at the lab that I get the opportunity to use — that same-day dentistry is preferable to two-week dentistry, mainly because of the temporary, and all the things that shift around during the two weeks while it’s on. So, hopefully, one of the benefits of the increase in digital dentistry will be a dentist prepping a tooth, taking a digital impression, sending it to their laboratory, and having it back in maybe 48 or 72 hours. Because I honestly feel that the less amount of time the temporary is in place, the better the chance that the cementation appointment is going to go smoothly, quickly and perhaps without anesthesia for the patient. So while one-hour dentistry is certainly preferable to two-week dentistry, I also think that three-day dentistry is probably preferable to two-week dentistry. So, yeah, we see a lot of benefit to dental practices. And, like you said, not every practice is going to want to mill their own restorations. But, certainly, digital impressions are within the grasp of every dental practice.
MH: I definitely know my heroes in dentistry, like Dr. Gordon Christensen, say that in five years everything is going to be digital. I respect him a thousand percent, whether that’s accurate or not. Digital dentistry is an idea whose time has come. So a word that I try to use with my patients and with my audiences when I speak is the word “appropriate.” What’s appropriate for your practice? What’s appropriate for your style and your temperament and your talent?
MD: How do you bring up one-appointment dentistry with the patient? Do you kind of make the decision whether or not you are going to mill the crown in-office before you mention it to them? Is it something you offer to most patients? How do you decide who might be a good candidate for a CEREC same-day crown?
MH: Right. You know, taking a half-step back, one of the great gifts I’ve had in dentistry that started in 1990 was working with an intraoral camera. So from that, the urgency has been created. We have eight operatories, Mike. We have eight Digital Doc cameras. We take a picture of every patient, every procedure. So while the patient is in the chair, all of a sudden they are turned on and motivated. And they want the care immediately. So when I have a captive audience, when I have somebody with a broken body part, I can create that sense of urgency to act, if we’ve got time in the schedule. The way the team and I work, the way that they’re trained and the flexibility that they have, we can solve their problem right on the spot. If we don’t have the time in the schedule, traditionally you would put on a temporary, put on a Band-Aid with Bondo and some composite if there’s a broken cusp, and they’d come back in how long, if ever? You know, with digital dentistry now, I can do the preps, scan them, and put on a quick provisional if we don’t have the time to run the whole thing.
For example, IPS e.max® (Ivoclar Vivadent; Amherst, N.Y.), I think, is an amazing material that has taken the profession by storm. With in-office dentistry, it’s really hard to deliver a quality e.max crown start to finish in less than two hours in my hands. So if we need e.max as a material and someone doesn’t have enough time, you could scan them, mill them in your chamber, or send them to your local lab and put on a quick provisional, and end up with a superior product without a traditional impression. So, if I can do them in the same visit, Mike, I will. I have found with today’s economy the biggest premium for patients is time. No one’s got the time, and if they bothered to walk into your office, they’re ready to purchase some dentistry.
In our office we’re huge believers in dental financing. We’re big CareCredit users. They’ve been phenomenal to work with. We’ve worked with them for ages. I think last year we put just under $400,000 on CareCredit.
MD: Yeah, I love CareCredit, too. Most of the patients I see aren’t walking in with an extra $5,500 in their wallet earmarked for some restorative dentistry.
MH: So we are very upfront with patients about asking them how healthy they want to get. How fast they want to get there. What their goals are for their health. We ask them why they left their last dentist. We take the time during our new patient experience to establish their values and their needs. We can’t be all things to all people, Mike, but 99 percent of the patients that come in love us, and they send their friends and they pay their bills with appreciation. When people ask me how I do this, I tell them I out-listen the competition. It’s pretty amazing to sit down in a consult room with a new patient, and at the end of that visit I ask them if they’ve ever had a dentist do that. Mike, it breaks my heart: 99-plus percent of my new patients say they’ve never had a doctor sit down and talk to them like this. So, as I tell my audience, I haven’t even examined them and they’ve already said yes to me. So you want to know how to improve your case acceptance and do more dentistry? My answer is, you out-listen the competition. You slow down a bit and let the patient define how healthy they want to be and how fast they want to get there.
MD: So walk me through that first appointment, if you could. Tell me a little bit about it, how much time it takes, and maybe the order of things. Maybe for the reader who doesn’t really even have a set first appointment that a new patient might go through — you know, where it’s just kind of seat-of-the-pants. Walk me through that first appointment, starting with the phone call from a patient with a broken cusp on #19.
MH: First off, we try to differentiate between a true dental emergency and an inconvenience. We see true emergencies within an hour. I mean, immediately. It’s, “How soon can you get here?” If the tooth has been broken for a month-and-a-half and now their golf game got canceled so they want to come in and I need to change my schedule to see them, that’s not a real emergency. We’ve got exceptional business team members, and they have a script that they go through to ask a bunch of questions to see if some patients are self-selecting at that point. They ask a lot of the questions on how long they’ve been in pain. Who referred them? We try to find out why they left their last dentist, if there are other radiographs at another office. What’s the urgency to act? Do they have a wedding coming up? Is this, again, a true emergency or just an inconvenience?
MD: This is all done on the phone?
MH: It is. Then we’ll email them, or they’ll go on our website and download the health history, or we’ll send them a snail mail copy, so that is already filled out for the initial office visit.
When they come in, our new patient experience is about an hour and 20 minutes, and we don’t clean teeth. We sit down in the consultation room and talk for five, 10, 20 minutes, whatever is appropriate. We take a panorex. We take a full series as well. If we think study models are needed at that point, we’ll take them, or do that at a second visit. We do digital photography with a nice background. We have two places in the office. One of our superstar hygienists has become our treatment coordinator, and she coordinates this visit. I meet with the patient first, and then she takes the photography for me, the radiographs, the full-mouth probing. We do a full-mouth tour with an intraoral camera, where we kind of co-diagnose. Then I do a complete exam — TMJ, occlusion and existing restorations. We go tooth-to-tooth with the intraoral camera again to look at nuances. And I’m real careful at that point, Mike, not to diagnose on the spot. I try to let the patient do that for me, when we put the broken body part up in front of them, and they say: “My tooth is cracked. You need to fix it.” And that’s what I found so liberating about the camera, about using the technology. I don’t ever say the word “need” to one of our patients — you need a crown, you need to floss, you need to do anything. I ask: “What do you want for your health?” And particularly when you put the camera shot in front of them, the verbal skill I use to close the deal is to just say the word “Wow.”
MD: (laughs) Exactly!
MH: And I don’t speak. We put the picture up there and I’ll say, “Wow.” I point, and when they say: “My tooth is cracked. You need to fix it,” I’ll ask how I can help them. How soon they want to get this done. So, you know, it’s a lot of fun to practice like this. If the patients come in at the first visit and say they don’t want an exam or X-rays, if they say: “I don’t want this. I just want my front tooth pulled,” I’m like: “That’s fine. It’s just not what we do. Let me find you a good dentist that will do that.” Often at that point they’ll say: “No, I want you. No one has ever sat down and talked to me. I’ve never seen an office that is this beautiful. I’ve never seen a staff as well dressed. They’re all smiling.” We hire smiling faces, Mike. The longest-term teammate that I have has been with me 20 years. The average time people on the team have been with me is at least 10 years.
MD: That’s a common theme from the successful dentists that I’ve talked to. The ability to attract and retain top-quality employees is super difficult, but I don’t know if there’s anything more worthwhile. You can go through all your levels of Pankey and reach a level of clinical excellence. And you can even do this kind of appointment that you’ve just described, the co-diagnosis with the intraoral camera, tooth by tooth, and let the patient kind of figure out for themselves what’s going on as you narrate it. But without the staff around you to pull this all together, it’s kind of all for naught, right? It’s not going to be dentistry that actually gets done.
MH: That is correct. If I could make the point: I think as a profession, we do a lousy job training our teams and ourselves because we’re so busy with the urgent, unimportant things in life. In our office we do a lunch-and-learn at least once a month, where we have a manufacturer come in. We do a ton of continuing education. We have staff meetings out the wazoo. I love going to the Scottsdale Center in Arizona to train for CEREC. I’ve been to Sirona’s headquarters in Charlotte, North Carolina. I’ve gone to every CEREC speaker around the country. But we now have four dental assistants, and to take everybody out of state, fly them, feed them, pay for tuition; it just gets really expensive. To have them trained in your office is amazing, and we’ve done that. So for our office, for our temperament, I do the preps and walk out of the room. The team packs the cord, scans, designs the restoration, mills it, takes a pre-cementation radiograph. If it’s e.max, they cook it in the oven. Then I come back when the tooth is etched and ready to roll.
MD: What a great way to practice! How fun is that?
MH: It’s a hoot! I’m not doing anything that anybody couldn’t do if you are passionate about your dentistry and care about your patients and teams. The last time I lost a teammate to another dentist in my hometown was 20 years ago. So I try to spoil them. The other striking piece of that, Mike, is everybody that I have working with me now used to work for another dentist. So it’s not that they didn’t have the talent. I just saw that they didn’t have the right fit, or they weren’t liberated like I have done for them. It’s a great way to practice, and it’s a lot of fun. We’re actually looking for a partner to join us if you want to get back in private practice or you know anybody.
MD: (laughs) Well, hopefully tens of thousands of dentists will read this and so you’ll get a few hundred emails and phone calls.
MH: One would be nice.
MD: Have you ever been to Disneyland out here in Anaheim?
MH: Many times.
MD: There’s a ride called the Jungle Cruise. If I had to work on any ride at Disneyland, it would be the Jungle Cruise, because it’s the only ride there where the person working the ride is telling jokes and having fun. So as you cruise around this obviously fake jungle on this “tour,” they are making bad puns, there’s silly wordplay, but it always kind of seemed like fun.
When I got my first intraoral camera and had the opportunity to do an exam the way that you’re talking about, tooth by tooth, oftentimes I kind of felt like I was one of the boat directors on the Jungle Cruise. And I felt like I was almost giving the patient a tour of their mouth. And I found it to be a really enjoyable process to kind of, as you’ve described, go tooth by tooth and show them things that they had never seen before, and spend the time to go over their entire mouth and all the posterior teeth they can never see. They were really familiar with #6 through #11 from looking in the mirror and the rearview mirror of their car. But to show them all their posterior teeth, they were the ones who would start to ooh and ahh and bite down on the camera. I’d have to take it out of their mouth so they didn’t break another tooth. So it got their interest into what’s going on there, and it created a sense of concern, so that when we got to the real things that needed explanation — like the bridge of calculus from #22 to #27, or the obvious perio conditions around a couple of the teeth — it was real easy for me to have them engaged in this conversation that we were having. So while it might sound like more work to a dentist reading this to do an exam the way you do, I find it to be a lot more enjoyable way to practice that just happens to lead to a much higher case acceptance rate. Would you agree with that?
MH: I agree completely. You know, at our age — we are a similar vintage, except that I have better hair than you, but that’s about it — I think life is too short, and I don’t want to argue with patients. We have an expression in our practice: There’s no hostages. You don’t have to be a patient here. You don’t have to work here. It’s free will. This is America. I’d rather see fewer new patients and thoroughly examine them and listen to them because the result over the years has been an extraordinary level of case acceptance. And what’s interesting, Mike, is these aren’t just upper class people. I’ve had people of very modest means accept extraordinary treatment plans just because I took this time.
MD: Well, not only that, but because of the CareCredit as well. People don’t have $15,000 buried in their backyard while they are waiting to meet the dentist who will redo their old crowns.
MH: CareCredit has been an unbelievable adjunct. The camera creates that sense of urgency. We do have a lot of technology in our office. We have eight operatories. We have eight Isolites (Isolite Systems; Santa Barbara, Calif.), which I think has been transformational for my career. We have a Digital Doc camera in every operatory. I have the two CEREC machines. I have three lasers. We use Discus curing lights; we have two in each operatory. So I made that investment in the equipment in the practice, so I can work efficiently. I wish our profession did more of that and looked big picture. I think one of the worst things we ever did was make intraoral cameras portable, because you’re a 2011 cutting-edge dentist in one room and you’re 1950s in the other.
MD: And the reality is, it probably won’t get carried from room to room anyway.
MH: They’re so affordable now, it’s just a matter of, how many days does it take to pay for itself? Everybody that has ever had to buy a camera on my advice says they easily add $100 to $500 a day, so that’s between $20,000 and $100,000 a year. You almost want to say, well, why do you care what the camera costs? If that was a stock, you would pay five grand for it and within 12 months it would be worth $100,000. Would you buy it?
MD: I would, and lots of it. Even my lululemon stock didn’t do that well this year!
Tell me a little bit about your hygiene department, your hygiene philosophy. Maybe how the hygienist takes care of those people who come in for a “cleaning,” who have obvious periodontal needs. And if you’re comfortable, maybe about how the hygienists are compensated, as well?
We have an expression in our practice: There’s no hostages. You don’t have to be a patient here. You don’t have to work here. It’s free will. This is America. I’d rather see fewer new patients and thoroughly examine them and listen to them because the result over the years has been an extraordinary level of case acceptance.
MH: Love to. Our hygienists are just outstanding. And, actually, everyone in the office has gone through Dale Carnegie Training courses now, which is a hint to your readers. We’ve all gone to the Carnegie course, and we’ve had them come in. They were already talented and charming before, but this refined their people skills. So nobody gets in the first day and gets their teeth cleaned. They’ve gone through the new patient experience. They’ve had the full-mouth perioprobing, so we have a diagnosis for what type of cleaning they’re going to get. Four of our eight operatories are dedicated to hygiene. So each hygiene room has a Cavitron® (DENTSPLY; York, Pa.) and a Prophy-Jet® (DENTSPLY) that shoots chlorhexidine. Every room has modern, state-of-art equipment. Every hygiene room has an Isolite also. Do you want to know how to double your hygiene productivity? Have them pop an Isolite in and go to town. The time it takes to do scaling and root planing is cut in half. And each hygienist has her own intraoral camera, so nobody scales a piece of tartar without a before-and-after shot. We have the before shots, so they’ll Cavitron that calculus bridge from #22 to #27, take an after shot, and print that out. That’s your business card for the day. So instead of thinking it’s just a cleaning, the patient thinks: This is disgusting. I’m infected, and now you got the infection out of my mouth. When there are quadrants of scaling and root planing, we try to do that as efficiently. We try to do two quads at time, if that’s appropriate for the patient. You know, again, we always do the before-and-after camera shots. We now have a hygiene assistant that is dedicated to keeping our hygienists on task. What I’ll try to say to my audience, Mike, is: Why would a doctor do a non-CEO procedure? Why would you spend your time doing something that a well-trained teammate could do for you?
MD: That’s a good point. You rarely see dentists taking alginate impressions for study models, for example.
MH: So, in the same vein for our hygienists, if they’ve got a dedicated hygiene assistant that’s setting up, cleaning up the room, taking the radiographs, taking the panorex when they’re due, taking the full series when they’re due, taking impressions for whitening trays, the hygienists can focus on their education, on their scaling, root planing, on their hygiene-only duties. We have just kicked that into high gear, and it’s been amazing.
MD: The Carnegie training for the hygienists, is that mandatory? Or did you just happen to attract winners who are more than happy to take it?
MH: I send everybody to Dale Carnegie. So is it mandatory? It’s part of the philosophy of this practice. People say, “How do you hire these people?” I hire smiling faces. I hire attitude over ability any day of the week. What I find is that most of the predominantly women in dentistry whom I’ve hired as teammates, they’ve just been dying to be cared for, and nurtured, and supported, and educated, and liberated. And that’s what we do.
MD: They’ve been dying to have a career and not just a job?
MH: Yeah, and somebody to care about them. My philosophy is, I’ll pay for any continuing education any teammate wants to take inside or outside of dentistry. If their church or synagogue has put on something special, of course I’ll pay for it. That has nothing to do with dentistry, but it makes them a better-rounded person, and they’ve got more interesting things to talk to our patients about.
MD: When was the last employee hired? Has there been anybody hired recently? I know a lot of people have been there for 20 years.
MH: Actually, we just hired our fourth dental assistant.
MD: Like you said, people are always asking you where you find all these winners, and you said you hire “smiling faces.” Tell me a little bit about the process of finding this new dental assistant, and maybe the kind of things you ask in interviews. Because dentists tell me all the time that hiring and, unfortunately, firing is one of the things that they don’t enjoy about private practice.
MH: You know, what’s interesting with my team as long as they’ve been with me, they really did the hiring for me. This young woman was interning with us from the local community college. I really didn’t have any intention of hiring a fourth dental assistant. Her attitude was sensational. She was the first one in the office every day. She almost beat me to the office. And I never saw her doing anything except setting up, cleaning up rooms, scrubbing instruments, running around, saying, “How can I help?” And her last day she brought these beautiful gifts for each of the teammates and wrote me this gorgeous letter, saying thanks for this opportunity. Would I please write her a reference for employment? And I thought, to heck with that, I’m going to hire her. Anybody that would go to this trouble, show this level of commitment, whether I need her or not, I’ll find a position for her. She’s just been a joy.
My philosophy is, I’ll pay for any continuing education any teammate wants to take inside or outside of dentistry. If their church or synagogue has put on something special, of course I’ll pay for it. That has nothing to do with dentistry, but it makes them a better-rounded person, and they’ve got more interesting things to talk to our patients about.
MD: That’s amazing. So you probably weren’t entirely sure whether you needed her or where you were going to put her, but you knew she was a quality person and these don’t come around all that often.
MH: With that attitude, I’ll find a position for her. What’s interesting is that one of our other assistants came in our office the same way. She interned with us. She was top in her class. And the joke is, the rest of the team said: “We want a puppy. This is our puppy. We love her. Can we keep her?” We didn’t have a position at the time. She went to work for another office. We had another woman follow a young man out of town and, basically, they called this woman, and about an hour later she was in our office working for us. She has been sensational. And the same thing happened with this young woman we just hired. She interned with us and the team was like, can we keep her?
MD: You know, one of the things that we’ve learned here at the laboratory over the years is that, in order to grow, we have to be slightly overstaffed. If we see somebody or somebody comes by who’s a quality person like you talked about, or who goes through our educational department, and we find that this is somebody great, although we’re not sure where we’re going to put them, we’ll do the same thing and hire them. So at any given time we may be slightly overstaffed by say, I don’t know, 20 people. Now we’ve got 2,000 total employees, so 20 people is not a huge amount. But do you feel like in order to grow, you should be kind of slightly overstaffed, as opposed to the dentist who maybe, in an effort to cut overhead, wants to be slightly understaffed?
MH: I do, and I say that with an asterisk: If people are standing around or they’re not self-motivated, it brings the whole team down.
MH: But for us, for example, in North Carolina, you can only have two hygienists per doctor.
MH: Yes. That’s the Dental Practice Act. We had a young partner with us who left, and I was left with three hygienists who were phenomenal. So what do you do? So I made my longest-term hygienist, who had been with me for about 10 years, our treatment coordinator, which sounded crazy, to take our number one producing hygienist off the production line. And for six weeks on the job she added $52,000 of treatment that was directly attributed to her sitting down with people and discussing elective treatment. Was that a good move or not? Will they say you’re nuts to have three full-time hygienists?
The other thing is that people are allowed to take vacations. Life happens. People get sick. I don’t want a part-time, fill-in agency person — no disrespect to them. But with our system, we have people that are trained on our software, trained on our cameras, with our verbal skills, with how we do our financial arrangements, with our philosophy and care. Our patients expect the level of patient care and experience in our office, and not a commodity. They don’t expect just a cleaning. They expect you to know their family, and love them and care about them. So, to your point, to be slightly overstaffed lets people take vacations without the practice having to run on three wheels for a couple weeks.
MD: One of the slides that I showed at that last talk that you saw me give was one of how, here at the laboratory, 2010 represented the first year in which we actually did more all-ceramic restorations than PFMs. This is truly striking because it’s been a long time coming with all-ceramics creeping up very slowly. The PFM has always been the workhorse restoration in general dentistry in the U.S., so it was really amazing to see all-ceramics actually pass PFMs last year. And it’s because of two restorations: the one you mentioned earlier, IPS e.max from Ivoclar Vivadent, and BruxZir® Solid Zirconia, the full-contour zirconia restoration that we developed. I’m wondering, what does the mix of restorations look like in your office? Are you still doing a lot of PFMs, or are you doing more all-ceramics? What are your current choices?
MH: We are doing probably 99 percent all-ceramic.
MD: (laughs) And one PFM a year?
MH: You know, I love gold, and nobody wants it. I think I’m a typical dentist. I’ve got three gold onlays in my mouth. I love working with it. It’s ugly. Basically we’re doing IPS e.max on the molars and IPS Empress® (Ivoclar Vivadent) pre-molars forward.
MD: It’s funny how when you’re going around with an intraoral camera in a patient’s mouth, anytime you see gold, you can just stop and ask them who the dentist is in their family, and they look at you like you’re clairvoyant.
MH: It’s amazing, isn’t it? Again, we love gold, but I find that virtually nobody wants it. If we need strength, these e.max restorations — I know it’s early, but I think you can stand on them and they don’t break.
MD: Yeah, we’re four years into it. Gordon, who I look up to like you do, typically says we need five years to see what’s going on. But, we see the fracture rates here in the laboratory, and we can tell that it’s doing fine. It’s holding its own against PFM. Now, there are certain things that need to be taken into consideration. If a dentist were to say to me: “Hey, look, I’m going to prep this molar, and by the way, I’m going to underprep it like I usually do, and give you guys less than a millimeter of occlusion reduction …”
MH: Not gonna work.
MD: Then, yeah, I don’t even want a PFM. Then I do want a cast metal crown of some sort. But, in that case, if it starts getting thinner and thinner, I’d feel better with a BruxZir crown than an e.max crown, because it is stronger, even though it’s not quite as esthetic. But, yeah, given close to ideal reduction, e.max is doing just fine, whether it’s cemented or bonded into place.
Another number that we’ve seen here at the laboratory that has slowed down and hasn’t really recovered since the recession has been porcelain veneers. I came out of LVI back in 1995 thinking I was going to have an all-veneer practice, and it didn’t really turn out that way. When you look at the number of veneers that we do compared to other restorations, you can see that it’s probably not a huge driver in a dentist’s monthly production. Do you find yourself doing a lot of veneers, or do you find yourself being more productive with other indirect restorations?
MH: It’s a mix. You know, we have two full-mouth rehab cases going right now, and those are tough. It’s a lot of work and a lot of time. They sound really sexy when you go to a course and see the superstars doing them, and they’re really hard to deliver in an exquisite fashion. Here in Greensboro, my hometown, our three biggest employers were furniture, textiles and tobacco. So you have a clue of how those industries have been doing.
But we’re still doing well. We’re successful because of our systems, because of the people, and because we’re giving the patients what is appropriate. We’re offering them the chance at comprehensive dentistry at a pace that’s comfortable for them. So, people still shock me and say yes. Sometimes it takes them longer to do the entire case. They may break it up. Again, having the dental financing is a big thing. And sometimes the limit of what they can afford is not going to be appropriate. I think one of the worse restorations is to veneer #6 through #11, and then you’ve got black buccal corridors going posteriorly. So I’ll virtually do two-for-one to go ahead and add the premolars, just so it will look right. You don’t want to end up with headlights.
MD: Yes, exactly. Where teeth #6 through #11 look nice, but it looks like they forgot to put their partial in because you can’t see their bicuspids or molars.
MH: Exactly. I’d rather do four, eight or 10 anterior teeth than six.
MD: For me it’s either four or eight. You can’t stop on the cuspids. It never works. Did you say something about having microscopes in the operatory? I have stuck with loupes even though the microscopes are out there.
MH: We don’t have microscopes, but we pretty much have everything else. We have lasers. We have the DIAGNOdent® (KaVo; Charlotte, N.C.). We have digital radiography in every room. And again, I’ll invest in my patients’ health. That’s where I see digital dentistry going. I see that as a tremendous opportunity for bread-and-butter dentists to partner with their labs, if they don’t choose to have the milling chamber, and the labs are set up so they can turn that around promptly.
MD: What do you think about the fact that the numbers I’ve seen show that still less than 50 percent of dentists have made the investment in digital radiography?
MH: I think that is criminal, Mike. When we invested in digital radiography, I was so embarrassed by how much I had missed. Crowns that I thought looked fine with my regular Kodak film, now with a digital radiograph, I was appalled at how much I had missed. There is a learning curve with it. But I don’t know anyone that has invested in digital radiography for whom it hasn’t paid for itself in a year or less.
MD: Yeah, you never hear stories about people investing in the system and then giving it back. You won’t find a lot of barely used digital radiography systems on eBay.
MH: Digital radiography is an idea whose time has come. Our challenge is that many of our colleagues aren’t farsighted. They’re scarcity-minded instead of abundance-minded. And that’s too bad. When I’ve been able to speak at meetings around the country, I hope people find me a liberation speaker, as opposed to being a motivational speaker. I hope I help them let go of things that are holding them back. I have never heard people regret it when they’ve added technology that set them free.
MD: How do you feel about talking money to patients? Will you do it?
MH: Absolutely, I’m pleased to! I think for the bigger cases that we, as a profession, need to re-grow our spinal column, and man and woman up. And say: We believe in this. This is an investment worth doing. An investment to secure this tooth, whatever your crown fee is.
I’ll often say, before that, to the patient: “Besides money, is there anything keeping you from getting this done?” They’ll say it’s just the cash flow. If they say, “Well, how much is it?” it’s typical in dentistry to say, “Well, so-and-so discusses that in our office,” and you run out of the operatory. I think you put the picture up in front of them on the camera and say, “It’s an investment to keep this.” One of my favorite things is to break it down to what it is per day.
MD: (laughs) Wait, what? Not even monthly? You’re going per day?
MH: I’ll say, you know, for three bucks a day over a year, you get to keep this tooth the rest of your life.
MD: That’s awesome! What is that — three bucks per day times 365 days — that’s over a thousand bucks, almost eleven hundred?
MH: Roughly. You know, it’s a cup of Starbucks a day to keep this tooth.
MD: I like that.
MH: It’s going to Redbox a couple times. I mean, come on. Don’t tell me you can’t do this.
MD: Will you actually say that?
MD: Right, depending on the rapport that you have with that particular patient.
MH: If they’re a Duke fan, all bets are off. I’ll say anything to piss them off.
MD: (laughs) How about on the bigger cases? How about somebody who does have a need for, say, 10 crowns or something like that? Is it the same kind of discussion, or is it a little bit different?
MH: Interestingly, once the urgency has been created, I find those cases easier.
MH: Because I think people have been hesitant, dentists have been hesitant, to show them comprehensively how to solve their problem. One of the great things our treatment coordinator does is, she does the imaging after she takes her digital photographs. So we do a digital case presentation, where we have Photoshopped their smile, and show them a before-and-after of their teeth. And then three or four other patients have given us permission to share their before-and-afters. So they see other people who had similar problems, from all walks of life, who have chosen to do this.
MD: Wow, that’s impressive. Obviously that’s another good example of somebody taking some training courses and becoming adept at putting together those types of presentations with Photoshop and things like that.
So to wrap this up, Mark, if I’m a dentist out there reading this, and my practice isn’t really where I want it to be, or where I thought it would be when I came out of school, and I like what I’m doing, but I’m not doing as much of the things that I want to do, give me some advice and tell me what you think the first couple steps would be in terms of what I might do to sharpen my clinical skills, and what I might do to be able to kind of get my practice running a little more like yours.
MH: Right. I think one of the greatest expressions I ever heard, Mike, was three words: Success leaves clues. So what have other highly successful dentists done? And, to me, they’ve invested aggressively in their dental education, and they’ve invested aggressively in their people skills — like a Dale Carnegie type of thing. As an office, we spend a lot of time reading success literature. If I read a book that I like, I buy a dozen copies and give it out to everybody in the office. So, as an office, together we’ve read “The 7 Habits of Highly Effective People,” “Good to Great,” “Raving Fans,” “Who Moved My Cheese?”
MD: And they’re all happy to do it?
MH: Well, we do it because at the next staff meeting we’re going to talk about it. Where else have they ever worked in dentistry where somebody handed them a book and said, “This is because I care about you”? Another book we did was “The Millionaire Next Door.” How many dentists have given their teammates “The Millionaire Next Door” because they said, “I want you to be a millionaire”?
MD: Yeah, more typically I think they hand them the Henry Schein catalog and the Patterson Dental catalog and ask them to find the cheapest cotton rolls.
Where else have they ever worked in dentistry where somebody handed them a book and said, “This is because I care about you”? Another book we did was “The Millionaire Next Door.” How many dentists have given their teammates “The Millionaire Next Door” because they said, “I want you to be a millionaire”?
MH: So I think part of it is, our dental colleagues need to have a career conference with themselves, and just decide. This work is too hard, Mike, to not love what we do, and to not be with teammates that we love. So a big thing for me was also working with consultants. Like I said, Linda Miles was a huge influence. Naomi Rhode was. And working with John and Cathy Jameson has been a singular ongoing relationship for us and for the team. These folks have seen it all and done it all. And it’s wonderful. A lot of times they’ll say the same thing I’ve been saying, but it’s good to get the affirmation from a third party. So again, I invest aggressively in myself, aggressively in my team, and I try to keep a balance in my life with my wife and with my kids. You know, there’s no perfection. I’m not a perfect dentist. I’m not a perfect father. Not a perfect son …
MD: Or lover, from what I’ve heard.
MH: Or brother. The lover, I try hard.
MD: (laughs) Yoda said there is no try…
MH: I’m very humbled by where dentistry has brought me and by the privilege of speaking like I have. I love being able to share my story with people and try to inspire them and liberate them. It was like hearing you years ago at the Holiday Dental Conference. I thought you were sensational. You had that real high-tech communication on the overhead projector. And now the whole world is digital and computers. But the bottom line is, Mike, you can buy all this equipment, it doesn’t create a relationship with your patients. If you deliver commodity care, you’re not going to thrive in today’s dentistry, in today’s economy.
MD: How dare you! That overhead projector was state of the art!
MH: Take the time to be a part of your patients’ lives and make a difference in their lives, and you will thrive beyond anything you’ve ever dreamed of. That has been my experience.
MD: Well, that’s fantastic, Mark. I think that’s a perfect place to go out. I’ve never interviewed a successful dentist who, when I asked them how they got to where they are, said they were born this way, that they’ve been doing this since they were 4 or 5. Everybody goes into dentistry for a different reason. But it’s about looking and finding somebody who’s doing it the way you’d like to do it, and then following them and attaching your wagon to them. And you’re right: Success leaves clues. And a lot of people are willing to give you those clues because they know they should share it with somebody else as it was kind of freely given to them.
I want to thank you for your time, and thank you for sharing your world with our readers.
MH: A pleasure, Mike. If anyone wants to get in touch with me, they can call me at the office, 336-282-8850, or go on our website, tarheeldentist.com, and zip me an email and let me know how I can help them.
MD: That’s fantastic, Mark. You’re the first interview we’ve done where somebody has actually offered to have people call them at the office and ask them questions.
MH: It would be my pleasure.
MD: If anybody had any questions about whether you meant everything you said during the interview, I think you answered them right there.