TC Course March 2019


The Times They Are A Changing

 “Come gather ‘round people

Wherever you roam

And admit that the waters

Around you have grown

And accept it that soon

You’ll be drenched to the bone

If your time to you is worth saving

Then you better start swimming or you’ll sink like a stone

For the times they are a changing”

Looking back to 1978 when I started in the orthodontic field (I worked in a general practice from 1974-1978), the majority of orthodontic practices were run by solo practitioners. People communicated in person, by telephone or by mail – although the first email was written in 1971, email providers such as AOL, did not make an appearance until 1993.  Patients were typically seen every month for an adjustment, which correlated with their payment plan.  In most cases, patients were treated using the same treatment modality- fixed appliances with bands and brackets.

In many ways, life and running a successful orthodontic is a lot more difficult today than it was in 1978. The orthodontic industry is fierce; you are competing with other orthodontic practices as well as general dentists, Smile Direct and Candid Clear. Corporate, group, interdisciplinary, and multiple doctor practices are now taking the place of many solo practitioners. Today, more than ever before, it is imperative to focus on your strengths, your vision, your mission statement and your goals.

Regardless of whether you have been in practice for 1 month or 20 years, make a list of your goals for the next ten years. Close your eyes and envision the type of practice you dreamed of when you were accepted to the orthodontic residency program. How does your vision compliment your current or desired lifestyle? Is there a specific demographic of patients you would like to target? Do you want to open a start-up practice, buy an existing practice, work in a group practice or join a corporate group?

Let’s look at some of the key “ducks you should have to have in order” to open and run a practice on your own. Being a solo practitioner can be very rewarding as you are in charge of your own destiny.  All practice decisions are in your hands. From the hours you work and your preferred modality of treatment to the number of patients you see daily and the size of your team.  It’s your baby to nurture and groom into something you will be proud of as it matures.

Develop your unique brand, one that reflects your philosophy and vision for the practice. There are several logo design sites that run a contest open to developers. For a minimal investment, you will receive dozens of designs created specifically for you.  I used to design my logo and the total investment was less than $250. Use your logo on all printed materials you give to patients, your referring doctors and within your community.

Take the time to put together your team member handbook before you hire your first employee. It makes managing the team a lot easier if you have a clear outline of rules, expected behaviors, and benefits. Material covered in the manual would be:

    • Mission statement
    • Office policies (90-day probationary period, health and safety, smoking, uniforms, patient confidentiality, harassment, verification of licenses, etc.)
    • Discuss chain of command if team members have a concern or need to call in sick
    • Office hours
    • Payroll information (payroll deductions, when are paydays, hourly or salary, classification of employees)
    • Benefits (sick leave or PTO, vacation, holidays, leaves of absence, bonuses, continuing education, etc.)
    • Copies of internal office forms (time off request, mileage reimbursement, non-disclosure statement, performance review, verbal and written warnings, etc.)

Rather than giving each team member a copy of your handbook, keep a copy in the office for them to read and review. Unfortunately, I have seen many office handbooks “shared” by employees who have left the practice. The team members each sign a statement that they have had the opportunity to read the handbook and have had all of their questions answered.

Create detailed, progressive job descriptions for your current and future team members. For example, you might start out with one administrative team member who is in charge of scheduling, financial and new patients. These responsibilities can be separated as the practice grows, just as the clinical team’s duties can be divided, based on licensure and experience. It is a lot easier to hire new team members when you know exactly what position and duties they will be responsible for.

Just as taking care of a baby can be difficult and time-consuming, the same can be said of a solo orthodontic practice. Non-clinical duties including accounts payable, payroll, marketing, HR specialist and practice planning consumes many hours, every week.  As a private practice grows, duties can be shifted over to a team member, outside accountant or a marketing company. A rule of thumb for solo practitioners who have been in business for 5 years or less is for every three clinical days you work, plan on one administrative day to take care of non-clinical duties, as well as treatment planning and submitting Invisalign scans. Mature practices can often have a 4 to 1 or 3 to .5 ratio of working/administrative days.

Keep your eye on key numbers when making decisions regarding office hours and the number of team members on your payroll. Following are goals to strive for:

  • Dollar earned for each clinical hour orthodontist worked      $1825 and higher
  • Dollar earned for each team member hour worked                  $ 150 and higher
  • Dollar earned for each patient visit                                               $ 275 and higher
  • Number of patients seen per doctor hour                                     8 or more

Another rule of thumb is to hire 1 team member for every $200,000 of production. Start out with 2 team members for a new practice, and then add a third employee when you hit $400,000. Once you hit the 1.5 million in production, you can typically stretch it out to an additional team member for every $250,000, if you utilize an effective schedule and cross train team members. You can effectively run a $1,500,000.00 practice working 12 – 15 patient days a month with 8 team members (2 administrative, 1 treatment coordinator and 5 clinicians).

Have your telephone covered over lunch and on non-patient days. Many patients will call for appointments when they have time over their lunch hour or on Fridays (many businesses now work four 10-hour days, giving them either Monday or Friday off.)  If you missed one new patient call a week and 50% of those patients might have started, you could be missing out on over $150,000 in additional production a year.  The increased production more than compensates for the additional team hours.

Seize continuing education opportunities for yourself and your team. The better the team is trained, the more you can delegate.  The clinical team can be trained to submit Invisalign cases, set up indirect bonding cases, as well as knowing your wire sequence which allows them to start on a patient without the doctor checking first. Send your team to your software company’s annual user meeting to ensure that they are competent and fully utilizing all features of your system. Offering them the opportunity to take a class on Excel or Word will give them the training needed to create spreadsheets, graphs and letters to keep you fully apprised of the progress of the practice.

Open, honest and clear communication with patients and parents is the cornerstone of successful orthodontic practices. Often, I observe doctors giving patients the answer they want to hear, even if it is “pushing the envelope.”  For example, telling a patient that their treatment will be completed in 18 months although in reality it will be closer to 22 months.  Although the patient and parent are told that patient cooperation is crucial to finishing on time, realistically a percentage of your patients go beyond the target date. Give yourself a cushion; patients do not complain if treatment is finished ahead of schedule.

The number one key action you can take, whether your practice is solo, group, interdisciplinary, or corporate), is to treat every patient as though they are your only patient. When you are seeing a patient, focus only on that patient. Quickly review their chart before they are seated, bringing you up-to-date not only on their treatment, but also on their activities and interests. Consider them friends and families of the practice, not just patients who are having their teeth straightened.

Above all, remember to smile. Your smile lays the foundation for excellent customer service. It is easy to do, does not cost anything and portrays a positive first impression.



We recently had our patio refinished with System Pavers, hoping to repair a poorly finished stamped concrete patio gone bad.  As we waded through several frustrations and delays, I started to compare the customer service we received from System Pavers with that offered in many orthodontic practices.

When our sales associate went over the design plans and fee estimate, he promised high service and results, then dropped the ball and neglected to inform us that something as basic as sealing the new patio was not included.  New to this process, we did not know what questions to ask as to what was included in the feel.  Sealing of the pavers is always done upon completion of the project, we could only assume it was included in the fee.  How often do we assume the patient and parent understands exactly what is included in the total treatment fee?  Are you charging additionally for clear brackets, retainers, x-rays, tooth whitening and broken brackets/missed appointments? Excellent customer service means reviewing the fee for treatment thoroughly and itemize exactly what is included in the fee.  Do not “surprise” the patient with extra fees.

When we signed the contract with System Pavers we were told by the sales associate that the work would begin the first week of May.  Unfortunately, the salesman was not kept up to date on the work calendar, leading to extreme disappointment and frustration that the work did not commence until the first of June.  How often is your treatment coordinator promising patients that they can start treatment on a certain date without actually checking the schedule?  Just as the sales associate with System Pavers is driven to sell, sell, sell, the same concept is often put on the shoulders of your treatment coordinator. Are you pushing your treatment coordinator to convert patients, not taking the time to follow up with them through the start of treatment?  Well informed customers and patients are more likely to be “wowed” by your attention to detail.

When the project manager came to do the walk-through before the project was started, in my opinion he made two major mistakes. He did not back up the salesman when we expressed our frustration about the delay of the project.  Instead, his comment was that the sales force does not know what they are talking about.  It was a reminder to me of the importance of standing behind your teammates, do not throw them into the fire when things go wrong.  Once you express the opinion to patients that a team member does not know what he/she is talking about, the patient will lose trust and confidence in the practice.  Remember, you are only as strong as your weakest link. His second faux pas was to push an up sale of the product and design we had committed to.  His “up sale” proposal was $10,000.00 more than the original contract.  When we turned it down, he came back with a price increase of $3400.00.  We felt that we were in the middle of an auction.

System Pavers neglected to inform us as to when the pavers, sand and cement would be delivered.  To my surprise, I opened my garage door one morning to find that my car was completely blocked in.  When I tried to maneuver my car around the materials, I ended up stuck in the sand half way up my passenger door.  Luckily my gardener was there and helped to dig me out.  Lesson learned- take the time to fully inform your patients and parents of every step in the process.  Put yourself in their shoes; this is new to them. Give them a step by step illustration of what to expect at every phase of treatment.

We were told that our project would take 6 – 7 business days to complete (we are currently at day 16.) We were out of the country for 10 days during the construction and to our dismay we found out that only one person worked on the patio for 1 day the entire time we were gone.  It was very disappointing to come home to the same mess we left. When you give patients their estimated completion date, keep them updated if treatment will be extended. If you estimate treatment will be completed in 18 months, you can be assured that the patient is counting down the months or days until they are done.  Even if the message is not what the patients want to hear, keep them informed.

Last but not least, communication (or lack of) is the common thread of our disappointment in System Pavers. If they had communicated openly and honestly with us through all steps of our patio project, we would have better tolerated their short comings. Take the time to educate and update the patient and parent at every visit.  A brief 30 second chat at the end of each appointment will keep everyone on the same page:

  • What was done today
  • What you should expect as a result of today’s visit
  • How is the patient doing overall (cooperation, treatment progressing, etc.)
  • When does the doctor want to next see the patient
  • What will be done at the next procedure (including length of appointment)

Just as we suggested to System Pavers they review their systems, from the sales person to the project managers, the same philosophy applies to your orthodontic practice. Raving fans are not created from mediocre service; in today’s world it is only the extraordinary companies who stand out above their competitors. Utilize secret shoppers to rate your customer service, ensuring that you do not fall into the pit of poor or just average patient care. Don’t deny your short-comings, use them as an opportunity to learn and improve. Partner with an orthodontic consultant to evaluate and implement systems to enable you to always put your best foot forward.

In summary:

W~ Work together as a team

A~ Always keep the patient and parent informed

L~ Listen to your patients, don’t assume you know what they are thinking

K ~ Keep your promises


T ~ The patient comes first

H~ Heed the good, the bad and the ugly.  Use it as a learning opportunity.

E~ Educate the patient and parents


 T~ Train the team so everyone is one the same page, giving consistent information to              patients and parents

A~ Ask for feedback from patients and parents throughout treatment

L~ Learn from professionals to establish systems and protocols

K~ Kiss philosophy.  Keep your systems simple and manageable.

Give your patients an outstanding treatment result through a well-thought out process, keeping your promises and all parties well-informed.  Do not become the victim of inadequate systems that taints the value of the end result.

My husband and I were watching The Voice a few days ago, catching up on the episodes we had missed over the past several weeks.  We both agreed that the incredible talent of the contestants surpassed that of previous seasons.  Rather than questioning if the artist should move forward, the decision often instead is which coach would be best suited to guide them through the journey to achieve their dreams. Each one of The Voice coaches offers a unique mentoring approach with the goal to help the contestant reach far beyond their wildest dreams and expectations.

Often I see the most veteran team member put in charge of leading and training- the Blake in the office.  Consistent and reliable with years of experience they understand the ultimate goal, bringing priceless wisdom and pearls to the training table.  Put them in charge of Stage 1 training, the first 90 days. If you do not have a formal systems and procedures manual, develop it the next time you hire a new employee.  As information is delivered, the new team member writes everything down to create the foundation for a written training program with systems and protocols.  Unfortunately, as with computers, no one has yet discovered how to transfer information telepathically from one person to another. Do not expect trainees to tap “Blake’s” knowledge and experience through osmosis.

The Adam (singer, song writer and multi-instrumentalist) in the practice can be compared to an employee who has either worked in more than one orthodontic office or has had experience in multiple areas of the practice. Rather than blindly accepting a system because it has always been done the same way using the same products, Adam would be the team member who is continually trying to find enhanced, streamlined systems that would better serve the orthodontic community. As well as seeing the big picture, they understand the intricate puzzle pieces needed to make your systems work. They can fill a vital role in your training and management program delivering Stage 2 of the coaching process – after the first 90 days.

The human resource aspect of owning your own business often causes the majority of your headaches.  Between monitoring employee performance to establishing pay and benefits, it can significantly increase the number of hours you spend working each month.  Having an Alicia on your payroll; calm, cool and unflappable, can enable you to share some of the HR responsibilities, freeing up time for you to see patients. Develop detailed job descriptions outlining duties and expectations as well provide a measure of performance.  The HR Manager is also responsible for fielding employee conflict and enforcing the 24-hour rule. Under the 24-hour rule if an employee has a complaint or concern with any member of the team, they are to go directly to that person and only to that person.  If they are not able to resolve the problem between the two of them, only then do they take it to a third party for input. If the concern is not addressed within 24-hours life is too short, just let it go. Your “Alicia” can be your human resource gatekeeper, from record keeping to performance auditing to making recommendations for changes in salaries and benefit plans. Update the manuals and job descriptions on annual business to ensure that the documentation is accurate and up-to-date.

Miley, Miley, Miley!  She will definitely bring the excitement into the practice. They challenge you to explain the why and not just the how. They have endless supply of energy and can be counted on to create fun and laughter.  Give her the responsibility of coordinating internal marketing and team activities. Toss her the ball and then let her run with it under your guidance.

The Voice coaches encourage contestants who do not successfully move forward on their first attempt; they highlight the positive and point out specific measures needed for improvement.  The key is to remember that that if you are not successful the first time, it does not mean failure.  Instead look at it as:

F          First

A         Attempt

I           In

L         Learning

Just as Blake, Adam, Alicia and Miley are not the perfect mentor for every contestant, it takes more than one trainer/leader to develop a gifted orthodontic team. Your “dream team” is obtainable with The Voice of the doctor partnered with a solid coaching and management program.




“The game of life is a game of boomerangs.  Our thoughts, deeds and words return to us sooner or later with astounding accuracy.”  Florence Scovel Shinn

My family loves to give me a bad time because every time I see someone with braces I feel compelled to ask them who their orthodontist is and what has been their experience. Other than the time a teenager told me that she loved her doctor because he was “drop dead gorgeous”, the responses I get remind me of Yelp reviews.  The response is enthusiastic if their experience was extremely positive (or exceptionally negative),   lukewarm or non-existent if the experience has been nothing more or less than what they expected.  Looking at this from a mathematical perspective, 20% of patients fall into the two extremes (hopefully more in the positive group), with the remaining 80% in the take it or leave it group.  They have not been inducted into the Raving Fan Club, nor are they badmouthing the doctor and/or team. The nonchalance of 80% of your patients is quasi – they can take it or leave it. Let’s look at some simple steps you can take to change the individuals you are treating into patient ambassadors for your orthodontic practice.

The mood of an interaction is established with the first word or facial expression.  Orthodontic team members are not fully dressed for work until they put on their smile – the most important part of their uniform.  A genuine smile must never cease to shine from the moment they walk through the door in the morning up until the last patient is dismissed.  Turn up the corners of your mouth and remember that your smile is a tool that is free, easy and always available.  Smiling is a catalyst for joy, from an improved mood to better relationships.

Every time you smile you are offering a gift to your patient, a beautiful thing.  Seeing another person smile stimulates the heart and brain even more than eating chocolates or receiving money.  Statistics have proven that it is actually hard to frown when someone is smiling at you.  Just think how handy this information will be when you are trying to schedule a difficult appointment.  People who smile more are generally found to be more trustworthy, sincere, sociable and competent. In Mother Teresa’s words “Every time you smile at someone, it is a gift to that person, a beautiful thing.”  If you want to bring joy to someone’s day smiling is an effective strategy for achieving a multiple of goals. A smile is just a frown turned upside down.  Stand on your head if you need to.  SMILE!

ALWAYS refer to your patients and parents by name; use their name often in your conversation.  Do not call your patient’s parents “mom” or “dad”, they are not your parents! I will never forget the time one of my clients addressed an adult as mom and proceeded to update the parent about the wrong child.  Using their name ensures that you are speaking to the right person.

Don’t be afraid to step out from behind the front desk to greet patients face to face, introduce yourself and shake their hand (this is especially important if this is their initial visit).  Guide them through the computer check-in process and offer them a beverage to drink.  Use the Nordstrom’s touch when patients leave the office, walk around the desk to hand the patient appointment slip and school excuse.  An added benefit is that it gives you the opportunity to ensure that everyone seated in the reception area has checked in (especially when you have seats that are not visible from the desk.)

Have the doctor personally confirm the new patient appointment two days prior to initial consultation. This gives the patient the message that the doctor is personally looking forward to meeting them and will provide the best care available for him/her. It is the most valuable 5 minutes the doctor will spend.

Educate your patients; take away the question and fear of the unknown.  In addition to explaining clearly what is involved before you start the procedure, update the patient and parent at the completion of the visit:

  • What was done today
  • What the patient should expect (closing of space, tenderness, etc.)
  • How is the patient doing overall (progress of treatment, oral hygiene, cooperation)
  • When does the doctor want to see the patient again
  • What will the next appointment involve

Finish off by asking the patient and parent about their experience when you hand them their appointment slip.  If there is a problem solve it quickly and turn complainers into advocates.

Utilize the back side of patient forms (fee estimate, truth-in-lending, patient handouts) to promote your practice.  As well as promoting patient contests and events, it is a great opportunity to promote your Kid’s Club and advocate adult treatment (clear brackets, Invisalign, lingual treatment, etc.)

Some patients feel that it is the end of the world when they are told to avoid hard and sticky food. Create a cookbook with brace friendly recipes along with alternatives for “brace contraband”.  Place several copies of each recipe in a plastic sleeve so patients can take a copy of their favorite recipes home with them.  Encourage patients to share recipes, giving them credit for their contribution (From the Kitchen of Madison).  Add at least one new recipe each month.

Develop your patient schedule based on school hours- take advantage of late starts, early dismissal, teacher in-service days, school closed and lunch hours.  Before school hours have gained popularity over after school and evening appointments. Take a survey of your patients to see if your current hours suit their needs; if not, look at alternative hours. When scheduling appointments, tell patients what you have available, not what is not available.

Identify and anticipate your patient’s and parent’s needs. Patients don’t buy braces; they buy good feelings and solutions to problems. Most patient needs are emotional rather than logical. The more you know your patients, the better you become at anticipating their needs. What can you give your patients that they cannot get elsewhere?  Listen carefully to what they say and check back regularly to see how things are going.

“Making one person smile can change the world, maybe not the whole world, but their world.”  – Author Unknown

Fun in the Sun

January 28 - 30, 2016

January 28 – 30, 2016