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Howard:
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It is a huge honor today for me to podcast interviewing Richard Inger, who is the President of the Pierre Fauchard Academy. Is that correct?
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Richard:
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Yes. The technical title is Section Chair for Utah. Yes, sir.
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Howard:
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Section Chair for Utah. You had a Bachelor’s from the University of Texas in '76.
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Richard:
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Oh, dear.
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Howard:
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You make me want those Texas on. I don't dare take that.
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Richard:
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I went to University of Utah, sir.
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Howard:
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University of Utah in '76 and University of Washington in 1980, general practice residence, Sinai Hospital, Detroit in '81. Private practice, General Dentist in Salt Lake City, Faculty University of Utah general practice residency program from 1988 to present. Here's why I really wanted to talk to you. CEO Professional Insurance Exchange Mutual Inc., 1991-Present, Fellow of the AGD in 1987, Pierre Fauchard Academy in 1990, ADI, ICD, ACD, married, wife, professor at University of Utah, three children. How are you doing today?
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Richard:
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Deprived because I was playing Mr. Mom. My son, who is a new anesthesiologist and his wife were in the big island in Hawaii. I'm watching the grand kids, who got me up before 7 today. I have to feed them, get them off to school and babysitter. I have real admiration for the younger practitioners who have to get kids off to school. Many stay single parents. That's what I've been the last week. My wife is a professor at the university and she has to be there really early so I've had to take the load. That's okay.
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Howard:
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What is she a professor of?
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Richard:
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Well, she teaches honors. Her degree is an English Literature. She's teaching a class. It's one of the core classes for the LibEd requirements, the history of thought and philosophy. She’s the top honors professor. She's their face, the face of the program, basically. She’s a big shot. I'm the peon. She's the big shot.
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Howard:
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You’re a big shot in two ways. Two things I really wanted to share with our listeners today. Utah is a very interesting state in the fact that most of the dentist now practicing insurance in Utah is all done locally in one Utah malpractice situation. Is that correct?
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Richard:
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That's right. We’ve been doing it since 1978 in Utah only.
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Howard:
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How many dentists are insured for malpractice?
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Richard:
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There’s probably 25 hundred licensed, but there's probably 16, counting oral surgeons may be 17 hundred. We don't insure oral surgeons, so that puts the pool of who we could insure about, 16 hundred. We ensure right now, about 13 hundred of them.
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Howard:
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That is a business model that works. Does that work where all the Utah dentist have their own dental malpractice dental insurance?
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Richard:
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Yes, for a lot of reasons. Number one, we’re cheapest or should I say, least expensive. We do have an introductory rate for the new dentist who have a huge debt load, so that helps. We’re self-managed, self-owned. I don't have corporate over lords. We have a nine dentist board of directors. That's it. We don’t have any outside people telling us what to do. We don't have corporate jets. We all fight cases. I've got two going to trial in a couple of months which generally costs us over a hundred grand to do that.
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My philosophy is I'd rather pay our lawyers who earn their money than these plaintiffs who don't. The system has worked and basically when a new dentist comes in, the first word from their colleague is to go apply for your malpractice insurance.
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Howard:
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I now you’re in a difficult situation because you're a dentist and your customers are dentists. I trust you enough to be extremely objective. Do dentist who get sued, is it usually the dentist is doing something out of the line, over the top and deserves it, or is it mostly crazy patients with crazy expectations? What is the balance of what you've seen for a couple of decades? What gets a dentist in a trial? What makes a claim? Give us your long life lessons on how to avoid -?
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Richard:
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Well, the short answer is for all of the above, there's a lot of fact going in. Obviously, you pluck an implant and at the inferior alveolar canal, you're going to have a problem. Patient is going to be numb the rest of their life. You've got a problem. Our high end cases usually involve oral surgery mishaps, permanent paresthesias. The worst cast we've ever had involved the dentist who did full mouth extractions without an informed consent. The bottom line there, is if you're going to take out all the teeth in a patient's mouth, make darn sure they know what’s happening, then they're on board.
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Another issue that comes up is usually finances. Patient doesn’t pay their bill. The dentist puts pressure on them so they say, "Okay. I'm not paying you because you did lousy work. You committed malpractice." They try that tack. A lot of it too, is somebody gets over their hip. In other words, you’re involved in a restorative case or endodontic case that you really shouldn't be starting. Patients don’t like to pay for the same thing twice. I guess the major issue is dentists really tackling procedures that they probably should refer out, not properly informing the patient using informed consent, and then not handling the mishap or the problem correctly and creating hard feelings.
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Another thing that gets patients mad is feeling like they've been blown off. I've got a little case going right now where a little seven-year old girl had a corner of her mouth burned, I think by an electric happy that that has overheated. Well, right away the dentist said, "Look, we’ll make this right. We'll cover the medical expenses." She set some plastic surgery things done. We've got some potential other expenses to take care of. That case will be taken care of for $5,000, where it could become a $40, 50, 60,000 case, if it hadn't been handled improperly.
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I’m not a lawyer. I don't have a JD, but I've been doing this for 25 years so I have a feel and experience. Another advantage we have, is I’m right here full time so if a dentist has a problem, he could call me then we could nip it in the bud. That's why this model is good. When I retire in few years, somebody else will take over and do the same thing I'm doing. The chairman of our board, who is also a dentist, he can fill in for me. He's just semi-retired. He can fill in for me when I’m not here.
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One of the things that the model insists on really is having a local dentist who knows the local climate and the local dental community in-house to work with the clients. Then we have a great group of lawyers, who are very experienced that are retained by me. They're in a firm so we don't really have our own lawyer per se, but I've got a team of three in one firm and a team of two in another firm that we use. We have experienced lawyers. You don't need a JD, DDS, I can fill up in them with all the dentistry treat they need and then they have all the law expertise that we need so that's the reason it works. Two reasons, I guess.
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Howard:
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If you placed an implant into an inferior alveolar nerve, you just messed up. Do you think a lot of it ...That is just won't give a refund, just won't make it right? They get cheap and chintzy and then the patient feels like, “I’m going to get an attorney."
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Richard:
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That's a big part, absolutely. That and just staying on top of it. A lot of our problems that don't become claims, the dentist will call me and say, "I did an endo, it's still hurting. The patient went to an endodontist. We missed the MB2 canal, or we’re sure, we broke a file." I just work out a deal where the dentist will refund the patient. The patient signs the release, meaning they agree that that's it. They're not going to take any further action and it’s over. It's basically just a sort of a refereed or coached refund and life goes on. In some cases, we can keep the report good enough that the patient wants to stay with the practice.
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In other words, we keep things from getting nasty, chippy and keep the lawyers out of it. I do a lot more of those. I probably do 1 to 200 of those situations a year as opposed to happen having to open 6 to 12 claims, where we have a notice that attorney is involved and they're going to sue. Absolutely! A lot about you like to cover a Dentaltown and everything else, just keeping patients happy, doing the right thing. Of course, using new technology properly. It’s not quite the standard of care yet to do a cone-beam study on all implant cases, but it's getting there.
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Howard:
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The biggest listeners of this podcast are under 30. These kids are getting out of school. You're talking to a 30-year old kid to 25 just got out of school. What advice would you give him to stay out of court, stay out of trouble, stay out of claims?
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Richard:
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I see this in a residency program a lot especially in endodontics because I’m not sure how well the schools were able to train young dentists, particularly, in doing molars. If their mentor, the corporation or whoever they are working for is expecting them to do endo, then they should start conservatively and handle central incisors, oral bicuspids, and get proficient at the easy ones before they tackle the hard ones. They should tell the person assigning the case, "Look, I'm the one who tackled this. I'm ready to do them."
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In my GPR at Detroit, I got superb training in endodontics so I was very comfortable. I was a huge part of my practice, but some of these residents I see have never done a molar. They should be doing molars until they've mentored and exercised. In otherwise, just refer those out. Again, it’s hard for these kids in debt because they want to try to do as much work as they can to cover their three, four, five thousand a month loan payments. The challenge is to stay in your comfort zone but at the same time, take CE. Do what you need to do to become proficient so these procedures are fun.
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To me dentistry is not fun unless you’re good at it. Then it's really fun and it's rewarding and you make patients happy. I think realizing your limits and learning also how to communicate. For some of these young kids, put your phones down, put your texting away and start talking to people. I think education ... Happy patients are educated patients. With videos, this, that and the others, there's a lot that can be done, so patients know what's happening and their happy about it.
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Howard:
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These young kids go numb up a patient and while they're soaking in, they’ll go back in their private office and surf on Facebook when they should be sitting there bonding. When you call patients at night and the patient feels like you care. They are far less to see you.
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Richard:
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Thank you. That's really important, too. Surgical procedures, any difficult procedures, that’s a really good patient bonding tool to call them up and see how they're doing. They may be great, but on the other hand if they're having a problem you're right on top of it. Then of course, documenting that phone call if they can enter it into their systems, great, if not, just write down what was said on a piece of paper. Then, put it in the records the next day whether it's digital or paper record. Most offices, I think, nowadays are using digital, but there's still are a few who use paper.
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Howard:
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Now when you do a case, what percent of a time are the notes satisfactory and you're pleased with the note taking and what percent of time are you looking at the notes taken, "Are you kidding me? You hardly wrote anything down."
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Richard:
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Ironically, we have more problems in the digital systems where the offices don't realize that every piece of data is what I need. You have your progress notes, you have your treatment notes, you have journal notes, but sometimes it’s hard to make sure everything is put in whichever it should go properly. Templates are great but they can also be poor. A long problem with templates is sometimes dentists get lazy and they just want to use the template and not put in some of the details particularly if something doesn't go the way you expected to.
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Let’s say, when you go a little deep; what base you're going to put in. It helps the document; the exact brand of composite. You're getting failures, you want to know what's failing and why and maybe switch to something, the amount of anesthetic, the type anesthetic, simple things. A diagnosis, unfortunately, that's the thing a lot of lawyers like to harp on is where the diagnosis and just keeping a good track of treatment plans is. Then prescriptions, sometimes dentists are a little lax. Most programs have a good area to record prescriptions, but some dentists don't do that properly.
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The worst thing in a case is he said, she said. If we don’t have the records to backup what the dentist says, then it's really difficult to defend. The summary is just making sure the template says exactly what you want to say and not being afraid to have things to it and identify who made the entry. If an assistance makes the entry, make sure the initials or whatever are standardized so three or four years later everybody knows who the person is because his initials are written down there, typed in.
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Howard:
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You also mentioned the collection policy. People owe you money. They don't want to pay. A lot of times they'll get an attorney. What percent of the cases do you think start off like that where the doctor just would have had a firm collection policy, they would have never been in court.
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Richard:
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Interestingly, most of our meritorious cases, in other words, were dentist goofed up, i.e. taking off a wrong tooth, plucking and implanting into the canal, poor endo, perforations, it doesn't really matter. I'd say, in these other matters we're dealing with the root canal problems, probably, at least to third to a half of them involve some collection element. One of the biggest problems is an officer have policies in place and they don't follow them. They're trying to be too nice and let the patient get behind.
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Cosmetic procedures in particular can be a problem if you don't have the money collected upfront because it's easy for them to say, "Oh, this doesn't look good so I'm not going to pay for it." We recommend that half be paid down before it even goes to the lab. Then the balance is paid at the front desk before the patient comes in. If that's all spelled out ahead of time in writing, it's not abandonment to tell a patient, "Oh, you didn't bring your check book, we can't seat this." You can't do that unless you have a prior agreement though.
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The problem with cosmetic procedure is they're not essential. I mean the person won't die; they won't go to a hospital with an infection whereas if something like a root canal if there's pain, people are highly motivated to do what they have to do to get the procedure done. They'll pay upfront. That's one of the reasons I like endos. I did a lot of referrals than people in my building and other dentist sent their cases to me and I can say, "Okay. My policy is you have to pay for this right up front." That worked out great. You really hit the nail on the head. It creates bad feelings and the office has to make sure that they stick with the policy especially orthodontists.
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One of the biggest problems orthodontists have, they have a contract but then the patient will miss a few payments and they don't get right on until they're six months in arrears. Then what do you do? See? For the young dentist, I think the important thing is to just making sure their accounts receivables stays current and that the basic policy is pay as you go, having patients to pay their co-pays in a timely manner. I've talked about a lot of I looked at in Dentaltown and it's right on, just staying on top of your financial. Obviously, you can pay your loans unless you're collecting the money.
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Howard:
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Is there any type of a profile of the average person that sues? Is it more likely a man versus woman or old versus young? Are there any red flags that a young dentist when they're working on patients should be thinking? I wouldn't think an old fat grandpa bald like me would sue on a cosmetic case? Are there any profiles to help this kid? I need to slow down, spanky, because of this might be...?
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Richard:
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Yes. I don't want to sound chauvinistic, but post-menopausal females that bring in pictures of them when they were 20-25 years old or pictures of their favorite actress and say, "This is what I want to look." Those are tough. They're very willing to pull a trigger and get mad and get a lawyer. You could do everything you can to try to let them know ahead of time, "I can't promise you that we are going to make it look like this and so forth." In the olden days, it used to be more middle aged, but I'm seeing it across the board. I've got files with 25-year old plaintiffs.
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I've got 60-year old plaintiffs. Back in the day it was mostly these post-menopausal females period. A lot of them are people you need a good health history that are on an anti-anxiety medication. Most of our plaintiffs are on antidepressants or anti-anxiety medications. They just have a hard time dealing with stress. They have a hard time dealing with situations that don't turn out like they expect.
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Howard:
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Is it more women than men?
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Richard:
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Right now, yes. Without pulling my files, I would say, yes, more women than men.
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Howard:
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Are there red flags on any type of brain medication; anti-anxiety, antidepressant?
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Richard:
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Correct. I think a lot of dentists aren't careful enough looking at the health history and particularly if you're considering doing any sedation on a patient because you send them home. The narcotics you give them are going to be potentiated and you can run into more problems feeding more drugs into their systems. Yes.
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Howard:
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Tell these kids, what is the price range? What are the average settlements for average things? If you run an implant to a nerve or if you pull the wrong tooth, what are some ballpark figure ranges?
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Richard:
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That's a fun question. The answer is it depends on where you live. California, Washington D.C., East coast, Appalachia, in those areas juries tend to award the people a lot higher. For example, I can settle cases ...A paresthesia case for example, I used to be able to settle those for $25,30,000 in the 1990's and it's gone up a little bit. You can almost add zero to the amounts I can settle cases for here, in a place like California. For example, there's a wrong full extraction case. I have to keep very confidential.
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The lawyers try to throw million dollar settlements, million dollar judgments of me that they found from cases in Appalachia. People there have an idea that it's lotto time. If you have a problem, you've got it made whereas this case I was able to settle for under $200,000 dollars, which would not have happened in California. There's a lot of factors involved because what happens is the mediator is an independent party who gets reports from both sides and then tries to meet somewhere in the middle, and they get both of us mad. At the end of the plaintiff's mad because they didn't get enough money I'm mad because I paid more than I wanted to but the case is resolved.
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Very often that's better than a jury trial because there's less risks. The other thing is I'm guaranteeing you losing your case if you alter your records. If you mess up your records, you're done because nobody is going to believe you anymore. That's the best way to foul things up in the event of a case. Whatever you do, don't think you can alter your records and succeed. It won't work.
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Howard:
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It also can sometimes take it from a civil case to a criminal case. I saw that in Arizona where somebody gave too much anesthetic to a child. That was going to be a civil case, but since he altered the notes then the state attorney general got in and on top of that filed a criminal suit.
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Richard:
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That's fraud and you can get a ... As you say, carry over into the state board and there's a criminal thing. It's considered unprofessional conduct. Then he can be put on probation. Of course, there you go, you're out of all the insurance panels and it's hard to find work if you're in a various corporate situation, you're down no near on practice or whatever. Absolutely. You've hit the nail on the head there.
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Howard:
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Do you ever have a paying customer and they have a claim and you as a business owner say, "I'm sorry, Frank, but you can't do root canals anymore or you can't play implants." Do you guys ever do that and say, "We're not going to cover if you do this." I know state boards can do that. Correct?
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Richard:
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They can tell you, you can't. We had a dentist, for example, who went before the Utah state board, because he was taking out second molars for orthodontics and there was a track record of problems. Let me just back up a little bit. Some companies have what's called consent to settle option, where you pay a little extra premium. The company cannot settle a claim without your permission. We don't have that, but I've never settled a claim over the dentist's objections. It's the same communication with patients. We keep the dentist surprised of everything going on. If there's a problem they know it.
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What we will do is if we have a meritorious claim, in other words, you plucked an implant and the inferior alveolar canal and I've to settle it safe for $40,000, then what we will do is surcharge the dentist ten percent of that amount. They're paying $4,000 over and above the regular premium. It's like an auto insurance policy,"Ah, you made the mistake so to protect the pool, you're going to be penalized. You better be careful and not do this, better to refer them." I don't specifically exclude them, but we can just say, "Better not do this anymore, because if you get a second meritorious claim, you're out." That's how we do it.
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It's like you got a strike against you so that's the deterrent. The other thing too, is if I tell somebody, you better be careful and not do this anymore and they get a second one in, I'll just not renew them. It's very, very rare that we have to do that. Every other year, I have to throw somebody out because it was a second meritorious claim. That does happen. It's unfortunate. It's hard to reject a colleague, but I've got to protect the pool. If hospital privileges can limit that, normally, the dentist learns, "Oh man, this wasn't worth all the time, and trauma and trouble." Plus they've got the surcharge; they've got this mark hanging over them so they naturally don't want to do it without the ramifications and the consequences.
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Howard:
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We talked about a profile of a patient. Is there a profile of a dentist? Is it usually young kids that they just don't have the experience or is the old guys who've been golfing too much and quit taking CE? Is there any profile to the dentist getting in trouble?
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Richard:
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Yes. We did a study on that a few years ago. It's the dentists who are 45-50 years old. The reason is -
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Howard:
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Really?
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Richard:
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The younger ones are generally more careful, more conservative. I'm like you, I thought, "Oh, it's going to be the younger ones." In fact, in the olden days, our company charged more for the first four years because they're thinking was all these newer graduates are higher risks. We're going to have more problems with them, but that's not the case. The 45-50 year olds, I think, are more brazen. They're more willing to take on new things. Maybe they're complacent figuring, "We don't need the CE anymore."
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You're like me, I mean, we're both big on AGD because you're encouraged to take the minimum 25 hours or whatever a year, 75 for the cycles for CE. Most states now, of course, have requirements for CE and they're 8-10 percent of the dentist so you got to make sure you do it and keep your certificates. The older ones are less wiser, I guess. They are the ones you got to watch out for.
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Howard:
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We always hear a standard of care being thrown about. What exactly is the standard of care? How do you define that? How do the judge and the jury define the standard of care?
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Richard:
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There's basically two-three elements that are involve in a malpractice case. One is you have a duty to perform the procedure the way you were taught in dental school. There's basically one way to do it. That is pretty standardized throughout the country, Canada, wherever. Now, the standard of care is a little more amorphous and that it can be variable. It basically is the expectation that normally should with treatment by a given dentist to a given patient and how the results should go.
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For example, they'll argue that when you do root canal therapy, it's the standard of care to use a rubber dam. The plaintiffs would get witnesses. You breached the standard care to use a rubber dam. Anytime you'll have a claim, if you don't use a rubber dam, the plaintiffs will get expert witnesses, one of the dental school's instructors you hated that's going to say, "You breached the standard of care because you didn't practice using a rubber dam so you're below this line that should be there. Let's say, in Payson, Utah, there's four dentists and none of them use a rubber dam. Then I would get an expert witness who would say, "Well the standard of care in Payson, Utah, is not to use a rubber dam it's to use other methods to isolate.
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The interesting dichotomy is there's a national standard of care that we're trying to push, but you can argue that there's also a local standard of care. My history in trials are my local experts to trump these national guys every time. That's not to say you need to be sloppy. Basically, if in doubt, you should practice the standards you learned in school as far as things like rubber dams and documentation. For example, x-rays, is it a standard of care to take a panoramic film every time you take out third morals versus PAs.
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I'd have to say yes. I've had a few cases where all the dentist did was to take PAs. Then I've had a hard time getting somebody who will testify under oath that, "Yes. You met the standard of care by taking these PAs because you're missing out anatomic structures." At the same time, is that the standard is that the standard of care to take a cone-beam every time you take out third morals, not necessarily, because if you can see all the anatomy with a two dimensional image, which isn't going to cause the patient as much nor submit them to as much radiation, then you're fine.
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Another one for example, is it the standard of care to use a rubber dam when you take x-rays on a pregnant patient. A lot of dentists who told me they've taken courses where they said, "Oh, you don't need to use a lead apron. That's just a myth." The 16-year old Medicaid patient was been on your office who didn't have the lead apron and then goes to the Medicaid clinic and they ask her, "Oh, you just went to the dentist. Did they use a lead apron to take the x-rays?" "Oh, no, they didn't do that." They're going to call and read you the riot act and tell the state to come after you because you didn't practice the standard of care. That's the problem. There's a lot of variability in it and that could be good and it can be bad. There's a long answer for you.
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Howard:
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That apron, it's basically the thyroid. That's what everybody is concerned about, didn't it?
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Richard:
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What I use to do, this sounds really funny. If I have a pregnant patient, I put two ledge shields on them. One this way up to their neck and another one on the side and they love me, "Oh, you're doing so much to protect my baby." It depends on what you read, but a lot of it again is patient expectations. Patients expect certain things and that's part of standard of care. What do patients expect to have a good outcome?
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Howard:
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I was wondering. What's your patriotic experience with the American jury system? Our jury is usually normal and predictable and they did a good job. What percent of the time you just think, "Are you kidding me? This jury system is crazy."
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Richard:
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Well, knock on wood.
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Richard:
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Well, knock on wood. I should've looked this up for you. Probably about every other year so we’ve had at least twelve or fifteen jury trials in our history. We’ve won every one with the exception of the one where the guy altered the records. It’s interesting because the ruling doesn’t have to be unanimous. We’ve had a couple times where there’s an eight jury panel and six of the eight voted no cause of action so that was it but we never fortunately had a case where we thought, “Man, these people are nuts!”.
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A lot of it has to do with jury selection and that’s where you need really good lawyers. It’s a complicated process and the plaintiffs want the dumbest people on that panel that they can get; we want the college educated and of course truly if you were judged by the jury of your peers it would be eight dentists but that’s never going to happen. Our experience has been good and our attorneys have their paralegals poll the jurors to get insights and help for the next time and that usually helps with the preparation and that’s where law comes in.
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You don’t want somebody who’s a great dentist and a terrible lawyer as a JDDDS. You want the best lawyers you can defending you who know the law. The expert witnesses can feed them the dental information. They need to know the law; they need to know how to make motions, they know what to exclude. I mean, it’s really a game, Howard. You know, people that know the rules and know how to implement them the best are the ones that usually win, but we’ve had a positive experience with juries and I’ve also had a positive experience with mediation.
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The first few got me really mad because the mediator get in my face and say, “Look, you’ve got a problem. You’ve got to pay up,” and I think “How dare you tell me what to do?” but the more I got into it… I mean, these mediators are usually lawyers who had a lot of experience and we get too subjective, we get too close to the case and often need somebody shaking us up a little bit saying, “No, no, no. You’ve got his problem,” and that’s another thing in these cases. Sometimes the dentists are absolutely certain they’re right, that they didn’t do anything wrong and that they met the standard of care but when I have other people look at it we get different insights.
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I can sit down with them and go over X-rays and educate them as to, “Well, this is what went wrong. This is why this is below the standard of care. This is what you’ve got to do in the future.” One of the things I really try to do is rehab and help these guys to avoid these problems down the road and it’s just like communicating with the patient. My job is to teach and educate and elevate the dentistry they’re performing. That’s another advantage with our model. A lot of these other insurance companies you’re not working with the dentist, you’re working with an adjuster.
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All they care about is the bottom line. They want to get out of it as cheap as they can and they don’t care what happens to you down the road. That’s the thing where we’re inbred dentists and we’re trying to make the profession look good and the way we try to handle these cases usually makes the profession look good but if somebody tries to take advantage of me and I think they’re trying to get a ride on a gravy train we’re going to be very tenacious and fight that plaintiff tooth and nail.
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Another thing I’ll do is, if we went in trial I can get a cost judgment for certain expenses against the plaintiff and I routinely do that. The last trial we had I got 3,500 bucks out of the patient so he goes and tell his friends “Man, don’t try to sue a dentist. I ended up paying 3,500.” The attorneys take a contingency. In most states they get a third so the patient doesn’t lose anything unless I go after him so that chills because people don’t want to take the risk and lawyers find out, “Man, this PIE. If you lose they’re going to go after you.”
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It’s not like England where loser pays the whole but none of these guys want to drop 1,000 bucks or even 2 or 3 and I’ve had some legal firms make the payment so they don’t get sued for malpractice so that’s one little thing we can do and I’m not the only one. I mean, most companies have that prerogative and whether or not they want to do it is up to their various policies and things.
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Howard:
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What is PIE?
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Richard:
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When I say PIE I mean Professional Insurance Exchange. That’s just our initials.
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Howard:
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That’s your website? pieutah?
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Richard:
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Yeah, pie@pieutah.org
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Howard:
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I want to ask you a philosophical question. We’ve both been in this profession a long time. We’ve seen a lot of new dental schools. When you got out of dental school and I got out of dental school, when I came to Arizona there were no dental schools and now there’s two. When you went to set up your practice in Utah and there were no dental schools and now there’s two, so you have a lot more supply of dentists, they have a lot more debt.
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Does that make you worry that maybe our young colleagues are going to be trying to do things they can’t do like, “I should refer these wisdom teeth but I need to pull them to pay for my big student loans. I don’t want to do this molar endo but I’ve got to.” Do you think Utah needed two dental schools? Did Arizona need to dental schools? There’s another five or six being planned right now. Do you think America needs all these dental schools and do you think that might get a lot more malpractice claims down the road just because of the perfect storm maybe? You know, many variable
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Richard:
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Well, it’s very possible. Here’s what’s happening, I always admire you, Howard, for being on top of things. You probably get that huddle thing that the ADA sends out every morning. A couple days ago there was a thing from US news and world report reporting that orthodontics is one of the number one desirable professions. I think general dentists was two or three on the list and the idea was, “Oh, dentistry is nice to go into,” and then the second things was “What is the top income profession?”, and I was happy to see it because my son’s one, is an anesthesiologist.
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Oral surgeon was like number three so there’s all these things out there in chatter saying “Oh, yeah, these are great professions to go into.” They don’t say anything about the debt it takes to get there but there’s all this things about, “Oh, this is so appealing.” Well, all these people that are in dental schools or in private entities see the bandwagon. Utah’s had a glut of dentists for years and years. I keep stats and what will happen is the ADA will do surveys and say, “When do you plan to retire?” What do most people say? “I want to retire when I’m 65.”
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The ADA takes that and says, “Okay, in Utah there are 41 dentists a year that are going to turn 65. The baby boomers are all going to retire at once. There’s going to be a big shortage of Utah dentists.” They get on this, there’s all this worry and hubbub and that's why Rosemond, the private dental school we have in South Jordan formed, because their people said, “Oh, there’s going to be a real shortage of dentists and we’re going to be able to fulfill the need. There’s all these kids and they’ll want to become dentists.”
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Well, in the meantime, for years and years and years the University in Utah has had people trying to get a dental school going and they had a 30 million dollar grant they got from a family, I think it was one of the big computer companies, so they had this 30 million just waiting to use to buy a building so they had motivation and Rosemond’s going strong and they graduated their first class so we’re cranking out dentists right and left just like you are in Arizona. 2008 hits, boom. Yes, it is a concern that you’re getting this poor younger dentists who got three to four thousand or five thousand a month they’ve got to take home just to cover their student debt plus everything else.
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Yes, I think there is a concern about trying to do too much. Now, we haven’t seen a lot of claims. What I’ve seen more are these senior dentists calling me saying, “I had to fire this associate. They’re not trained well enough. They don’t know what they’re doing.” Then these poor associates are trying to find another location and another place and there’s always so much to go around. Of course, cosmetic dentistry was big for a while but then the patients can’t afford it. We’re still suffering the effects of 2008 here, I think.
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You know how things went in Arizona. You’ve had these mass bankruptcies and just this real problem for a lot of this influx that you had so I think it is a concern and communities there are people moving in. That was another thing about Utah, they said, “Oh, the economy is good, you’ve got a lot of people moving in, there is going to be a need ...” but the average Utah dentist is 70 when they retire, not 65. I’ve got plenty that were in their 80s when they retired. There’s not too many that are in their late 50s and even if they’re still working away, they’re taking patients away potentially from these younger dentists.
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We’re not a placement agency. I don’t try and keep track and say, “Well, so and so is selling their practice.” I try and keep my eyes and ears open, but it is a little bit of a worry. I hear this more from some of these 50-55 year old dentists saying, “Man, these young kids. I’m getting all these people coming in with treatment plans saying they need twenty fillings where I can’t even see that many,” so I think over-treatment is a possible concern and where you go and what you do about it is hard. Compound that to the fact that they may not be trained as well.
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I see that in the residency. They don’t know how to take teeth out; they don’t know how to make dentures ... Some of these schools, I think, are training their dental students to pass the boards so they focus on those procedures that they need to pass the boards but there’s still plenty of people that need dentures, there’s still plenty of people that need partial dentures, there’s still plenty of people that can’t afford implants, there’s people who for medical reasons can’t have implants so it’s back to some of these old things.
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It’s interesting, everybody who likes to do composite resin and, of course, insurance companies will pay for those to be redone every five years, but twenty years ago when we were in school if you’d said “Well, maybe this amalgam will last five years, I’m not sure,” there’d be a big hue and cry, “You’re kidding?! You can’t do anything better than that?”, so there’s a lot of interesting factors going on in dentistry today.
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Howard:
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I think the aesthetic health compromise of going from all amalgams of probably the last 38 years to all plastic and air composites of probably the last 6 and a half years has been a real step back. This country really created a price of tooth colored fillings.
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Richard:
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Well, I wish they could come up with a material that had bonding abilities and the longevity and strength of amalgam. I mean, it’s interesting, I was in a faculty meeting the other night and was talking about amalgam and two people at the table jumped all over me saying, “Amalgam is terrible! It splits teeth!” and I sad “Sure, if you’ve got terribly wide prep that’s overdone, but composites leak and wear out.” It’s interesting. Philosophy has changed and we do need some better restorations. I mean, metal is not pretty, nobody likes it, nobody likes mercury in the water, blah, blah, blah, but we’re still working on better alternatives altogether.
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Howard:
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It seems like so many dentists though just have zero respect for literature. I mean, the literature says they’re averaging 38 years and then lived around composite six and a half and then they immediately go “We're not buying. If they’re done right ...” I'd come back and go “Well, what do you think will last longer: the metal fork in your kitchen drawer or the plastic one from Kentucky Fried Chicken?”
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The metal fork is made out of five ingredients that kill bacteria: silver, zinc, copper, mercury, tin and the other one is inert plastic fork, but I don’t want to digress. I want to go back to logistics. You do the majority of dentists in Utah. Do you also do dental students in the two dental schools? Do you insure those guys? What’s that like?
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Richard:
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They’re in a different realm and a different classification. Most dental schools have these blanket, large, corporate type policies that will cover the faculty as well as the dental students. The residency program is the same way. The University of Utah has a complete risk management department that handles any problems with the medical residents as well as the dental residents. It’s rare that we have problems in dentistry. Occasionally somebody will get a paresthesia and for years we attendings had to have private insurance.
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I’ve kept my PIE insurance to be an attending up there but with the advent of the dental school they did away with that BS, so I don’t insure any of the dental schools. Some of the faculty, if they strictly work in the school, the school will cover them. If they work outside then they’ll need private coverage and we do have that a discounted rate for them if they only work one day a week. I think there’s companies that specialize in providing that coverage for dental schools and faculty.
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Howard:
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I was also wondering if you could think about a win-win situation. I’ve been hearing a lot of women telling me to learn hands-on implants. You know, the courses are in Mexico, Dominican Republic, Brazil and they don’t feel safe . A lot of those people won’t have courses in America because of the lawyers. If you’re licensed for the State of Arizona you can’t go to another state and do a hands-on surgery, but in Arizona they have a homeless shelter just for vets and the dentist there who is my idol went to the State Board and said “Can I have hands-on implant surgery courses here at the Cass Institute?”
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That’s Chris Volcheck, and licensed dentists can come here to do volunteer dentistry on the vets in a homeless shelter and they have the license to practice dentistry and I just think if a lot of states start doing that then a lot of these American dentists who want hands-on training don’t have to go 1,000 miles away into a foreign country where they may be scared. I was wondering if you could think about that and maybe talk to your State Board. I’m sure you have the State Board on your speed dial.
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Richard:
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Well, I’ll tell you. We already have an entity called the White Cap Institute up in Heber City where dentists come from all over the country and learn to do implants. In fact, we send our residents from the University and they go up there so that’s a Utah or nationally recognized entity right here that provides a course that can help people get good at implants. Now, speaking of that, the Pierre Fauchard Academy, I just got a sheet from them where they’ve got a program where they are looking having Pierre Fauchard Academy members agree to see veterans for either a limited or no fee to help them with things like implants. If you wanted me to, I could scan and e-mail this to you just so you can see.
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Howard:
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I would love it, and on that note explain the Pierre Fauchard Academy. A lot of the young kids in school aren’t familiar with it. Talk about that.
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Richard:
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Again, it’s an interesting thing because the millennials and Gen-Xers I’m not sure are as interested in some of these old traditional type things. You may not remember we met in the good old HED days where I think you got your fellowship certificate. I was the one who handed you the fellowship certificate because I was the regional director at the time. The idea is you can get honors and experience by taking CE courses and be rewarded by getting your fellowship. Well, the Pierre Fauchard Academy is an honor organization where you’re nominated to be a member based on your leadership in organized dentistry or humanitarian.
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If you haven’t been nominated, Howard, you should be a member because of what you’re doing. I mean, I’d nominate you in a second but it would have to be somebody in Arizona, because I think what you’re doing for Dental Town example is something that gets dentists together, gets dentists communicating and is a good thing. You usually have to be practicing for five years to be nominated at the Pierre Fauchard Academy, and then we have various scholarships. We have a foundation and through the foundation grants can be given for various humanitarian efforts either in the United States or in Mexico and places like that.
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The idea is to reward people for being ethical, leaders in the dental profession and provide a vehicle for them to go on and do humanitarian projects. It’s an international organization so it’s a way to meet dentists from Japan and what not. In my younger days when I’d go to the ADA meeting and whatnot it was fun. I still speak Japanese so it was fun to meet some of these people and talk to them. There are other organizations: the International College, the American College is the same thing. You’re nominated based on your leadership. With all the stuff I did in HED, being a trustee and is how I got involved. It’s fun, it’s one more thing to do. It doesn’t take a huge amount of time but it’s fun to facilitate these opportunities.
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Howard:
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Tell them about Pierre Fauchard. G.V. Black would be the father of American dentistry but a couple hundred years before that was Pierre Fauchard in France. He was basically the first physician who wanted to just focus on the oral cavity. Is that fair to say?
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Richard:
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Correct. I mean, back in the good old days being a physician was almost self-trained, there was a lot of charlatan, quackery, the whole thing. Pierre Fauchard was considered the father of modern dentistry. He was born in 1678 so it was many, many years ago. There weren’t any useful books or anything and he tried to create a mechanism for learning and for treating things medically and logically rather than just old wives stuff, voodoo. He went on, took some training and got a reputation as being a skilled practitioner in Paris.
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He lived a long time. I think he was in his early 80s which is long for that but he wrote a book on ways to do dentistry which became one of the Bibles and basic early things so that’s where he came from and that’s where his name, I guess, to honor what he tried to do back in those good old days. Yeah, he and G.V. Black, the one on the nitrous oxide, there’s a few of these just classic people. I mean, in modern days we talk about people like Dugoni and people like that but empowered with what you’re doing at Dental Town which I think is great, getting young guys, you’ll be remembered probably in a good way.
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Howard:
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I just want to be remembered as oldest dentist who ever lived. That’s all I want to be remembered for. Yeah, Pierre Fauchard was born in 1678 and Sir Isaac Newton’s book ‘Principles of Mathematics’ 1687 so he’s about the same time as Newton. They would have been about the same age.
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Richard:
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Well, the Pierre Fauchard Academy was founded by this guy, I think Elmer Best was his name and the idea was—
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Howard:
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Was that back in France or was he an American?
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Richard:
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American. He was an American and the foundation was established in 1986 and the idea was to set up an organization where people could be honored ethics. I’m just trying to look at the date when it was set up. I know you had asked me about that. I think it was in late 50s, early 60s. The idea’s just to provide a vehicle to recognize dentists for trying to be ethical and also create a vehicle where these humanitarian efforts could be funded a little bit.
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Howard:
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His book was written in French. Did you ever read an English version of that book? Is there an English version?
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Richard:
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No, I haven’t seen it. I actually lived in France for a year when I was a kid and spoke French like a native till we came back to America and I didn’t use it and forgot it, but I’ve never seen a translation. I’m sure there were editions. The English translation was done in 1946 so there is one and I imagine it would be interesting to see it. It might be something fun to read.
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Howard:
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Yeah. I’m still kicking myself because 20 years ago some dentists from Kentucky called me up and they offered me first three books ever written by G.V. Black, autographed and signed by him and they wanted more money than imaginable and I thought “You know what? I’m going to get them,” so I got them and then about 5 years later someone offered me an original of Pierre Fauchard’s book but he wanted a boatload of money for it, so then when I finally decided I do want that book now I can’t find it.
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Richard:
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Do you know Eric Curtis in your state there?
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Howard:
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Yeah, he was the editor of our Inscriptions Magazine in Safford, Arizona.
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Richard:
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He is a real aficionado of dental history stuff and he might have access to some of those things. You may have to get in touch with him. He is a huge history guy. He wrote the history of UOP, for example. Of course, he’s a superb writer. He has a feel for history and he might have access to some of these things. You know, that book you’re talking about, he’s just a contact you might want to check with.
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Howard:
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Yeah, I should, and it’s funny you just said his name. We’re talking about history, we’re talking about Eric Curtis because last weekend I actually could get away and I drove down to Tombstone, Arizona where the most famous dentist in America, Doc Holliday lived, and that’s right by Eric Curtis in Safford, Arizona. I actually took a picture of myself standing at a row of people that were shot down and killed on the O.K. Corral by Doc Holiday, the dentist. Do you think ”Do I ever get a malpractice claim in Utah where a dentist mows down five people in a bar fight?”
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Richard:
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No, but we had one where this dentist suspected his wife having an affair so he got home when the guy was there. They weren’t, they were just talking on the couch but he got so mad he stabbed the guy and so the wife runs out to their SUV to take the guy to the hospital and the dentist jumps on the hood holding onto the windshield wipers while she’s trying to knock him off. I mean, it would have made a great B-movie about dentists but that’s the closest thing we’ve had In Utah.
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Of course, he got hauled in to jail, blah, blah, blah. I’ve got a few interesting tales about near murder by dentists but the gigolo lived and I don’t know what happened to the marriage but that’s as close as I can give you there. If you haven’t, Eric would probably be an interesting interview for you some time.
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Howard:
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Yeah, I’ll do that. Pierre Fauchard Academy is fauchard.org. How many members do you have?
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Richard:
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In Utah we’ve got about 95 active. A lot of people, when they get retirement age, will become life members. We have an annual meeting every year in conjunction with the UDA meeting. Probably 50-60% of them come, we kick of the meeting. A large number of them are involved in humanitarian projects and they’ll tell about it and people will be interested and sign up and that’s one of the vehicles we have. We’ve been involved with the scholarship at the time, the ARDA program which was a precursor to the dental school so those are some the things we do. Everybody’s busy; we don’t try to put any CE courses or anything.
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I did do an ethics lecture sponsored by Pierre Fauchard a few years ago but those are the things we do. The American College really pushes ethics. The International College is also involved in international leadership bringing various dentists together and trying to help the quality of dentistry. The American Academy of Dentistry Internationals is another one and they try to improve the quality of dental care in countries like Vietnam and places where they’re just trying to develop, so there’s a lot of these various organizations like that. I suspect you have a fairly large Pierre Fauchard Academy section there in Arizona.
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Howard:
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Who is the founder? It’s Elmer S. Best. Where was he from?
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Richard:
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I think back east somewhere.
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Howard:
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I guess my walnut brain would have figured that the Pierre Fauchard Academy was started in Paris, France.
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Richard:
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It was basically, I think, started here with the idea of ‘let’s push the image of quality’, and that’s what Pierre Fauchard tried to do in dentistry, ‘and making it worldwide’. Obviously, US and Canada lead that in a lot of ways in dentistry and the idea, I think, to just bringing dentists together. Like what you try to do with Dental Town. Just get people communicating and talking amongst themselves trying to make things better.
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Howard:
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Well, I’ll give you this piece of advice to you young listeners out there. When you view the dentists in the same medical dental building with you or across the street from you as your competition and you practice that way your whole life you are twice as unhappy and unfulfilled. I notice that all the dentists who have three or four dentist friends in the same zip code, same city and every Thursday they go eat lunch at the bowling alley or whatever, their 30-year career or 40-year career is so much more fun and rewarding.
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I’ve been in this one zip code forever. Most of the second opinions I do of an upset patient for one of my friends in my zip code, I just say, “I’ll tell you what. I’ll just fix it free right now,” and I’ll redo the whole thing for free. I’ve done bridges, implants, everything and I usually don’t even tell my buddies because I don’t want them to feel bad and then three months later they’ll call you up and say, “Are you kidding me? Blah, blah, blah.”
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If it’s a Pierre Fauchard Academy, if it’s your local study club, your competition is Disneyland and TVs and cellphones and those homies across the street from you they're your colleagues, your friends. Another things is the more closer relationships you have with them, they’ll keep you out of trouble too. They’ll be telling you at lunch, “I don’t think you should do that” or “Why don’t we go ask the oral surgeon?” or “Why don’t we go talk to the periodontist or whatever?” I really love all these different communities in dentistry. I think they really help dentists get through. The hardest thing they’re ever going to do is their dental profession. It’s a tough profession.
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Richard:
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Well, I had the same thing. I came in the building fresh, starting a practice from scratch in 1981. There were two dentists on either side of me and instead of the attitude of “Oh, gee. That’s all we need. One more guy in this building,” One took me to lunch and told me "I need to get involved in the dental association and These are the best insurance companies, da, di, da, di, da." We agreed to cover for each other. I did the same thing with the one on the other side and it worked out great. If I had a question I’d go talk to him. If he’d had patients he didn’t like he’s send them to me and I was happy to take them. He sent me root canal cases and the other one started sending me root canal cases.
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Don’t get me wrong, I knew what I was doing. I’d refer to the orthodontist if I didn’t want to take the case so they didn’t get mad at me but the whole thing was this communication. He was my mentor and the irony is after a few years he’d come asking me questions about things because of my residency I was on top. He’d refer me patients that needed to go to the hospital or whatever because I did that, so you’re absolutely right. It's a way of having this idea of collegality instead of competition, that’s the professionalism rather than the trade business, I think.
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Howard:
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I think Dental Town was so successful is because they could do that with a dentist in another state far, far away. I can be your friend because I’m in Utah and you’re in Washington, but they need to forget the website, they need to put down the cellphone and be a friend in the flesh with the guy in the same building. Most medical dental offices I walk into I go in and I’ll see there’s like six dentists and I’ll say, “When’s the last time you went to lunch with any of these dentists?” and 90 percent of dentists will say, “Well, I’ve never had lunch with any of those dentists ever,” and I’ll say, “Are you not right in the head?”
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Richard:
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Well, let me tell you. You’ve hit something else that creates claims and that is a patient will come in and the dentist will take X-rays or whatever and just say, “Ugh, who did this work? This is terrible!” You know, criticizing without knowing all the facts. I mean, if there is a question you call the prior dentist and say, “Hey, I just had somebody come in. They said this crown was done six months ago,” and usually they say, “It wasn’t done six months ago. It was done six years ago and the guy never paid his bill!” That’s one of the things we preach all the time: Don’t criticize the dentist without all the facts. Call him up, talk to him, find out what really happened; patients are good at fabricating and saying anything to get money.
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Howard:
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We’re out of time. We already went over an hour and last but not least I think it’s also insane how many of these young kids will fly to a different state to take a course when they could have walked over to a periodontist or oral surgeon, orthodontist and said “Hey, Fred, can I just come in and observe? I want to learn about gum surgery. I want to learn about bone grafting,” and that periodontist right up the street, he wants a friend, so why get on Southwest Airlines and fly a 1,000 miles and pay $4,000 bucks when there’s a guy in your zip code that would spend a whole damn day with you?
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Richard:
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Right on. That’s absolutely right, very good.
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Howard:
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Alright, Richard, thank you so much for spending an hour with me. This was so informative on malpractice, Pierre Fauchard words of wisdom and good luck to you buddy, I can’t’ wait to see you again and thank you for handing me my fellowship at the Academy of General Dentistry.
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Richard:
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It was my pleasure. You earned it. Once in a while I get down to Phoenix for things. I’ll come by your office and say hello.
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