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How To Help Sleep Apnea Patients with Erin Elliott, DDS : Howard Speaks Podcast #102

How To Help Sleep Apnea Patients with Erin Elliott, DDS : Howard Speaks Podcast #102

7/21/2015 12:00:00 AM   |   Comments: 1   |   Views: 1184

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AUDIO - Erin Elliott - HSP #102

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VIDEO - Erin Elliott - HSP #102


Listen to Erin Elliott explain how you can specialize, and why you should communicate clearly with staff and patients.

Dr. Erin E. Elliott grew up in Southern California before traveling across the country to Western New York to play soccer at a small Christian college, Houghton College. 

After graduating Creighton Dental School in 2003 her husband and her settled in North Idaho. Dr. Elliott is an partner at Post Falls Family Dental in Post Falls, ID and is happy doing general dentistry, dental sleep medicine and raising her two sons.



Howard: It is a huge honor for me today to be interviewing, I'm a huge fan of you Erin, Erin Elliott. In fact my dental office is on Elliot Road. That street, I assume, was named after you because ...

Erin: As long as it has 2 Ts.

Howard: You know what, I don't even know if it does have 2 Ts. I think it does. Yeah, I think it does. There is Elliot with one T and Elliott with 2.

Erin: Every good Elliott knows that it's Elliott, 2 Ls, 2 Ts. It will probably say that on my grave stone.

Howard: Really? You are an amazing woman, and I'm a big fan of yours. The new breed ... I got to tell you Erin, I'm a lot older than you. I'm 52 and you're still in your 30's. When I went to dental school, there was one girl in the senior class. Now when you go into dental schools, 45 percent of this year's graduating class is women dentists. I'm a big fan of women dentists. I love it because ... The thing I love the most about women in dentistry is that when you go around the world, when you go to poor countries and there is no money in dentistry, it's all women. When you go to America, when you go into professions with no money like teaching it's all women. I always feel that there's hard wired genetic component that says women always do it for their heart, for all the right reasons.

A lot of times men show up because there is a lot of money in insurance, and banking, and financing, and as doctors or dentists in rich countries. The women are always there whether there is money in it or not. Most people don't realize when they think that women are new to dentistry. That when you look at the 2,000,000 dentists around the world over 1,000,000 of them are women. Because in all the poor countries when you can't make any money in it, it's only going to be women in dentistry, or teaching, whatever. The first thing, I got to start out with you is when I was in high school, if you were a boy like me and had a 3.5 five they told you to go to school and be a doctor or dentist. If you are a girl with a 4.0 they told you to go be a nurse or a dental hygienist. Your mom was a nurse, and your dad was a dentist. What made you follow your dad and not your mom?

Erin: To be honest I didn't even want to be a dentist. 

Howard: Really?

Erin: I grew up in Southern California.

Howard: I was not expecting that answer.

Erin: I grew up in Southern California, and my dad had a long commute on a crowded freeway. I didn't ever really hang out at his office. I wasn't really familiar with dentistry. Growing up in California it's more about what you're going to be, not who you are going to be as a person. It's career. Because I did graduate at the top of my class I like in action and blood and guts, I wanted to be an emergency room doctor.

Howard: Really?

Erin: Yeah. Before the show came out.

Howard: Before the show came out. There were so many, oh ER, that's so funny. You're giving away your age because when you're my age there was the paramedic. I forgot the name of the show, but it was an ambulance, and the doctor then there was Marcus Welby. You wanted to be an emergency room physician. What happened there? How did you go from ER to dentistry?

Erin: It was my senior year, I was looking into colleges. I'm a big soccer player. When I went to UCLA, one weekend which is my dad's alma mater. I was born and raised in UCLA Bruins fan. Then I went to a small school in Western New York in ...

Howard: On a soccer's scholarship?

Erin: On a soccer's scholarship. I went there the next weekend, and chose my path which changed everything in my life I believe.

Howard: When you went to the small college in New York, Western New York to the play the Christian College ...

Erin: Houghton College.

Howard: That's when you chose that you're going to be a dentist.

Erin: Yeah. I met my husband or soon to be husband, and realized that I wanted a family. I needed the life besides my career. Dentistry, I fell in love with dentistry. It comes out of my pores. I don't think I can really hold it back. We just have such a wonderful career, and an opportunity to help so many people and support a family.

Howard: You met your husband freshman year of college in Houghton.

Erin: Yeah. Houghton ...

Howard: In Houghton College. What city is that in?

Erin: Houghton New York. It's an Amish country. I'll tell you. It's Southern California. It's an Amish country in snow. It was quite a ...

Howard: Did you ever go to an Amish dentist?

Erin: I did not.

Howard: That had no power tools or electricity? I was wondering how that would work. That's an amazing story. You decide you're going to be a dentist. When you met your husband, you realized you wanted a family. You never went to the emergency room. I have to tell you. My emergency room deal ... My dad told me when you're at Creighton, they have a dental school and a medical school. He said, "Make sure that you don't want to be a physician." I told the 80 year old priest in my dorm, Father [Mcgoyn 00:05:13] and he's said ... He goes, "I'll arrange your ... You know you get 15 hours week of the student work program. He goes, "I'll put you over at Creighton Med school." There is St. Joseph Hospital and I got stuck in the emergency room. When you were done, the walk back to my dorm was at least 20 minutes because you had to walk underneath the interstate and across the ...

Erin: I know exactly what you're talking about.

Howard: Oh yeah, because you went to Creighton.

Erin: Yeah.

Howard: I was in Swanson hall. Which hall were in you in?

Erin: I was a married student. I lived in Bellevue at the time.

Howard: It was called St. Joseph hospital wasn't it?

Erin: Yeah.

Howard: I just remember that when I walk back, every time someone died, like a car wreck ... I'll never forget this one where when they brought her in she was talking. She was internally bleeding. I didn't know it, but they knew it. She comes in and she's talking, and 10 minutes later, they pull a sheet over her head. I walked back and I was tearing, I was crying. Then I walk in my dorm, my friends ... It's like Friday night, like midnight and they are like, "Common Howard, we're going out. Let's go out and have some fun." I'm just like, "I just want to sit in my room and cry." I just thought, "This is not a job. I don't like this job." Then in dental school, at UMPC, there was a med school [inaudible 00:06:31] Medical Center east. We had to do this rotations in the hospital. One of them was in this pediatric cancer ward.

Erin: Uh devastating.

Howard: You were in there. I was in there for a week. All these beautiful little kids are dying. This one little girl, I'll never forget she made me just break down and lose it. She said to me, "I just want to go to sleep and never wake up." I just thought, "Who could do this job?" I want to go work on a molar, I don't want to work on a dying child. I don't want to see a dying mother in a car accident. Bless those people that want to do that, that's more power to them. I actually have the most respect for pediatric dentists.

If I had to do that or shovel horse manure, I'd shovel horse manure for below minimum wage with no benefits before I'd be a pediatric dentist. I'm really excited to have ... I hate it when my podcasts are a bunch of male dentists and everything. These women in dental school, they need more role models like you. I can't think of a hotter, rock star, role model than you because you're crushing it. You went to a small town, you have a huge practice. You didn't go in with your father. He's in Seattle right?

Erin: Yeah. When I was away at undergrad, my dad ended up at I think 52, selling his practice in Long Beach California.

Howard: That's how old I am. Am I expecting a midlife crisis?

Erin: Moving to Vancouver, Washington and building from the ground up. He bought the property and built the building. What's fascinating bout that, I think he just knew that if he wanted to live longer and not die in traffic on the freeway, that he needed to make a life change. Fortunately they gave me a forwarding address. It's a wonderful practice. I had the opportunity to move back there but we chose Coeur d'Alene Idaho. 

Howard: That's even a more amazing story because you didn't walk into a practice hand to you by dad. 

Erin: No.

Howard: You started a scratch practice in Coeur d'Alene where they have the Iron Man in 6 weeks. 

Erin: Yeah. You need to come visit. Actually it wasn't a scratch practice. I joined another guy that has been in practice. He had been in practice for about 18 years at the time. It was pretty established but we were in an old cruddy 5 op building and there was no room for me. Literally I worked Mondays and Fridays and Thursday evenings and that's it. I was the breadwinner in the family. My husband was a teacher but the teaching jobs didn't come very easily. I don't know if I could be contained to just 2 days a week. Like I said it just oozes out of me. 2 days a week would be hard to only do dentistry that little.

Howard: Did you buy this practice or are you still a partner with this guy?

Erin: About 3 years ago I bought it. I was an associate for a while. The beauty of it is, he gave me ... He allowed me to have that ownership mentality. I was out doing the marketing and community events and community involvement and I just really liked that aspect of it. We really built this up and about right when we shouldn't have, we bought some property and built a 10 op practice. 

Howard: Don't tell me it was in 2008.

Erin: Yes. I think we built it 2007/2008. 

Howard: Oh my God Lehman Brothers collapsed September 2008. 

Erin: Great timing, I was getting to become a master at Sudoku because in between patients that's what I did. It felt deserted but it was one of those things of if you build it they will come. After listening to Dr. Blatchford's podcast, Coming From Abundance instead of fear of scarcity. We had that attitude and now we're out of room in 10 ops. That's a wonderful problem to have.

Howard: You bought the practice, is that guy still with you?

Erin: He is, he'll be around for another 15 years or so. 

Howard: Unless you start putting crushed glass in his Subway sandwich, then it'll be shorter. 

Erin: He's about to be 50.

Howard: He's 50, that's so old, I'm 52 so he'll probably be dead tomorrow. You used to be the associate to him, now he's the associate to you. 

Erin: No. No. No. He's a partner. 

Howard: He's a partner in a 10 op, okay. I want to back up all the way to the beginning. Not to be sexist or anything but you are a ... If I was going to go into a dental school class and it was 45 percent women. You've been out what, 12 years? I was going to think who if you wanted to grow up to be like someone, I would say Erin Elliott right out of the gate. My first question, I want you to address tomorrow night I'm going to the dental school ball, graduation thing Thursday. If you were giving the commencement ceremony and you were aiming at 45 percent of these women. What would your advice be to start their journey? I want you to walk through your journey out of dental school because they're sitting in class Erin.  

The first things they're thinking, there's 9 specialties, should I specialize? There's residencies. You got a job as an associate, why did you pick that guy? Let's go to the kids coming out of school. What would you say at the commencement address? Should they specialize? Should they do a GPR? If they're going to get an associate, why did you pick the guy you did? Did you pick Coeur d'Alene because of the right business reasons demographics with your brain, or did you pick that with your heart because that's where you wanted to live because it's so damn beautiful there.

Erin: That's about 20 questions which I hope I can get to.

Howard: Take it away Erin.

Erin: First if I were speaking to a graduate class, even male and female. What would be the motivation to specialize? Is it because you're passionate about that specialty or is it because you're going to make more money. For me I didn't want to give up 2 years of my life and I knew I wanted to do it all. Especially now that I've discovered Dental Sleep medicine I'm very happy I chose general dentistry. In addition, gosh you asked so many questions. I chose Coeur d'Alene because tats where we wanted to live. 

Howard: Your heart.

Erin: If I were thinking rationally which I always do, I'm very cerebral that way and not very emotional. It's where I wanted to raise my family. It has the best of all worlds. At the time in 2003, I found an affordable house on 5 acres. Even though I worked 2 1/2 days a week we were able to live within our means. I did go travel and work at my dad's office every other week for 2 days. I'd fly to Portland and work. It wasn't an easy decision because I only got 2 1/2 days here but I met with other dentists and no one really new how to pay me. How to schedule me. What they were going to do when I walked in Dr. Lynn's office.

It was like, "Here's the contract, this is what you would get paid. Kind of what's mine is yours." It worked out beautifully. I was just reading some statistics that I think it said in 1980 less than 5 percent of dentists were women. Now the overall workforce, it's 27 percent. The dental schools are graduating more and more. What's interesting is the corporate dentistry, how many more women they have there. Their percentage, they have about 46 percent women which makes me wonder if that's the path that the women dentists are choosing after graduation so they don't have to manage and run a practice. 

Howard: I'll tell you there's a lot of demographic differences on women, look at the suicide rates. I can only find one woman that's committed suicide as a dentist and she had a whole history of mental illness and dentist have been in the top 5 forever. It seems to me that divorce is a third substance abuse, a third finance and a third sex. Men dentists always marry a woman who destroys 10,000 dollars a month in capital. Women dentist, 30 percent of them marry a male dentist. Women dentists always marry a man with a job and women dentists always marry a man that makes 10,000 dollars a month, that has a job. The difference between someone sitting home destroying 10,000 a month and someone bringing 5 to 10 grand home is a world of stress. [crosstalk 00:15:26].

Erin: It's a dynamic, yeah.

Howard: I think when people are out there earning money, when you're not earning any money. You're just like, I want a Gucci purse, so you go buy one for 5 grand. When you're a dentist and you just had an incredibly rough day and you didn't even gross 5 grand. You've got 2/3 overhead. You come home and find out the only thing your partner did today was buy a 5,000 dollar Gucci purse and get a mani/pedi and wants a new car, it's incredibly stressful. I think women marry more with their brains and men ... You see that across the entire planet. You see across in all cultures that men tend to marry down socioeconomic and men tend to marry up socioeconomic.

I've never lectured in dental school where I didn't man the smartest thing they could do in dental school is marry one of the girls in the class. That would be my first prerogative going in dental school. Not am I going to specialize, it's which one of these girls am I going to marry? That would just be ... Did you know the dentist/physician/lawyer marries a dentist/physician/lawyer they have the lowest divorce rate measured in the United States? It's single digits.

Erin: Interesting.

Howard: One study says 8 percent, one study says 9 percent. For the country it's half. Whenever I see these guys bitching about how much student loans their debt is, that they graduate with. I'm like, "Dude, your first divorce will cost you 3 times that money." Yes, I think women can easily say I'm fine with corporate America and by the way corporate America has such a bad name because every dentist I've ever heard that says he hates corporate dentistry is a corporation, is an LLC. He's incorporated.

Erin: Technically yes, but we have a lot of autonomy. I get to write stuff off and I get to be a business owner and make decisions. I think you lose some of that with that. I do have to say that I was married when I entered dental school and definitely married for love. I married a PE teacher. I was going to touch on the student debt and people complaining about that. My first question would be did you take out every loan you could, every dollar?

Howard: Oh hell yeah. They all go to the Caribbean on spring break. 

Erin: I was a valet, a beer cart girl and a tutor. That's a little bit of a dichotomy though but I worked and my husband worked. We lived within our means. I drove a crappy little Honda Civic and I didn't take out all the loans. I also lived in Omaha, Nebraska not New York City, so I made some decisions based on that because I'm very frugal. Some would say cheap but I just don't spend a lot and don't like to be in debt. 

Howard: It's funny because if you saw 100 Mercedes Benz in Scottsdale, 90 percent of them would all be leased and have a 5 year mortgage on it. It's funny because you fake it til you make it, because people who are truly rich don't have, don't wear Rolex watches. I don't wear a watch and my Lexus has 107,000 miles on it and is 10 years old. I didn't have a car all of undergrad and the first 3 out of 4 years of dental school. I walked. Now I see people complaining about student loans and they're driving a 30,000 dollar car. 

Erin: I got my first new car last year because I was just tired of having [inaudible 00:18:55]. I was probably the youngest person in my county driving a Buick Rendezvous, in fact I just parked in the handicapped spots because I figured they assumed I was old and decrepit anyways. I finally got my first new car, but I had been a dentist for 10 years. I'm still paying on my student loans [crosstalk 00:19:16].

Howard: The biggest take away so far is that doc, when you're stressed out of your mind and you're living in too big a house and too nice of cars and every time you want to recharge your batteries you fly to Hawaii for a week, quit spending money. Warren Buffet always says that about CEO's, 95 percent of CEO's spend their entire day learning how they can raise their overhead, spend money they don't need to spend and just complicate everything. Only about 5 percent of CEO's go to work saying, "How can we do this faster, easier at lower cost, higher quality and drive down cost and increase sales and make a ton of money." Just like dentists that always go to courses and seminars of how could I go into more debt and figure out how to do this the most expensive way on the planet and solve a problem that no patient has ever asked for. 

Erin: I'm all about efficiencies and systems. I just got back from the IDS in Germany there's a lot of sexy technology, but is that going to increase my efficiency and production or is it just going to increase my debt. Those are a lot of the questions I ask. 

Howard: When I heard that you were going to the IDS I thought to myself because I've been to the IDS a lot. For an American to go, basically the United States has 50 states, they all have a state meeting there's way too many meetings it's way too fragmented. Europe basically has one big blow out every other year it's in Cologne, Germany. 110,000 dentists come from every single country on Earth. Basically I've been there several times there's not many American individual dentists there. When I heard that little old Erin in her 30's was there. What was that about? What made you go to Cologne, Germany?

Erin: I think it was an awesome opportunity to see the world and someone dentistry at its best. There wasn't CE there so really a lot of it was for industry it felt like more than anything. 

Howard: Can we talk about that for a second because that's a little nuance thing I didn't pick up til I'd been there the second or third time. The American dentists are extremely cynical. 3M and Ivoclar each have 60 PhD organic chemists in white lab coats that know everything about bleach, bonding and the resin. The American dentists won't listen to them because they're selling something for a profit. Dude, what are you doing? Are you giving away free crowns? Are you giving away free dentistry? I'm pretty sure you make a profit too. It's a stupid mentality.

Then you'll go to a lecture and listen to some dentist who couldn't even go to the white board and couldn't even write down the organic chemistry model of the resin, the bonding and is just feigning expertise and doesn't know his ass from second base. When you become friends with these organic chemists, they go over the lecture notes and just butcher, how could these idiots say this? Blah, blah, blah, it's just crazy. When you go to Europe they don't have that stupidity in their brain. A European will go to the booth. They don't have lectures at this meeting. It's so big you couldn't even at a walking pace of naturally walking around the block, you could not walk by every booth in 5 days could you?

Erin: No. I wore comfortable shoes and I did find your booth though. 

Howard: It's so big. A European dentist, he would rather or she would rather speak to the CEO of the company and say, "Sir would you tell me about your product?" In America it's like, "You can't listen to that guy, he's a whore. He's selling something for money. He's for profit." Then it's the same guy who doesn't believe in government and believes that free enterprise rules. He won't even listen to free enterprise. Americans get horrible information because they go to intermediates between the company and listen to lecturers who have no idea what they're talking about.

Compared to 60 men in white coats who have PhD's in Polymer Chemist, Organic Chemistry all this stuff like that. Europeans have trust and they go there. They don't distrust their government. In Denmark and Norway ad Sweden and Switzerland they don't have this anti-government where get an M16 because the tanks are going to be coming next week. They listen to the manufacturers and the manufacturers have all these mini booths. They want to talk to the owner. 

Erin: They're there. 

Howard: They're there. I've always enjoyed hearing about Ultradent from Dan Fischer. From hearing about  Den-Mat from Bob Ibsen. I love to go talk to Buddy Mopper who owns Cosmedent, I love to talk to these dentist CEO's and I believe them. I no sooner say, "Hey, come on Dan you're selling something, you're a whore." I'm going to go listen to a lecture talking about Ultradent products. I'd rather listen to Dan the man Fischer about his own company, that's a weird deal. That is a very neat meeting to go to. By the way I've met a lot of millionaire dentists from the United States from that meeting. 

They go there, they saw a rocking hot new implant that was from Russia or Israel or Turkey or whatever. Find out they don't sell them in the United States, pay one dollar for the US distribution rights. Say in 5 years if we're not doing 1,000,000 dollars a year I give you back the distribution rights. If I can clear these economic hurdles it's mine. Some of the biggest products I've used in the last 28 years has been from someone like you who went to IDS, saw a rocking hot product made in another country. Made in Korea and at that part of their growth cycle they didn't have the money to have an office in the United States or Australia or whatever. It's a rocking hot meeting. 

Erin: I think it was something like 260 implants. It was so overwhelming, so overwhelming. What is best? I talk to my rep a lot from Henry Shine for advice. I want my reps in the office all the time. My reps love me because I actually come out and talk to them, but I need to learn about these products. 

Howard: Let's go back to dental school, I loved your advice on specialties. Don't give up 2 years of your life just because you think you're going to earn some more money. Just specialize if that's where your passion is. If you truly only want to do pediatric dentistry then go to pediatric school but don't do it for any other reason. What about a GPR?

Erin: I think that would be fantastic. The thing for me was that I felt at Creighton that I got a ton of experience. We didn't have specialists there so I was able to experience ... We did a lot of different things and work. No matter if you go to a GPR or go straight into practice it's still the practice of dentistry. Dental school tries to prepare you as much as they can, but you're still practicing dentistry. I felt prepared, I wanted to settle down, I wanted to start my family. That's another thing, I waited until dental school was over to start my family. 

Howard: I obviously know the number one reason you moved to Coeur d'Alene is because that's where the Iron Man is every year and it's in 5 weeks. Are you ready to go swim your 2.5 miles, bike 112 and then cool down with a 26.2 mile marathon?

Erin: Not everyone can get this joke but you can imagine how many triathletes live in my town. I tried to do triathlons for a while and then I realized how much I hated it. I'd rather run after a bouncing ball for 90 minutes. I got my first bumper sticker ever and it says, "0.0."  

Howard: 0.0, that is awesome, because 140.5 is the Iron Man and 26.2 is the marathon and yours says 0.0. I learned to become a runner very young because I always had sirens behind me. Was running across the park.

Erin: That's a sprinter though. 

Howard: What type of dentistry do you do? Do you place implants? Do you do molar endo? You talk about sleep apnea but we'll get to that. Tell us your mix of dentistry?

Erin: I'll tell you I'm very blessed by having this partner because we never really close our doors. Very rarely do we take an entire week off. Having someone here that I'm not always on call for emergencies and while I'm on vacation, I can actually have someone here to take care of my patients, so that's a blessing. In addition we each have our little niches. I could go take an implant course but he does those and he really likes them. He just took the Doc's sedation course and I A do general dentistry, crowns, fillings, we do a lot of dentures and extractions still. Recently I do Six Month Smiles and Invisalign but more recently my practice become about 60/40 dental sleep medicine. 

Howard: 60 percent dental sleep medicine?

Erin: My part of it. 

Howard: Your part, 60 percent. I've got to stop you right there. How did that happen? This is 2015, when did your sleep medicine journey begin? Was it when your husband was snoring so loud in the middle of the night you had to almost suffocate him with a pillow? What made you get into this?

Erin: I'm going to have to admit it's me that snores.

Howard: It's you.

Erin: There's video to prove it because I didn't believe it. 

Howard: Is it on YouTube anywhere? What do I search? Erin Elliott secret videos?

Erin: I actually have always been accused of being an old lady because I would put myself to bed. I never stayed up late. I would take my own naps, my parents never had to worry about me sleeping because I loved to sleep. When I found out about ... I was at the Idaho State Dental Convention. I heard a sleep physician speak in the morning and then a dental sleep medicine dentist in the afternoon and I knew immediately that I wanted to pursue this. That was in 2009. 

Howard: That was 2009, after those lectures did you think you had sleep apnea?

Erin: I thought I could.

Howard: Did you [crosstalk 00:29:28].

Erin: I thought I had narcolepsy.

Howard: You thought you had narcolepsy, you were getting sleepy during the day? When you should be awake you were tired. 

Erin: I'd never fall asleep in class or anything like that but I don't drive more than an hour because I'm going to fall asleep at the wheel. I just know myself and I didn't start snoring until more recently. 

Howard: Did you have sleep apnea?

Erin: No. I tested myself, I wear an appliance when my husband is around to actually hear me snore. 

Howard: Who gave the sleep apnea? Who's the sleep dental in 2009. Do you remember who that was?

Erin: Yes. It was Jamison Spencer because he's out of Boise. 

Howard: Spencer. Shout at him that's a huge turning point in your life, that one guy's lecture. That's amazing. What made you, by the way when I heard my first sleep medicine deal I went to a facility where you go to bed. Take a device [crosstalk 00:30:36].

Erin: I've done one of those too. 

Howard: Everybody said, how are you going to sleep with all of those cords or whatever. I just went there, you get in your underwear and they taped all these things to you and I laid down with all these strings on me. It didn't bother me, I slept. The guy said I can't officially tell you, you have to get a report at legal. I said screw the lawyers, I'll get the report, what do you think. He goes, "Seriously dude, you sleep deeper than 99 out of 100 people." He said, "You are the least sleep apnea person on the planet." 

Erin: Wow.

Howard: My first question to you is should they buy a take home device for their patient to see or do you refer these people to a outpatient clinic to sleep all night to see if they have sleep apnea? Walk us through why you got interested and how you find patients coming in your office with sleep apnea. Do you send them home with a box to do it themselves? Do you send them out? Just walk us through. I'm going to shut up. You just take it away on sleep because there's not a dozen dentists in America that have 60 percent of their practice as sleep medicine that I know of. 

Erin: It's 0 percent endo which makes me very happy. When I took Kent Smith's course, it's a 2 day course.

Howard: Kent Smith, is he from Kentucky?

Erin: Dallas.

Howard: Kent Smith from Dallas.

Erin: He's a wonderful mentor. That was 2 days and I went by myself, actually I went with my dad but no team members. Then I come back all excited saying, "We're going to implement this, this is what we're going to do first. I got all my forms it was very slow to take off. I decided I was going to charge the patient up front and they could try to get their medical insurance billed themselves. I did maybe 2 a month, maybe. It was all people I did not run a home sleep test. It was all people that were already diagnosed.

I did some advertising, I went and spoke to physicians, visited the sleep labs. I hit the pavement, which you have to do, really. When it was finally ... I finally decided to bill medical insurance. That's where it took off more and more. Even then there was some hiccups along the way. That's why when I teach or speak to other dentists trying to get in to this I said, just learn from my mistakes. 5 years of my mistakes and that is not having the entire team trained. Not delegating what you can to the entire team and learning the ins and outs of medical billing. Ever since that happened, I have been established. 

Howard: You said team, medical billing, what was the other one?

Erin: Having the entire team, medical billing and delegating what you can. 

Howard: I'm just going to tell you every speaker that I've known personally for 20 years. Always says that when you go to the lecture, say there's 200 people. The right side of the room is 100 people because it's 20 dentists who brought all their staff. The left side of the room is 100 dentists all by themselves. You can go pick out the 1041 income from all the people who bring their staff and it's all million dollar practices with dentists taking home 3-400,000 a year.

The guys on the other side are all saving money, they all come alone and they're all just barely getting by, because dentistry, you have to be very egocentric to think it's all you. It's your assistants, the most important people is the ones answering your phones. The hygienists are in there for an hour and the dentist, the online CE. I know dentists who've  said, "I've taken every one of your courses, well actually I didn't it's just that we have staff meetings and I play one every week." I'm back in ... 

Erin: He's on Dentaltown posting. 

Howard: By the way if 60 percent of your practice is sleep medicine, I hope you create an online CE course for Dentaltown and walk us through your journeys. That would be amazing.

Erin: My whole focus and hopefully inspiration is actual implementation. I once had a friend tease me and he said, "I think you're going to have to move from Coeur d'Alene soon." I said, "Why?" He's like, "I think you have everyone in town in appliances already." It's not that, it's just that we're screening them. We're creating value in it. As far as our communication goes. We track all our numbers, we monitor everything because numbers tell a story. Am I treatment planning enough? 

Do we have good case acceptance? My case acceptance is through the roof. A lot of that is because our communication and our team working together. The patient is seeing value in what we're providing. Most of the time I hear, "How do you convert a patient that's sitting in your chair who's never heard of sleep apnea?" We have a protocol in our system for that and most of the time they're ready to listen to you because they know we've been doing this for a long time. They see the investigations and symptoms. We have ...

Howard: Walk us through some of these and by the way as far as details, I think it's funny. You're also a business person, no doubt about it. In my 28 years, I was a dentist in 87 but I started a media company in 94 with Friend Report which turned into Dentaltown. Every single dentist that walked in my office and couldn't tell me about what he was doing til I signed a NDA non disclosure agreement or spent the first 3 or 4 years getting a patent. 99 percent of all patents will never generate enough revenue to pay for the patent. 100 percent of all NDA's that I've signed never came to fruition because those are what the idiots do, it's the idea it's all I have an idea I have to protect it. Dude look at McDonald's it's on the corner of 4 lane intersection, they sell a hamburger a fry and a coke. Do you not get it.

They got a play area for kids. What is there you don't understand? How many people have been able to go against them. Maybe McDonald's or Wendy's or Whataburger or whatever. It's never the idea, it's never the non disclosure. It's never the patent. It's always the details, people like you and me are the operators. We're the ones who get all the little ... Everyday we just get up and knock out all the little details. We do it day after day, decade after decade and we just get up the mountain one step at a time and everybody else just thinks it's going to be this grand idea or this secret weapon or this patent or whatever. Then you just said, it's all the details. It's all the implementation. Walk us through some of the details. How do you find a sleep apnea patient? How does the process work?

Erin: Most of the time we get referrals from physicians we get referrals from physicians and that has been key because those people were tired enough to go get sleep study. Tired enough to try a CPAP and still pursuing treatment. Then we have people that I get from external marketing, yes I know marketing is a 4 letter word in dentistry sometimes. I think that we've created a lot of awareness in our town and people are asking about sleep.

Howard: Physicians, we have 9 specialties in dentistry, they have 58. What type of physicians? Family physicians or what type of physicians are sending people in for sleep studies?

Erin: Sleep physicians are on the front line, I do work with them. 

Howard: Sleep physicians? Is that a specialty yet [crosstalk 00:38:09]?

Erin: No. It's usually Neurologists or Pulmonologists. 

Howard: Neurologists or Pulmonologists. Explain why?

Erin: They get board certified. I think that sleep apnea was discovered in the 50's in Germany and Spain. It didn't catch on in the states for a long time because no one knew which specialist was going to take it, right. I don't know the history of why Neurologists and both Pulmonologists started but there became a board certification in sleep.

Howard: Americans are still doing ulcer surgeries, 10 years after the Australians stopped doing it and started treating with antibiotics. There's all kinds of literature making fin of the Australians for doing surgery with an antibiotic. 

Erin: I'm sure there's some jokes about sticking a reverse vacuum on someone's face as well.

Howard: You're referring to the CPAP?

Erin: Yeah.

Howard: Actually I went on a missionary dental trip North of Acapulco and [Atioc 00:39:11]. The dentist that I was bunking up in a room with, I didn't know he even had one on until the morning and it looked like a little DVD player.

Erin: Oh yeah! They're getting so much better.

Howard: I don't know if I drank so much I didn't hear it or if it was just so quiet. I wasn't aware of it until the morning when he asked if it bothered me. I was like, "Did what bother me?" Talk about the CPAP versus the appliance and all that.

Erin: I do work a lot with the primary care physicians, just to finish that point. In fact, tonight I'm giving a lecture to about 20 primary care physicians, ENT, as well as some of the team members; staff members. We're going to talk about CPAP and we're going to talk about oral appliances. I'm very blessed in my town because the sleep physicians are on board with oral appliances. The read the studies, they know that there's a place for them. First oral appliance, if the patient prefers, in mild to moderate cases and if they're CPAP intolerant.

I always like the analogy that the industrial revolution probably could have started 30 years prior. We had the technology, but we had to wait 30 years for all the old managers to die off. Then the new managers rising up could actually take on that technology and change the world. I think we have to wait for some of our newer sleep physicians to come on board and realize there's a place for oral appliances. Now Resmed, the world's largest CPAP maker, a multi-billion dollar company bought an oral appliance company. 

Howard: Really? Give the details of that one. Who bought who?

Erin: Resmed. They make more money in hoses ...

Howard: "Rez" R-E-Z-I.

Erin: R-E-S-M-E-D.

Howard: Resmed is the largest CPAP maker and they bought who?

Erin: They have the appliance called Narval.

Howard: N-A-R.

Erin: V As in victory, A-L.

Howard: What does that name come from? What's nar and val?

Erin: Who knows. It's a nylon sensor, it's made from a cousin to Kevlar. It's pretty sleek, virtually indestructible. I really like it, it's the one I wear. 

Howard: It's the oral appliance you wear. It's made out of Kevlar because it's bulletproof. 

Erin: A cousin to Kevlar, you know in Idaho we have a lot of [crosstalk 00:41:36].

Howard: Because you're in Idaho all those para military groups. Are there really a lot of para military groups in Idaho? It seems like if you ever read about any of them, they are in Idaho. 

Erin: They're far, they're not near me but I'm sure they're here.

Howard: You don't really someone them or anything? They're not hurting property values or anything?

Erin: No.

Howard: How many people live in Coeur d'Alene?

Erin: In the county it's about 100,000.

Howard: 100,000.

Erin: Post Falls where I practice is 27. 

Howard: I'll tell you, one of the neatest things about becoming a lecturer is to find all these golden things and a lot of the nice places you've all heard of. The ones that are the nicest that you've never heard of is North Carolina, Arkansas, Idaho and Montana. They're some of the most beautiful country in the world and all of the other beautiful stuff, you hear about all the time. Who would have ever thought Arkansas was one of the most gorgeous places in the world. They got all Four Seasons. I went Trout fishing for 4 days and my dad on the White River. Unbelievable. Idaho is just the Buttes. Oh my God, I could live there in a minute. My very good friend Louis Korr, a dentist in Glendale, he's doing the Iron Man there in 5 weeks.

Erin: Oh, cool, you'll have to give me his number.

Howard: He admits that he's afraid of clowns, so I'm going to have you dress up in a clown suit and during the marathon jump out of the side and scare him.

Erin: That would be hilarious. 

Howard: That would be. You have to do it. He's got 6,000 posts on Dentaltown. If you can catch that on a video, that would be the biggest joke in my world. I want to go back to the details. This person is driving to work right now. They're listening to you and they're saying, "Okay, you're telling me we're going to go from the first floor to the second floor." What's the first step, the second step, the third step. What would the first thing ... If I'm driving to work and I don't even know what apnea stands for. You're saying, sleep apnea. What does apnea stand for and what would be the first step?

Erin: The first step would be to get more education so that you're not making snore guards for your patients, because what we're doing is far more than making a piece of plastic for someone. What sleep apnea is or what we treat is sleep disordered breathing. Sleep disordered breathing has a range of different types. Ranging from purely snoring, upper airway resistance syndrome. That's basically the sleepy snore, someone who snores so much that it interrupts there sleep and they wake up not refreshed. Then there's full blown obstructive sleep apnea. I actually was the co-founder of the Latin Club in undergrad, at Houghton College and I loved Latin. Apnea literally means without breath. That has to last 10 seconds or more to be classified as an apnea. The only way to test it, the only way to test it is with a sleep test. 

Howard: Take home or in a facility. 

Erin: Either. You don't need a lot of fancy equipment or spend how ever much 3D imaging is. You don't have to have that to screen or treat sleep apnea. 

Howard: What would be the fastest, lowest cost, highest quality way to screen, take home or go to a facility?

Erin: Take home. Just simply observing the signs and symptoms. One in 4 men have sleep apnea, one in 10 women and 50 percent of the population over 50. Therefore, if you do the math and up to 90 percent of them remain undiagnosed. If you do the simple math, look how many sleep [apneacs 00:45:18] you have in your own practice who don't even know about the disease. That's where a lot of my team members have been so impactful. First of all I treated their spouses, so they're my biggest cheerleader and they want to tell everyone about it. We screen in pediatric kids as well. All the signs and symptoms have taken time to train them as well as have a little checklist and all that. They talk to the patients.

Howard: What are the signs and symptoms and what is the disease? Why should I be worried that I have sleep apnea or sleep obstruction? Am I going to get male pattern baldness? Is my hair going to fall out? 

Erin: Too late.

Howard: What is the disease.

Erin: Basically it's repetitive desaturations of oxygen and cessation of breathing. The body needs oxygen, it's the body's number one drug of choice. Instead of being able to get into their deep sleep, the brain wakes them up, it doesn't wake them up awake. Most snorers, most sleep apneacs will tell you they sleep just fine, but it takes them from a deeper state of sleep to a lighter stage of sleep. They're never getting that deep restful or REM sleep. Also when they're fighting for breath, they're releasing cortisol. They're activating their sympathetic nervous system. The cardio-vascular distress that you're putting on your body when it's supposed to be resting leads to high blood pressure, stroke, heart failure, atrial fibrillation, diabetes type 2 is totally associated with sleep apnea, untreated sleep apnea. Depression, erectile dysfunction, you name it, it's probably related to good sleep or lack there of.

Howard: See, I thought heart disease is from getting your finger caught in a wedding ring. You're saying there's other causes. I'm just kidding. Again what are the signs and symptoms? Are you finding these out of hygiene? Do you have a questionnaire in the waiting room?

Erin: You can do that. I have posters and brochures and stuff around. My hygienist, we have their medical history at our fingertips. We see them twice a year. We stare down their airways all day long. In fact the grandfather of sleep apnea in the country who's an MD said, "One of the most ironic things is that dentists have looked down the throats of sleep apneacs for years without even knowing about the disease because it's not in dental school." It's still not. I almost feel like I'm a preacher I want to spread the good news. Therefore, we look at medical histories, we look at their medications. Then we look at the dental signs and symptoms. Mouth breathing, constricted arches, vaulted palate, lingual tori, acid erosion, bruxing, clenching, abfractions, scalloped tongue, a high tongue level. Does the tongue retract into the airway when they open. There's about 30 of them that we could look at. 

Howard: If you went in and you're talking right now B to B, dentist to dentist. If you were giving a presentation B to C business to consumer. You were giving a lecture at some church or a picnic or some gathering, what would you tell lay people, the signs and symptoms would be?

Erin: I've done those lectures too. I talk a lot about fatigue and when we talk to a patient we'll say, "Do you snore?" They'll say, "No, but my wife tells me I do or yeah, but it doesn't bother me." We ask further questions because snoring is a joke, everyone makes fun of it or they sleep in separate rooms, it's not impacting their life per se. We ask, "Do you wake up refreshed?" Many times they say, "Are you supposed to." Yes after 8 hours of sleep you should wake up refreshed. Then we talk about some of the other medications or problems that they have.

Do you sleep peacefully, restfully because a lot of insomnia is actually associated with sleep apnea as well. Sometimes we're just planting a seed. I like to say I don't should on my patients. I'll send them home with a brochure, give them the information. Hoping that their spouse or something  will look at the brochure and ask them to pursue treatment. We always set them up for another consult because this is a long conversation we have to really get people to explain the impact it has on their body and how we can treat them and treatment options. That's a conversation you can't have in 30 seconds with your hygienist looking over your shoulder wanting their oportory for the next patient. Then we look into their medical insurance and bring them back for a consult. 

Howard: Erin, there's a lot of buzz right now, we're sitting here May of 2015, there's a lot of buzz about the new Apple Watch. There's a ton of articles about the future watches are biomedical, that they might be someday telling you your heartbeat, whether you're sleeping or not. Our common buddy, Mike [Ditola 00:50:44] posts on Facebook everyday his sleep score for the night. The one thing he's learned from his smart watch ... Are they called smart watch or biomedical watch?

Erin: I don't know.

Howard: He's found out that he can't get a 90 percent unless he sleeps for 8 full hours. If he wakes up and it's 7 hours he's going to roll over and go back to bed. Are any of these watches accurate. 

Erin: Accurate.

Howard: Tell you that you're rolling around in bed, you couldn't have been sleeping, you have sleep apnea?

Erin: No. I'm a little disappointed that I feel like some people put way too much trust in that. "Oh they say I'm fine." I think what it has done, which I appreciate, is the awareness of sleep and how it contributes to health. It can't really tell you you have sleep apnea, but it can tell you if you have restless sleep or peaceful sleep. It's not going to tell you how much REM you have or anything like that, or if it does it's probably not real accurate. I do appreciate the fact that a lot of patients are actually more aware of why we're even talking to them and why it even matters. Americans are horrible, we have horrible sleep hygiene. That doesn't mean clean sheets, that means getting 7.7 hours of sleep, going to bed early, getting up early, same schedule all the time. It's brought awareness to Americans.

Howard: Now when you said America was that a joke because you're an American or do you actually read compared to other countries we have worse sleep hygiene?

Erin: We really do, we don't sleep enough and with the advent of technology, TVs in the room, iPhone, even reading off of iPads before going to bed can affect Melatonin release and affect sleep cycles. I think we have a lot of bad habits. 

Howard: I'm going to interrupt, before I die I want to write a book called "The Giggle Factor", because I've lectured to dentists in 50 countries and it seems like the richest countries giggle the least. As you go poorer, and poorer, and poorer everyone's relaxed, and having fun, and giggling. My God the Americans, and the Germans, and the Japs, and the Korean are ... By the time you get to Brasil, and Shenzhen, and Kathmandu everybody's just so much more relaxed, they're so much less stressed. When you do that you see the importance about how you've got to reduce your spending. You can't be killing yourself for a house, and a SUV, and a Rolex watch, and a Gucci, it's just crazy. None of that stuff is going to make you happy-

Erin: I laugh a lot, does that mean I'm going to live long?

Howard: Yeah. Erin, I've only got you for 6 and a half more minutes so I want to change subjects again. You're this kid out of school and you talked about going into specialty if it's your passion, you talked about things like that. I know you also are big into Six Month Smiles, I want you to answer this question then explain to me Six Month Smiles. If you didn't do sleep apnea or Six Month Smiles and you graduated 5 years ago and you're looking maybe to add more procedures. You can be adding implants, or whatever, tell us about your thoughts on Six Month Smiles. Would you just call that short term ortho?

Erin: Yeah.

Howard: What is Six Month Smiles, what is short term ortho, and why did you get into that and was that a good decision?

Erin: Short term ortho you need to realize what they're saying about that. It's adult orthodontics for cosmetic reasons in 6 to 9 months. Why I chose that, it's actually a system that's created because again I'm all about systems and efficiencies. Therefore a lot of the wheel was already invented. The quality of the product is great. It's clear brackets, white wire, everything's ...

Howard: White wire? How do they have a white wire?

Erin: I don't know how they coat it, but it's white.

Howard: Oh, it's coated white.

Erin: Yeah. It's NiTi .

Howard: It's a NiTi wire, it's clear brackets and it's adult only and it's just cosmetic?

Erin: I have to tell why I got into it though is I did get frustrated with aligners. The whole reason I got into aligners is to be honest I really hate doing veneers. I hate cutting down good enamel.

Howard: I share that passion with you too-

Erin: When ...

Howard: How can you be a dentist and want to peel the banana on all the teeth? 

Erin: I do them when they're necessary, but if tooth position is the problem then tooth movement is the answer. I'd refer these patients off to the orthodontist and they would never go, or they'd be in braces for 2 years. I respect orthodontists, I respect what they've committed to their profession, to be honest I think you have to be at the top of your class. The treatment planning part, I think is not real easy. What we're trying to accomplish with Six Month Smiles is those people in between, the ones that were going to get Invisalign and or clear liners and get frustrated in refinement and all that, or there was instant ortho with veneers. I feel like with Six Month Smile like Dr. De Tolla says he can put a steering wheel on the tooth and you can move it much more controlled and much more efficient. I've had some great [crosstalk 00:56:25]

Howard: As opposed ... You said you started with aligners?

Erin: Yeah, that was 5 or 6 years ago [crosstalk 00:56:32]

Howard: What type of aligners?

Erin: I did Invasalign. I still do, I still do.

Howard: You're calling Invasalign aligners?

Erin: Yeah.

Howard: A clear, removable-

Erin: Clear ...

Howard: Some people aligner might mean Inman Aligner.

Erin: Yeah, yeah, yeah, I've seen those too. No, I do Invisalign.

Howard: It's Invisagign, there's some other brands similar, what it is? Clear Choice or, there's other ones. You do Invisalign and you do Six Month Smiles? You do ...

Erin: I think it needs to ... Yeah, there's a place for them for sure.

Howard: You do them both?

Erin: Not on the same person.

Howard: Right, but you offer both.

Erin: Provide.

Howard: When would you do Six Month Smiles and when would you do Invisalign?

Erin: I would do Six Month Smiles in almost every case unless the patient really wanted Invisalign. That's what my last 2 cases have been. If it's ortho relapse and it's going to be about 5 aligners then Invisalign would be a good option as well. You always have that patient compliance factor.

Howard: What's the lab bill on the Six Month Smiles versus the Invisalign? Is that a factor?

Erin: That's a great question, it's about a third.

Howard: What's a third? The Six Month Smiles toward the Invisalign?

Erin: Yeah.

Howard: The Invisalign's still a hefty lab bill isn't it?

Erin: They have different categories now, 5 aligners, 10 aligners, or assist, do you need help with it? I think that was 16 or 1,700 dollars for a full case.

Howard: I've only got you ... 2 minutes, we talked about specially GPR, you felt that you went Creighton since they didn't have a lot of specialists, you felt like you were ready to go. I'm going to end by throwing you under a bus with the most political controversial question I can ask you. When I was in school in 87 a lot of people that didn't have experience said "I'm going to go join the Navy, I'm going to join the Army, Navy, Air Force, Marines for 4 years and work down some student loans and get some experience." Today, the most number of jobs is corporate dentistry, what would say to a kid coming out of school said "I think I'm going to go join corporate dentistry, get some student loans paid, and just get some experience." Do you think corporate dentistry is the evil nightmare, it's Godzilla killing dentistry or do you think that's a place to go to go do a residency.

Erin: Use those patients to practice on. I am very passionate about dentistry and I feel like especially now that I'm in medical doing a lot of medical insurance. I do feel like the physicians have let it get taken over by hospitals and corporations and lose that autonomy. Insurance ...

Howard: The physicians lost it all.

Erin: Control, everything. As a dentist I think we can still maintain that. In fact, I'm the Political Action Committee fundraiser for the whole state of Idaho, that I feel so passionately that we have people working everyday on our behalf to preserve what we have. I do think that some of corporate dentistry can take some of that away. What I would suggest-

Howard: You're on the Political Action Committee for the Idaho State Dental Association. You're raising money and the Political Action Committee is trying to keep insurance companies and corporate dentistry out of dentistry?

Erin: Yeah, we work with lobbyists in the local state senators as well as the ones in DC, just helping dentistry stay on top of mind and preserve, like I said preserve ...

Howard: What would you say to a kid coming out of school that says "Erin, I got 250,000 dollars in student loans, should I join the ADA?"

Erin: Yes they should, and there is a break for new dentists. I think that we all owe it to our vocation. Again, I'm that Latin nerd, voco means calling, I think it's our calling. I think we should not just stick our head in the sand, I think it's really important so support it. 

Howard: I've been a due paid member of the ADA every year, ever. Everybody complains about their family or this or that, but when the people complain and then they quit it's like then who's there?

Erin: If they're complaining about things that are going on, even if they complain about the ADA but they're not doing anything about it, that's when I get real frustrated. If you don't like the situation do something.

Howard: I just want to tell the young kids, this might be applying to you, I think you're young enough you might've missed it. Do you remember the 1984 Pulitzer Prize winning book by Paul Starr the Rise of the American Healthcare System? That's one of the few books that I ever had to go back 10 years later and reread again. I think the only other Pulitzer I did a reread 10 years later was Guns, Germs, and Steel. In 1900 healthcare was 1 percent of our GDP, and in 2000 it was 12 percent, 14 percent and then by 2010 it was 17 percent. 

It completely explains the entire healthcare system. When you travel around the world India, and China, and Brasil are now going through where we were. They say in 1962 the physicians got in bed with the government, in a Medicare and they got in bed with them at the state called Medicaid. When you get in the bed with anybody you're going to get screwed, and they got in bed. It's a game changer. I'm not saying that it's right and wrong because it depends there. You have physician, patient, a government, there's different viewpoints. I would go back and read that Paul Starr book and ...

Erin: I know we're running out of time, but to go back to the student I would run the numbers. I did consider helping with student loans because I hate debt. When I ran the numbers I could make more in private practice by working my tail off, because I'm getting paid on production or collection and I can put more in retirement and just extend my student loans. I had 2.8 percent interest. Really, do the math. Does it make sense for you? What's your demographic of where you're moving back to? Does it make sense, you get to go see the world and join the military and get more practice or do you work for community health for a while? I think that's an admirable  thing.

Howard: We are out of time and I just want to say thank you for all that you've done. I'm a big fan of your 100 posts on Dentaltown, I think you're just amazing. Most people are probably 55 or 60 when they've reached half of your accomplishments. Erin, I think you're a rock star, I think you're a role model for every dentist. Thank you so much for giving me an hour of your day.

Erin: Thank you so much.

Howard: When can we expect an online CE course from you?

Erin: We'll chat.

Howard: All right Erin, thank you very much.

Erin: Thank you.

Howard: Bye bye.

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