Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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205 Back To Basics with Shelly Ryan : Dentistry Uncensored with Howard Farran

205 Back To Basics with Shelly Ryan : Dentistry Uncensored with Howard Farran

10/23/2015 12:00:00 PM   |   Comments: 0   |   Views: 666

If you do it more than twice, you should have a checklist for it.

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AUDIO - HSP #205 - Shelly Ryan

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VIDEO - HSP #205 - Shelly Ryan

Going back to basics includes how to create and use checklists effectively!



Shelly Ryan is a Registered Dental Assistant with more than 20 years of dental experience in clinical, front desk, office management, training and consulting.


Shelly often works as a player coach, side-by-side with administrative and clinical staff as an experienced colleague. Staffs respond well when Shelly works with them on verbal skills, communication, conflict resolution and accountability.

Howard: It is a huge, huge honor today for me to podcast interviewing Shelly Ryan who works with my buddy, Bill Rossi, who I think is one of the most down to earth dental consultants out there. He has been crushing it in Minnesota for literally 30 years. We did a podcast interview on him. Shelly I really wanted to get you because you're a licensed dental assistant with over 30 years experience. You've worked with front desk, office management, treatment corners, training, consulting, dental speaking. You've been on sight with more than 250 dental practices. You speak nationally to dental teams, voted one of the top speakers at the Excellence in Dentistry Destin Seminar with my good buddy, Woody Oakes, who thinks you're a legend and Bill Rossi thinks you're a legend. 

The reason I wanted to get you on today is you're talking to thousands of dentists right now. I'm not aware … No one has ever e-mailed me that said, "I'm a big fan of your podcast. I'm a dental assistant." Occasionally I get a hygienist, maybe 10% in dental businesses. It's mostly all dentists that you're talking to right now and they're probably all mostly under 30 because old grandpas like me, all my friends don’t even know what a podcast is. Anytime someone e-mails me, I always reply to them, "Give me your demographics" and it's pretty much under 30. 

Dentists see everything from their perspective and all the older dentists all agree that if you're going to have a rocking hot successful dental career, it's all about developing a rocking hot team. Talk to the dentists. You've seen 250 practices. What do the dentists who are happy and their staff stays with them and they don’t quit every 2 years and they stay with that dentist for 10, 20, 30 years and their patients always keep coming back, what are those offices doing more of than the other end where the patients never come back, the staff doesn't stay more than 2 years, the dentist is miserable, he's putting all his money into his 401K because he wants to retire tomorrow and he's selling Amway on the side? What do you think makes a dental office more successful? 

Shelly: Well, we could keep it simple and say open communication but, boy, that’s a big topic all in itself. I think the newer grads coming out, they know dentistry. They know the clinical side of dentistry. I don’t know exactly what dental schools are teaching but to my knowledge when I talk to the new grads, they don’t get a lot of information about behavior, about communication, about the other side of dentistry outside of the clinical aspect. It's scary I think to a lot of them. I was just with a client last week in southern Minnesota. He has been out of dental school for about 8 months now. He is an associate, unfortunately, working alone in a practice as a satellite, a satellite practice. He doesn’t have a lot of guidance from the senior doctor, the owner doctor. He's in this practice. It's a strong practice and the staff has been there for quite some time. The staff is used to communication. They're used to talking with the patients. They're used to having fun with the patients. They're used to getting direction from the dentist. This dentist's style isn't that. His style is "I need to focus on the clinical side of dentistry". 

We took him from focusing on the dentistry to finding a balance with the behavior and the communication with the patients. Honestly, I don’t believe patients for the most part really care how good your margins are. I think they care about how they feel. They need to feel better when they leave your practice than when they walked in and I believe that can be done even if there are multiple clinical issues going on. 

I think the important thing is being able to communicate with your staff, having your systems in place, have a plan. I think a mission is important. What do you want? At Advanced Practice Management, me in general, I don’t care where I work, the focus isn't on a program. The focus is on what you want. What do you want? What's your vision? What do you want to see in your practice moving forward? What do you want your patients to feel? Do you want your staff long-term? Coming up with ideas that fit each individual practice or each individual dentist's style. 

Here's the key in my opinion, getting the team involved with understanding what that vision is and helping him see step by step what they can do and need to do in order to make that vision become a reality. Kind of broad, I think what I just said, but that’s the basics of it. I think finding that balance between clinical expertise and behavior management. 

Howard: I agree with you one million, trillion percent. I just think your damn cool, damn grounded, been around the block several times, a couple of decades, 250 practices. You even opened up with … The dentists call this the soft stuff. They don’t want to hear about it. They want to hear which burr to use, which implant to buy, how do you op tray a canal. They want all the monkey stuff that someday a droid will do. Right now we have a droid called a CAD/CAM that's making the crown. It's not a very big leap of the imagination; you don’t have to watch Star Wars too many times to know that that CAD/CAM machine someday will be a robot fixing the teeth. Then you're going to be stuck 100% with what the dentists call the soft stuff, the fluffy stuff, the stuff that doesn’t matter when in reality it's just everything that matters. 

Shelly: That’s right. 

Howard: You're talking to a bunch of dentists right now. Communication is everything. They’re technical brain because they only became a dentist because they got an A in calculus and think Sir Isaac Newton is their father. They're thinking, "Well what do you mean Shelly? Does that mean we should have a morning huddle?" They're technical people. Talk to them softly. How to do you communicate better with specifically an assistant, a receptionist, a front desk, a hygienist or do you, Shelly, do you see the more successful offices with the dentist just raises his hand and says, "Look, I suck at this. I'm going to get an office manager."?  A lot of them just say, "Oh that’s going to be by default the poor girl that married me" so now they drag in their wife who hates it, doesn’t want to be there, and is not the reason she married doc in the first place or her husband. Do you think the spouse should do it? Do you think more successful offices the dentists just delegate that to an office manager? Talk about how a dentist could be a better communicator with an assistant. Does this mean we go to happy hour with him at 5:00 or invite him to our Halloween party at our house? Talk more about that.

Shelly: We'll go backwards first. 

Howard: Don’t you love the way I ask 28 questions for one questions?

Shelly: It's kind of awesome. 

Howard: Most podcast interviewers are cheap. They just have one question out there. I give you a cafeteria style. I throw so many questions out there; you can just pick and choose. 

Shelly: That’s good. It gets my brain working, that’s for sure. I think, one, good question about having family members in the practice. I see it work both ways. I've seen everything from the dentist and/or his wife working together and unfortunately that turns into an affair with a staff member and, boom, somebody's out. I've seen it work perfectly, bringing in more new patients because they are a strong cohesive team. When people say to me, "Do you think it's a good idea to have a family member in the practice" … Oh, here's another side. Right now in rural Minnesota for example, people don’t want to live 70, 80, 90, 120 miles outside of a metropolitan area. These small town areas, quite honestly it's hard to, do I dare say this, to keep the wife happy in a small town or perhaps the husband happy employment-wise, etc. We see a lot of dentists what we call growing their own. I have a lot of practices that have the father or the mother with a daughter or son associate dentist in the practice and their whole plan of transition is allowing their son or daughter to take over the practice. 

I think it's okay for family members to work together in certain situations. I think there's strengths in different people whether you're a family member or not, maybe it is an office manager, maybe it's not the wife or the husband in the practice. I think regardless of who you have at your side, strong office manager, a good treatment coordinator, all of those things are important, but you still have to have a working basic knowledge and understanding of what's happening in your practice. I don’t know of a dentist who cares to know the exact system of past due collections, for example. That is the last thing they want to hear about or they want to know. They do need to know and understand, is there a system and is the system working. We use a lot of checklists more to help the dentist stay informed as to what's going on in the practice as much as it helps support the team in understanding what their direction is. I think systematic tracking and monitoring behavior helps drive revenue for sure but it is also provides a stable environment for the staff. It helps hold people accountable. 

Over and over and over again we hear "We talk and we talk and we talk but nothing every changes, Shelly." That’s when we decided, number one, you can't do everything at once. You have to take things incrementally. Do things in stages. Management is a process. One of the things that we do is I do a lot of brainstorming with my teams. I feel like if I can walk into a practice and I can say, "You should do this. You need to do that" no one will listen to me. If we brainstorm on a subject, it could be delivering adult fluoride for heaven sakes. Can you imagine if I walked into a practice, a very successful practice generally, and I said, "All right. You guys need to deliver more fluoride." If they weren't believing in what they're recommending, if it's not … How do I word this? Change is really a great thing when it's your idea. When someone else is telling you to make changes, it's very difficult. Brainstorming allows teams to be part of the solution. Does that make sense?

Howard: Absolutely. 

Shelly: We do a lot of brainstorming. Brainstorming helps us identify what is the mission, what are we shooting for. It helps the staff believe in … Let's use adult fluoride. I love that example. I believe in adult fluoride for numerous reasons but I can't make you believe in it because of what I believe in. Instead I ask you, "What situations or conditions in your mind would warrant the need for fluoride in an adult patient?" We have everyone on the team, administrative team, who maybe really don’t understand what the benefits of fluoride would or wouldn’t be, administrative, clinical, doctors, everyone is involved in the brainstorming. Through this brainstorming they come up with their own basis of why they want to implement this procedure, in this case procedure not system, but it could be a system as well. When we do that exercise, for example, we come up with a list of situations or conditions that might be present in a patient's mouth and that’s the cue for the hygienist or the assistant to help the patient based on their specific needs and belief of the practice as to why they might benefit from fluoride. 

Getting the teams involved in understanding what is it we're trying to accomplish, why do we want to accomplish it, and then step by step how are we going to do this. Every checklist … I love checklists because I think they're structured and we have maybe a dozen or more. We could create a checklist for everything. I love them because they not only hold us accountable to the system but the behavior side of the systems as well. In every single checklist that I develop or help my teams develop or we customize for them, there's role-playing involved. If we're talking about case acceptance, we role-play how are you committing a patient to care, how can we do better at this, what are the patient objections, how do we overcome them, how do we make sure that before we send a patient … I'm going all over the board with this. If we have a patient in the treatment room and we're going to send them up to the front after we presented their need for treatment to discuss the finances or meet with the treatment coordinator, are we sure that they are committed to that care before we send them to the front? 

One of the things that I hear doctors say all the time is, "Shelly, we're presenting the treatment in the back but it gets to the front and they're not closing on the sale." I have a little story about that if we have time for this. I can't remember who said this but I took it and made it my own so I completely stole. When it comes to a patient flow, for example, the clinical team thinks they're recommending treatment, they've told the patient what they need, they maybe asked a few questions, and then they send them up front and they expect the financial coordinator to flow based on money. Well if the patient isn’t committed to understanding why they need the dentistry, how it's going to benefit them, what the consequences are if they do nothing, then talking about money is really very, very difficult for the treatment. You can't close a case based on money alone in my opinion. 

Do we have time for me to tell you …?

Howard: You have all the time in the world. You have all the time in the world. This can be an all day podcast. I would never tell you I've heard enough. 

Shelly: All right. You maybe can tell me where this came from because you've talked to so many people. I like using the analogy of the wounded bear. I tell my staff in regards to this systematic flow, pretend that you are all one big Native American Indian group. I am talking 18th century Native American not casino Native American now. That’s not a blast on Native Americans. My kids are Native American. That being said, pretend you're all …

Howard: Isn't your name, Shelly, a Latin word for Pocahontas?

Shelly: I don’t know. Maybe. That could be. I like Pocahontas. I like that. You made me feel really good there, Howard.

Anyway, you're one big Indian tribe. Clinical team, you are the warriors in the Indian tribe. The warriors do what? What's the role of a warrior in the Indian tribe? What do you think the role of the warrior is?

Howard: Hunting. Hunting deer. 

Shelly: That’s right. They're hunting deer. They are hunters. The clinical team are the warriors. They are the hunters in the tribe. The administrative team, they are what I am going to label as the women in the tribe. What was the role of the women in the Indian tribe?

Howard: Domestic. Raising the kids and cooking and milling corn. 

Shelly: Pretty much everything else. Right. One of their main functions was to take care of whatever was brought back, skin it, prepare it, whatever animal they were hunting. In this analogy today warriors, clinical team, you are going hunting and you are hunting for bear. The bear illustrates the patient. We're hunting for bear. You all go out. You hunt. You see a bear. You track the bear. You do everything right. You all circle around the bear. Everything is perfect and, I don’t know, I guess you bow and arrow. You shoot the bear. You drag that bear back to the women. You lay the bear at the women's feet. This is the administrative team. The bear is the patient. You lay the bear at the women's feet. It should be taken care of. The bear should be dead. The warriors have done their part. 

There's still daylight so the warrior leaves. In this case the clinical team leaves and goes back to their patient because they are still busy. They leave the bear at the feet of the women in the tribe, the administrative team. The women begin doing their work. They start skinning the bear and low and behold, all of a sudden they realize, holy cow, this bear is not dead. This bear has only been wounded. They do as much as they can. They work with it. It's bloody. It's messy. They might even be able to kill the bear themselves, skin it, and keep going and continue with the process but it's difficult. If you have a wounded bear, it is very difficult to skin it. 

The moral of this story, I guess, is warriors before you bring the bear to the women, please make sure the bear is dead. In other words, make sure you've committed the patient to the care that you're recommending. Make sure that they see the value before you send them to the front desk to talk about the money. Money might be a barrier but it is not as big of a barrier as everyone seems to think. 

Howard: I think Disney should make a movie on this. I think it should be called wounded bear and be filmed in a dental office and I volunteer to be the bear. 

Shelly: Atta boy, atta boy. 

Howard: That’s a great example. That’s a very great example. Before I go to case presentation I just want to finish up on the fluoride. You've been in dentistry … How many years have you been working in dentistry?

Shelly: 30 years altogether. A little over 30 years altogether. 

Howard: 30 years. It's always a huge sign of intelligence when we're talking about family working in the office where the young minds everything is binomial, yes, no, up, down, left, right and you are smart enough to see it's a full spectrum. It sometimes works, sometimes doesn’t work. You've been in dentistry 30 years. Why are you a benefit of adult fluoride treatments and if the office does not do this, what do they usually bill for an adult fluoride treatment? About what percent of adult recall patients get an adult treatment? How much revenue does this add to the office? Finish that analogy. 

Shelly: I'm going to start with the revenue. Generally we're all using varnish at this point I think for the most part and varnish costs maybe $3.00 per application. 

Howard: What brand are you liking?

Shelly: You know, there's a new one out now. What is it called? I just heard about it a couple of days ago. One of my offices is using it. Clin-something. The product is better. It's clear. It's not as sticky. It's just as easy to apply. Oh shoot. I'll have to get that from my notes. I might know what that’s called. It's a newer product. Patients seem to appreciate it more. 

Howard: Do you know who makes it? 

Shelly: I can't remember. It's not 3M though. It came from … I just heard about it. I dictated it. I'll get my dictation and send it over to you. That being said, the cost of it to the practice is maybe $3.00 an application. The average practice right now according to our surveys and we survey Minnesota, South Dakota, North Dakota, Wisconsin, Iowa, the edges of those, about 3,000 dentists that we survey and the average fee is about $47.00. I honestly don’t agree with that fee not because I think it's not a good product but I think it's difficult for patients at this stage though we're getting better at it to see the value in a 30-second application of fluoride for $47.00. We kind of think along the McDonald theory that put it on your dollar menu, reduce your fee to something under $30.00 and you’re going to have more acceptance of that because of the questions that patients … They're not clear. Staff isn’t even clear on why fluoride might be of benefit to an adult. Sometimes reducing the fee … A high fee can be the barrier to the staff in presenting it. Reducing the fee can help your staff feel more comfortable presenting it. You're still getting a massive return on your investment. It's a 30-second application process. 

Howard: What do you think the fee should be?

Shelly: I think the fee should be $29.00.  

Howard: $29.00? 

Shelly: Uh-huh. I do. I think keep it under …

Howard: Even if it was $15.00 it would be an amazing deal because the fluoride varnish, the stickiness of the varnish the way it sticks to your teeth, it has an obvious impact on a DMFT rate, diseased, missing, fill teeth rate. It lowers the diseased, missing, fill teeth rate and with children it's a must. Your right. We have double standards in dentistry. We're more preventative with children and then for some reason we turn 18, we're less preventative, yet by 65 10% of Americans don’t have 1 tooth in their head, by 70 it's 20%. Both of those numbers again for Americans that have lost half their teeth. It doesn’t make sense. 

Shelly: I was in a practice a couple of years ago when, maybe it was 3-4 years ago, when we were just beginning to understand the benefits of fluoride for adults and I was observing. I heard the hygienist say to an 18-year-old young lady in the chair, "Well, the good news is you're 18 now so you don’t need fluoride anymore." It blew me away. I think even trying to reach us. 

Howard: We're just now getting into evidence-based dentistry. There are a lot of hardcore researchers who cannot show any reduction in diseased, missing, and fill teeth with 6-month cleanings but at 3-month cleanings it makes a huge impact. Then you've got to say, "Why do we clean them every 6 months?" because who created they hygiene department? Amos and Andy. The first toothpaste, brush your teeth with Ipana and see your dentist every 6 months. See your dentist twice a year. The insurance companies picked up on that first and so did dentists and now we're at 2015 and we're saying …

That reminds me of a story. I've got to tell you my story. It's not nearly as good as yours. A new couple gets married and it's Easter and they want to cook a ham. She calls her mom. "Mom, how do you cook a ham?" She says, "That’s so easy. Just cut off the end of the ham, put it in a pan, cover it with aluminum foil, blah, blah." She says, "Why do you cut off the end of the ham?" She goes, "I don’t know. That’s they way my mamma taught me." She calls her grandma. "Grandma, how do you cook a ham?" She goes, "Oh it's so easy. You cut off the ends of the ham, put it in a pan, cover it with aluminum foil." She goes, "Why do you cut off the ends of the ham?" She goes, "Oh that’s how my mamma taught me." She calls her grandma. "Grandma, how do you cook a ham?" She says, "Well you just put it in a pan and cover it with aluminum foil and cook it for 350." She goes, "Well the other two said, your daughter and granddaughter said you got to cut the ends off." She goes, "Oh I used to have to do that when I had a smaller pan but now I don’t have to do that anymore." 

So many thinks we think and believe and everything is just culturally handed down and there's no rhyme or reason to it. Adult fluoride treatment, what would be the financial impact for an average practice would you say if they started doing that?

Shelly: One of our goals is … Let's say we're beginning with a practice who isn't delivering fluoride to adults. I set their goal based on what their philosophy, their belief, their reasons of why patient's would benefit. Usually after this brainstorming session we come up with a list of 15, 16 reasons or situations or conditions that might be present and then I say to the staff, "What percent of your adult population do you think have one or more of these situations or conditions present in their mouth?" Almost every time they say, "Ooh, yeah, like 99% of them." Okay so when you see a patient with one or more of these conditions, that means it's time for us to start talking about fluoride. 

You think 99 to 100 percent of your patients might be able to benefit but what's real? Let's start with 30 percent. What if we can get 30 percent of our patients? What if we can deliver adult fluoride to 30 percent of our patients and believe in it and see a benefit from it? If I said, "All right then, starting tomorrow every single patient should have fluoride, shouldn’t they?" Well, yeah, maybe they should according to their belief system but it doesn’t happen that way. That’s why taking it is a process. Taking it in steps. Let's start with 30 percent as your goal. If you're charging $30.00 to 30 percent of your adult patients, your growth in hygiene production per visit, which is how I measure it, is going to increase by $10.00 a visit. Does that make sense?

Howard: Absolutely. $30.00 for 30 percent would be $10.00 a visit. You surveyed 3,000 dentists. What does the average hygienist of those 3,000 of dentists, what does the average hygienist make per hour and bill per hour and then what would be the net per hour?

Shelly: You asked what their wage is per hour? 

Howard: What would the average hygienist of these 3,000 dentists mostly in Minnesota, North and South Dakota, of these 3,000 dentists, what would the average dentist … What were the states you said? Minnesota, North and South Dakota …

Shelly: Iowa, Wisconsin. Mostly the edges of those but we go pretty deep actually into all of them now. 

Howard: Of those 3,000 dentists, what would you say the average hygienist is earning per hour? 

Shelly: $35.00.  

Howard: $35.00 an hour. Okay. 

Shelly: With some experience. 

Howard: Okay. What do you think the average hygienist does bill an hour? What do you think the average hygienist is billing an hour?  

Shelly: Of course that depends on the demographics. The fees are going to be higher than in the metro area than they are in a rural area for example. On average in the metro area hygienist production per visit, which is how I measure it because per hour there's just too many variables in measurement there. Per visit the average is probably running at about $130.00. Our clients, we shoot their average up to about $147.00. We want them producing or delivering care to the equivalent of $145.00 or so per patient visit. 

Howard: Explain the nuances between per hour and per patient visit. Why is per patient visit easier to measure than per hour? Explain the nuances there. My job is to try to guesstimate the questions of 7,000 people driving to work right now thinking what, you know. 

Shelly: Here's an exercise that I do that helps the team see. Number one, we're not just talking about money. Talking about production or money to a hygienist is like talking to a wall. They don’t want to hear it. They don’t want anything to do with it. When you can put it into a picture of, "Let's keep it simple. You see 300 patients each month in your hygiene department."

Howard: Is that one hygienist or two?

Shelly: It might be two, might be three, might be four. I don’t know. 

Howard: Sorry to interrupt you but of those 3,000 dentists what percent would have zero, one, two, or three or more hygienists per dentist?

Shelly: In general there's two hygienists. I believe this. Two hygiene columns will support one operative column in basic general dentistry but not a lot of specialty services being offered. It takes two hygiene to support one doctor. 

Howard: One doctor or one doctor's operatory? Are you saying two hygienists for one dentist or two hygienists for one dentists operatory of restorative fillings and crowns?

Shelly: I'm going to say two hygienists for one doctor, probably two columns, two operatories. Most of my practices work out of two operatories, most doctors do. They usually have two assistants. If you want to add … Boy this is variable. They all work differently. 

Howard: It is true. I said that back in 1987 that when I was setting up my office I studied everything. It seemed like the dentist had two hygienists and then two assistants working two chairs and then a fifth room for emergency overflow and then two front desk. They were just crushing it. It just seemed to be … The other thing, when two hygienists are trying to fill two doctor's chairs then you have so much fillings and crowns and all that that if you don’t want to do that molar endo, you refer them. You don’t want to pull that tooth, send it to an oral surgeon. You're so busy doing your comfort zone that you don’t ever have to sit there and say, "Well, I have nothing else to do so I'm going to try to retreat that molar endo" even though you don’t want to and you hate it and it's going to ruin your day. 

Shelly: Yep.  

Howard: Do you agree the ultimate model is two receptionist, two hygienists, two assistants, one dentist? Each hygienist has their own room, a dentist has two rooms, and then a fifth room emergency room overflow.

Shelly: I think that’s a good scenario and it can support a strong practice but I also think that there's room … If there's room to grow in a practice, I believe the strongest area of growth in a bread and butter general dentistry practice is going to come from your hygiene department. Yes, I think two columns support, two columns of hygiene, or two hygienists will support two columns of operative, the administrative side, boy, that really depends on what you're doing. I look at that completely different. You might have three administrative people and one of them might be a treatment coordinator. It would be worth it in my opinion to have a treatment coordinator depending on the skill level of the clinical staff. 

Howard: Do you like your treatment coordinators to have come out of dental assisting or a hygienist? I've seen some of the most amazing offices where the treatment coordinator is actually a hygienist so she's the go-to to numb. She totally understands the clinical. She makes sure the bear is completely killed. Whereas some of the treatment coordinators who come from the front office who've never even have seen or assisted during a root canal or extraction … Do you think a treatment coordinator should come from clinical?

Shelly: Absolutely. 

Howard: Absolutely. Yeah. I agree. How nice is it with expanded function where you're treatment coordinator is a hygienist and does your numbing. When you go to the doctor he says, "Okay, Howard. You need a flu shot." He didn’t give it to me. He tells me I need a flu shot, a tetanus shot, a vaccine, whatever the hell and leaves and then the nurse comes in and starts her vampire treatments. I think a hygienist is the best. Would you recommend a hygienist at $35.00 an hour? What would the average assistant make in that 3,000 person survey?

Shelly: You know, assistants are few and far between here right now. It is very difficult to find an assistant so that’s a good question. We're seeing the wages of assistants skyrocket. Remember 10, 15 years ago when hygienists were in demand and they went from a pay scale of $20.00, $22.00 up to $30.00, $35.00 and it pretty much held over the last 10, 15 years at that point. More graduates came up. The demand is less for them. Now the demand for assistants, at least in our area, is much stronger. You can't find one. Their wage scale is going up closer to the $25.00 mark directly out of school. If they have expanded functions, it can make a difference but the dentist has to allow the assistant to do her expanded functions in order to feel it's worth paying her for that. Does that make sense? For example, some of the expanded functions … I'm not talking about expanded functions as far as putting a temp on, taking an impression, things like that. I'm talking about restoring teeth. Not dental therapy level but the doctor cuts the tooth, the assistant can fill the tooth. There's room for a higher wage but we don’t see it that often actually utilizing those talents. I'm going to say the wage right now in Minnesota for an assistant is $25.00 and going up, $25.00 an hour and moving up. 

Howard: What do you think overall labor should be for a dental office? Of those 3,000 dental offices, what would labor cost be?

Shelly: You mean as far as a percentage of income?

Howard: Yeah, of revenue. That would be of revenue. Some dentists call that … I don’t care that you produced $1000.00 if you only collected $800.00 because you had to adjust off for the PPO is paying. We're talking revenue, dude. We're talking the dollars you collected not the fantasy unicorn dollars that you produced. Adjusted production. Of collected dollars of those 3,000 dental offices, what would you say average labor is and what would you like it to be?

Shelly: I'm going to say the average labor is about 30%. We like to see it at the … It would be awesome if we could see it at 25% to 26%. We don’t see that very often. Usually 27%, 28% is where it's sitting. Sometimes 30%, 31%. 

Howard: Talk about that number. The dentists out there, they get so much misinformation. They are a study club and the density next to him says, "Well my labor is only 22%". Then I go in there and I look at the numbers and he's not counting FICA matching, he's not counting uniforms. What do you put in that? You say it's normal you see 27%, 28%. You'd say often times 30%. You'd like it to be 25%, 26%. What does that number include?

Shelly: Staff salaries only. Straight staff salaries. There's no benefits. Nothing like that is included because the benefit structures vary so much in every practice and in every area. 

Howard: Does that include FICA matching, payroll taxes?

Shelly: Yes. 

Howard: So what did you say 30% was, the average?

Shelly: Unfortunately I'm going to say yeah. 

Howard: You'd like it to be 25% to 26%?

Shelly: I would love to see that. I think we've brought them down to 27%, 28%. That’s a more reasonable area. 

Howard: Would you also say … What's the easiest way to bring down staff labor? Trying to replace your dental assistant with a girl you met that lives in a box under the bridge, steal a Wal-Mart greeter, or increase your production?

Shelly: Increase your production. 

Howard: They turn down the most rocking hot talent because they're trying to save two bucks and that rocking hot talent would have increased your production and she actually would have been cheaper.  

Shelly: That's the treatment coordinator, right?

Howard: Yeah. They see it in professional sports. They're like, "Who's your favorite team?" I've never heard anyone say Green Bay from your area.  They always say the Arizona Cardinals.

Shelly: Oh, yeah. Right, right. 

Howard: No matter where the dentist lives, they always say the Arizona Cardinals. I'll say, "You know, Lawrence Fitzgerald, number 11, cost a chunk of change but he's making about two touchdowns a game. Why don’t they see the dental assistant and the treatment coordinator and the hygienist like is see Lawrence Fitzgerald?

Shelly: I don’t know. You want to know another question that I'm looking for this. I'm waiting for this to happen. I'm curious to hear what your thoughts are. You know how everything with the electronic health records and everyone is struggling so much with the technical challenges of digital charting and everything. Medical has scribes available to them. Now when you go see your physician, it's not just you, the physician, and the nurse. It's you, the physician, the nurse, and a scribe in there who does all their documentation of their notes. It's my understanding that they're paying these scribes anywhere from $13.00 to $15.00 an hour and one of the number one things that I hear from my teams is, "We don’t have time. It takes us time to document. I'm working through my lunches. I'm here late trying to get my documentation in." Do you think that we'll ever come to the point where we'll have a scribe in dentistry?

Howard: It very well could be and I think the oral transcription services that started with Siri and Google Search with voice, voice activation software … In fact, Ryan, what was the voice activation software you were looking at the other day?

Speaker 3: Transcribe Me … Oh no, Dragon. Dragon. 

Howard: Dragon and Transcribe Me. 

Speaker 3: Yeah.  

Howard: I think it's very close to being automated. We're doing that with our podcast transcripts. We've had a human do it for a long time. The problem is it takes them a month to do a transcript before we can load it up on Dental Town and when I do the transcribing orally to my iPhone notes, it rarely ever gets one word wrong. 

Shelly: Yeah. We're experimenting with Dragon Speak as well because after we see clients, we dictate and then we send it back to our secretaries, they type it up. We've been experimenting with it as well. I can't say we've had as much as you have. Maybe we need to look at our iPhones. 

Howard: I have a very limited vocabulary because I was born in a barn in Kansas. I'm not high class enough to be considered trailer trash. I would have to go to a cultural refinement school just to be consider trailer. Maybe the vocabulary … I've been told by a programmer that it actually has self reinforcing algorithms. The longer you use it, the better it gets. 

Shelly: Right. 

Howard: Is that how you understand it?

Speaker 3: Yeah. 

Howard: Yeah so I've been on my iPhone for a long time. I mean a long time. As I get older and blinder now I've got the 6-inch screen which is nice because now I'm not a … On the smaller screen, if I didn’t have my readers on, I can't do anything. Now with the 6-inch screen I can do it without my readers. I think it's because I've used it so long. Every time you use it, it gets better and better and better. I want to get a case presentation. You talked about that. You opened up a Pandora's Box. We both agree. 

My assistant Jan, she does all that. She's been with me 28 years or 29 years. She's coming up on 30. I promised her at 30 I'd put her out of her misery. I'd just take her to a vet and have her put down. She just has one more miserable year to go. She knows the clinical. She knows every way I think. When she's assisting me, sometimes I shoo away an instrument. She's handing me an instrument and I shoo her away. If that’s really the next instrument I need, she hits my hand with it. When she smacks my hand and it hurts, I always realize, "Okay, we've done this for 30 years. I know I need it next." The problem in my mind, I'm ADD thinking about the hygiene checker, I'm thinking the emergency room, I'm thinking about the last root canal and my mind is wondering and Jan's like, "No." It's just an amazing relationship. We could do these fillings blind because we've done them so many times. 

I'm looking at your case presentation checklist. By the way, I would give anything, I swear, Shelly, I will give you whatever you want. I wish you would start a thread on Dental Town with all of your checklists. I'm looking at several of them from your website right now. If you just posted those checklists … It'd have to be great marketing. I'm sure in those states somebody would want … I know Bill's going further and further out to further and further states but I'm looking at your case presentation checklist. The reason I want to bring that up is because I think successful people talk about the uncomfortable things. I know my homies. They didn't go to school eight years to sell dentistry and they're not a salesman. They are the mentality where, "I'm a doctor. You're not. I told you, you need this. If you have a question, you’re kind of not right in the head." 

Go over your case presentation acceptance checklist and please don’t use any four-letter profane words like sell. They would unsubscribe from my podcast if they heard that four-letter word.

Shelly: Right, exactly. 

Howard: Is the clinical team briefing the doctor at the evaluation consistently to include patient concerns, medical history, x-rays, perio evaluation, recare recommendation, clinical needs, enteral cameral pictures, carry view utilized. That’s a whole other conversation. Adult fluoride recommendations, role-playing the briefing, what is the hygienist. Talk about case presentation. What are the offices doing the best at case presentation and what are the ones that don’t have any production. Their overhead is really high because they're not selling and producing any dentistry. Do you think the number one variable is a treatment coordinator or not really? Is that something that some really successful dental offices do or would you say, "The bottom line is, I've seen 250 practices and there's million dollar practices and say this percent don’t have one." Of the million dollar practices, where they're collecting a million dollars, the doctor's taking home $300,000.00 or $400,000.000, what percent of them would have a treatment coordinator?

Shelly: 5%. 

Howard: 5%?

Shelly: 95% of my dental practices do not have what I call a full fledged treatment coordinator on board. They have variances of a treatment coordinator. They have pieces of a treatment coordinator but in most situations there isn't a person or an area where the patient can go and sit down and talk about the treatment, have it explained, help them see the value, help them understand the cost, help them see what type of benefits they night have available through their dental benefits or insurance if you want to call it that. I don’t see that as often as I would like. Most of the time what I do see is a financial coordinator who's trying to be a treatment coordinator but doesn’t have the skill or the knowledge. 

Howard: First of all, let's define the 5% that does it. What's the care? Why should a dentist chase and be this 5%? Do they produce and collect a lot more?

Shelly: I think those who have a treatment coordinator do produce and collect a lot more, absolutely. I think they're able to spend the time. I think the whole idea of behavior and managing a patient is allowing them the opportunity to get to the point where they have acceptance. You know about the stages of loss and …

Howard: The stages of what?

Shelly: The stages of loss. The stages of acceptance might be another phrase. We heard a speaker …

Howard: What is it? Denial, anger …

Shelly: Denial, anger, bargaining, depression, and acceptance. Those are the five stages that humans go through. 

Howard: Every time I look in the mirror, I go through all five stages in like three seconds. That’s when you know you're 53.

Shelly: Right? Oh, you're 53 now. You had a birthday. 

Howard: I did, I did. Continue I'm sorry to interrupt you with that horrible joke. 

Shelly: You can go through all of these stages in three seconds or 30 seconds, which is why in some situations a dentist can day to a patient who's been there a long time, they have the trust, they have the relationship base, and he can say, "Howard," or she can say, "Howard, you need a crown on this tooth and here's why" or "We need to restore this quadrant and here's why." In moments that patient is at acceptance because they've developed that relationship. In other situations, it could take a patient years before they come to the acceptance stage of understanding that, "You know what? I really do need to take care of this situation." Whether it be a filling, a quadrant of dentistry, whatever the situation might be. I think having team members that understand the base and that’s why I mean when I say let's get back to the basics. 

Understanding human behavior … If I have it my way, every dental professional would have a degree in psychology as well as a clinical degree because I think they're equally important. Understanding what makes a patient tick, where are they at in regarding to accepting. I, as a patient, could tell you, "Yep. I'll go ahead and schedule this" but if I don’t really believe in it, if I'm not at acceptance, if I'm still in bargaining or I'm still in denial for that matter, I'm going to call up and I'm going to cancel that appointment. I think it's important that we understand human behavior and I think a treatment coordinator gives the patient enough time to get through these stages in many situations. Not every time but you have a better chance of helping the patients get through these stages if you've got someone sitting there holding their hand, talking to them, helping them work through their objections than if we simply say, "Here's what you need. Here's why you need it. Let's bring you up to the front and they'll talk to you about the money."

Howard: Just yesterday our office time were kind of almost laughing and rolling our eyes about that because she was in with one person for two hours, two hours, for a $1000.00 treatment. I'm like, "Wow. Two hours for a $1000.00 treatment." This is a complicated … Humans are complicated and this is a complicated thing. Then when  you go look at divorces, they say a third are about money, a third are about sex, a third are about substance abuse and a lot of the case presentation is that raw button, money. I want to talk to you about money because, Shelly, you know in America 90% of homes and cars sold are finances and mortgaged. The average … 9 out of 10 homes are finances on a 30-year mortgage. Only 10% are bought in cash. 90% of cars are financed, four years, five years. I've seen six years. 

What percent should this treatment be financed? How much money are you looking at financing? Is Care Credit still the go-to financier of your 3,000 dentists? Talk about financing the treatment. Do you recommend in-house? Some people are having them sign 3 credit card statements so they don’t need you to come back. We're going to finance this in-house and you've already given permission. We're going to bill your credit card this much at today a third, thirty days a third, six days a third. Talk about financing because that’s a huge part of selling anything that costs over $1000.00 in America. Would you agree?

Shelly: Oh, absolutely. In fact, I do a four-hour seminar just on this topic, exactly this.

Howard: What would I have to give you to put that up on Dental Town?

Shelly: To put the seminar up or to put payment options up?

Howard: The four-hour seminar. 

Shelly: Well I'm having one in less than a month. Maybe we'll video tape it and send it to you. 

Howard: Can you? Can you do that? It's so important. When you look at the go-to list, there are a hundred sewing machine companies and Singer was the first to finance it and to this day it's the biggest brand sewing machine. It was the first installment credit. Henry Ford was the biggest car maker and then GM decided they were going to start financing their cars with GMAC Financing and they shut down Ford's Model T plan. Installment credit is one of the biggest issues. I'm talking to dentists who won't say the word sell and then you say you've got to sell it and finance it, not I'm somewhere between Satan, Lucifer, an Attila the Hun. They're looking at me like I'm from a different galaxy. If you've got a four-hour presentation on it, God dang, film it. I would send the camera crew there to film it myself. The reason it's important if no one calls 911 that a house is on fire and the dispatcher at 911 doesn’t tell the fire department then a fireman can't do his job. 

If somebody doesn’t sell the dentistry and collect the money then dentists can't lower the disease in our community. We can't have an impact on the diseased, missing, and filled teeth rate if we're not getting fluoride in the water and selling preventative dentistry, selling fluoride treatment. In order for us to be outstanding contributions to our society, we need someone to sell the damn dentistry and collect it to people who are going to spend all their money on bat-shit crazy stuff anyway. I always tell my staff, "They're going to max their credit card. Do you want them maxing it out at Wally World or on their teeth?" I think it's a victory every time a doctor or a health care provider … I'd rather you spend your money with a membership to the gym than spend it every Monday night bowling in a bowling alley drinking two pitchers of beer and wings. Do you know anybody who has any money left over at the end of the month? 

Shelly: Well, I don’t … I …

Howard: For 330 million Americans, what percent of them spend all their money every month?

Shelly: True. According to the American Dental Association, and I don’t think this has changed in at least 12 years, probably longer, almost 8 out of 10 people have less than $500.00 in their checking account to spend, let's say have less than $500.00 available in their checking account to spend on dentistry. 

Howard: You're talking about all the people paying alimony?

Shelly: Yeah, yes. Yes, sir. That’s correct. If we think of it that way, that 8 out of 10 people … When I'm in a staff meeting or at a seminar I'll say, "Look around you. 8 out of 10 of you have less than $500.00 in your checking account right now to spend in this case on dentistry." How do we get people to spend $5,000.00, $10,000.00, $30,000.00 on their dentistry? How do we get them to see the value? They might have less than $500.00 in the their checking account to spend but you're absolutely right. They'll still go out and buy a new car or they'll still go out and, I don’t know, buy shoes or jewelry or gamble or whatever the case may be. It is a good question. I think that because of that and understanding that, such a small portion of the population can really afford to go all in to dentistry and what we might want to see happen with all of  our patients. 

We have to have various payment options available. Payment options that fit the needs of our patients. Some of those, depending on the practice, some of those might be considered somewhat risky depending on your patient base and who you offer those to. For example, I do recommend that … I kind of go along with my teams the almost, some, and then whatever we can do kind of route. When we invite patients to pay in full at the time of service, that’s the first option. I do recommend that you have perhaps … Still bout half of the practices have a 5% savings, we call it a bookkeeping savings, for patients who pay at the time of service. That used to be 75%, 80%. That’s dropped down. I think people have removed that. I'll say if you want to offer a savings for payment on the day of service, I think it encourages patients to pay versus getting a statement especially if you're transitioning them. If you've had a practice for 20 years and you've always billed your patients, having a savings to pay at the time of service is a good way to transition them into understanding we want you to pay at the time of service. 

Let's say it's the opposite practice where, you know what, most of our patients are paying at the time of service. Why are we giving them a savings for work that we're doing and we deserve to be paid for? Then I'll say, "Let's look at another type of statement. You can transition to another option that might be you receive a 5% or 7%." I have an office in St. Cloud, Minnesota that offers a 10% savings for patient's who prepay on the day of diagnosis. If you're in my office and you schedule for your treatment that we've recommended and you prepay and schedule that appointment, you get 10% off your services. What that does for the practice, why it's beneficial is the patient perceives a massive savings. Second they've scheduled their appointment. The appointment is paid for. Patient's generally unless it's an extreme emergency, they don’t cancel appointments that are paid for. The 10% that you might be giving away in a savings, actually is a certain sense an insurance policy in one way. 

The other thing about that is we live in the land of ice and snow and PPOs. The average PPO discount in Minnesota is 15% if not more. We're happy as heck to bring in a patient with let's say Delta Dental. We would want those patients all day long. We hesitate and we'll take a 15% to 20% adjustment on that patient and welcome them in. We have a cash patient and we could in essence save 5% to 10% just by offering them a savings. I'm not saying given the farm away but sometimes having a savings as an instrument to encourage patients to pay, and I like the prepay option because it helps support and guarantee that their going to keep their appointments and you're still not adjusting as much as if they were a patient who had dental insurance or a PPO in our area. I think that having a prepay option is a great advantage. It's a win-win for the patient and the practice. 

I do think that yes, I do think outside financing has a place in dentistry still. I happen to love Care Credit and here's why: Not because their acceptance rate is awesome. I think that has definitely dipped in the last five, eight years. 

Howard: It crashed in 2008 when the economy crashed but I think it's back to it's highlights now that it's 2015. 

Shelly: You know what? I wonder if the success of that program would have crashed if we would have all really thought about and used the options available within it. One of the things I like about Care Credit … I don’t endorse any of them. I think any financing partner that you can have or outside financing source that you can direct the patient to to help them move forward with their treatment is a great idea. What I do like about Care Credit is their cosign option. 

Howard: Their what?

Shelly: Their cosign option. 

Howard: Are you saying coast line?

Shelly: No co-sign.

Howard: Oh cosign option. 

Shelly: You can get a cosigner. 

Howard: You sound like a Canadian who's been drinking. 

Shelly: I was just going to say, "Is my Minnesota accent poking out now." 

Howard: Am I interviewing the lead star from Fargo?

Shelly: Yeah, right. It's so funny. When I go south and I go to southern areas like Mississippi or even Dallas for that matter and I talk, I love that southern accent. I would do anything to be able to comfortably say you all in stead of you guys. It's so much sexier. When I go there, they say to me, "Oh we love your accent" and I'm like, "I don’t know what you're talking about."

Howard: When you listen to a southern belle accent, the reason it's so charming is because you're not thinking of your accent of stuffing a lady in a wood chipper in Fargo with a leg sticking out. That’s why we love that southern accent. It's the farthest away from Fargo we can find. 

Shelly: That may be, that may be. 

Howard: Did you ever see that movie?

Shelly: Oh yeah, of course. 

Howard: Oh my God. 

Shelly: Now there's a series on it. I haven't seen that. 

Howard: Is there really? If you're under 30 and never heard of Fargo, it's a classic from back in the day. God, that’s a great movie. Anyway, continue. 

Shelly: All right. Where was I?

Howard: We were taking patients who didn’t pay their bills and putting them in a wood chipper. 

Shelly: Yeah, that’s right. Payment options, that’s where we were. I think that the cosign option through Care Credit is under utilized. I think it's a great option. We offer interest free financing to a patient and a patient says, "I don’t have any credit, that’s not going to work for me." Maybe at the moment it's not the immediate option. We keep going through our payment options. By the time you get the bottom of them, and I'll list a few for you in a moment, you and the patient both realize that, "You know what? None of these payment options are going to work for me. I want my treatment. I want it soon. Paying $50.00 a month." 

I don’t recommend that we allow a payment plan with a patient, even a long-term patient, to go more than three months. Never under any circumstance should you finance a patient longer than six months simply because they'll be back in the practice in six months and chances are there's the possibility that they'll need things. We don’t want to carry that out. I do think it's okay … I'm going to come back to Care Credit in a second. I do think it's okay in certain practices, and I get the logic behind this, back when I started consulting I had practices where their aged receivables, the money owed to them was two, maybe three months' worth of production and they were fine with that because it gave them security. In their minds it meant, "I still have income coming in every month for the next two to three months."

Howard: I know, I know. Yeah, you sure as hell wouldn’t want to already have it in your savings account. You just want to have that safety net of it slowly trickling in. You wouldn’t want to have it already in the bank. 

Shelly: That’s just crazy. I know. That used to be … I still have practices that think that way. Depending on your demographics and your patient base, extending in-house financing cam be acceptable but in my opinion it should be a back pocket option and it should only be offered to select patients. The benefit of that is patient retention. They've been good for it all this time, what are the chances, it's a risk but what are the chances they're going to default after 30 years? Pretty slim. I think there's a place for it but I don’t recommend it for a new patient, for example. 

Now getting back to Care Credit. We get to the very bottom. The patient can't do anything. They can pay $50.00 a month. That’s all they can do. They want the treatment done. It's a $2,000.00 treatment plan and they want the treatment done within a month or a couple of weeks. One of the things that I work with my teams on is the administrative team should never have to say the word no to a patient ever. The patient says, "I can pay $50.00 a month." One of the options would then be, "Mrs. Patient, I'm good with that. We can do that. We have other patients who do that. Here's how it works: You give us $50.00 today, next week, pay us every month, every week, whatever works for you and once your balance accrues that $2,000.00 we can get the work started. That’s going to take a little while, as you can see. Another option for you might be to consider looking at our financing partner, who's Care Credit and they have a cosign option. While we're working on building your balance up, I want you to take this information. Talk to your friends, talk to your family. See if anyone might be willing to cosign on this loan basically. 

Howard: Oh so you're not having the dental office cosign it. 

Shelly: No, uh-uh, uh-uh. 

Howard: Okay. At first I was wondering …

Shelly: The patient has the opportunity even if they don’t qualify to find someone to help them qualify. If they can find a cosigner they can not only get the dentistry done that they need but they can also start repairing their credit. I like Care Credit for that reason. You know another company that I'm really liking right now and we're just getting into it? The Lending Club. 

Howard: The what?

Shelly: The Lending Club.

Howard: The lending club? Really? 

Shelly: They have specific dental financing that they're … They're working with everything right now. Their terms are broad. They have low interest. They have long-term, they have short-term loans. I think there are hundreds of financing options out there for dental practices. 

Howard: How does a dentist find that? Is it or is it

Shelly: and I think if you backslash dental you'll even come right into the dental page. 

Howard: Is that related to the Lending Tree or not really?

Shelly: I don’t know. You know what? As I think about it, their colors are similar. 

Howard: I imagine financing with a name that starts with Lending you'd have to be really …

Shelly: Lending Club itself is different than maybe the Lending Tree. I don’t know. They're probably the same concept. The idea is they find lenders who are willing to take your credit risk. Maybe Tree means this, I don’t know. I never researched that. The Club side of the Lending Club means it's not one back who's financing you. They're putting it out over hundreds of different lenders who based on whatever criteria and how bad your credit or how good your credit is will offer to finance you. 

Howard: I don’t know if I like these guys. I'm on their site right now. and they do dentistry, hair, and fertility. I have no hair and a vasectomy. I'm down to one out of three. I'm almost dead.  

Shelly: I didn’t know they did hair. That’s funny. 

Howard: Do you think I should call them up and say, "How much for me to get new plugs?" 

Shelly: I'd be curious to hear that conversation. 

Howard: Let me back up. On your survey of 3,000, how many of them do you think are using Care Credit and how many of them are using this new Lending Club. This is a hell of a perk. I was not aware of this. Financing is everything and thank you for turning me on to the Lending Club Corporation. 

Shelly: There's Lending Club and then there's other forms of financing or groups or companies out there who will help patients with the financing. It might not be necessarily on the basis of a loan. You've heard of Dental Bank, right?

Howard: No. 

Shelly: The company that will for a fee and it's minimal. I can't remember what it is exactly. For a fee they will handle the payments of patients. There's risk involved but basically they take over collecting patient checks or automatically debiting patient accounts for their monthly payments but there's recourse. If the patient doesn't pay, the dentist is still stuck with the debt. Depending on your practice, I think there's room for all different types of financing. I lean more toward those who there's no recourse to the dentist. 

Howard: Okay. Explain recourse. A lot of these kids listening, they're seniors in dental school. They've been out a couple of years. They don’t even know what the term non recourse means. Please explain it.

Shelly: If I'm a patient and I agree to make monthly payments to you via check and my car falls apart and I need new tires and a new engine and I don’t pay you, well you're stuck with my debt. There are companies out there who will agree to handle the financing as far as collecting the payment such as, let's say, Dental Bank is one. I'm not saying they're not a good company. In certain situations I see them work very, very well. They say that they only have 1% default. I'm not saying they're bad but I am saying the recourse comes in with if the patient decides they're not going to pay and the dentist is stuck with the debt, the dentist is stuck with it. I'm not sure how to explain recourse. If you go to a lending company such as Care Credit, for example, and they're financing it, if the patient defaults on that agreement you've already been paid. The Care Credit is now the one who is stuck with the debt. Recourse means, in my mind, means you're not stuck at the end. If the patient changes their mind and doesn't pay you, you're not stuck with that. You've already been paid. It might have cost 10%, 12% but you're not stuck with it if the patient chooses to not follow through. Can you explain it better? I don’t think I do better.

Howard: No. I think that’s great. One of my friends started Ugly Duckling Car Lot. He'll finance to anybody because he's got a boy that when you stop making your payments …

Shelly: Vito. 

Howard: He's got another key to the car. Yeah, Vito. He's very transparent about it. Somebody's going to come get his car back. He'll finance it to anybody. By the way, he tells me that people don’t miss their car payment and cell phone payment. Who cares if you didn’t pay your dentist? I'm not going to lose my phone or my car. If you don’t make you're payment, he'll just come and get his car back. If you change the locks … Dentistry, you do dentistry in someone's mouth and they don’t pay, you can't go get the dentistry back. You just can't. What's the point of financing it if they don’t pay? The finance company comes back and makes you pay for it. You should have just in-house financed it. Another thing I want to talk about Care Credit, which I thought is amazing. I assume they still do this. I haven’t don’t this in my office for it might be a year or two. Do you know that Care Credit can come in and show your staff your financing history compared to other offices in your neighborhood? So many staff believe, "Well we're in Parsons, Kansas and nobody does that here" and then they come in and say, "Here's 20 dental offices in your county and the average one is doing six cases a month at this dollar amount and you're not doing any." They look at that data and they're like, "Oh my God." 

It's why I started Dental Town. Ever dentist I meet that’s in a medical dental building with eight other dentists, he's never gone to lunch or breakfast or dinner with any of the other dentists one time in ten years. It's like, "Are you kidding me?" They're all painfully shy introverts. They grew up in libraries. How do you go meet another who's next door and you both went to dental school and you're both the same age and you both have 98% of your life in common. Again, some of the most successful dentists I know, they've just been knocking on … I never met a specialist in Arizona where if I called him up or knocked on their door unannounced, they'd just let you in. They let you watch them all day. 

I've got to tell you my funny story. When I first opened my practice in 1987 the most famous practice management leader consultant whatever was right in my back yard, Omar Reed. He had this massively expensive course. You remember Omar Reed?

Shelly: Yes. 

Howard: I couldn't have paid for that course. If I had that kind of money, I would have upgraded my $600.00 car. You know what I mean? I just didn’t have the money. I thought in my head … You know what I thought to myself? I said, "Well I'm 24 and I don’t know how old he is but he's got to be 20 years old than me. I bet if I showed up at his deal and said, 'I don’t have the money to go to your course. Someday it's my goal but I just wanted to come over here and shake your hand.'." That’s what I did. He says, "Oh I know you don’t have the money. Just come in. Make yourself at home." I got the whole damn seminar for free because I had the balls to just walk out there and say, "Man, I'd give anything to go this course. I just don’t have a dime." He smiled. People who love to share want to share more and they don’t even care that one guy's in the clueless and not paying money. 

Shelly: Right. I think part of what you're saying is get out there. Get out there, dentists. Get out there. Start networking. I think … What is that saying? The strongest form of flattery is mirroring. What's that? What am I …? 

Howard: Imitation. 

Shelly: Imitation, thank you. 

Howard: The most sincere form of flattery is imitation and there's no geniuses. They just stand on the shoulders of everybody. Everybody will sit there and … Albert Einstein's the smartest mathematician that ever lived. I'm pretty sure if Newton didn't figure out calculus, he wouldn’t have been that smart. It just goes on and on down to the guy from the Middle East who invented zero. The Romans didn’t even have zero. How far would we have got without zero until someone in the Middle East figured that one out? If some other dentist has already figured out, and usually it's the ones that are just older than you. Obviously, a lot of you ask me, "How did you learn that?" "Dude. If you've been doing something 30 years, you better figure some things out." If you didn’t figure anything out in 30 years, you probably need to tell a neurologist. 

I'm at an hour and 14 minutes with you so I've got to wrap this up. 

Shelly: Already?

Howard: I could talk to you for 40 days and 40 nights. Shelly, I think your grounded. I think you're down to earth. I think what you and Bill and your team has is … A lot of these consultants it's a lot of big and wiz and cosmetic dentists and you've got to just be some tall, dark, and handsome cosmetic legend in Beverly Hills and you guys are just in the Midwest and you're just taking averages practices and making them a lot better with just simple, down-home stuff. I can't get enough of you guys at Advanced Practice Management. If someone were to have you come in their office of get your consulting, how would they contact you?

Shelly: You can e-mail us at

Howard: The APM stands for Advanced Practice Management. your headquarters, is it still at Minneapolis-St. Paul?

Shelly: Yeah, Minneapolis-St. Paul area yeah. 

Howard: The reason I got real familiar is my oldest sister went straight into the nunnery out of high school and it's a cloistered Carmelite monastery. You know where Lake Elmo is?  

Shelly: Yes. 

Howard: She's in Lake Elmo. To visit her tax deductible I have to spend 4 hours and 1 minute somewhere so I always fly down there I either go to 3M from 8:00 to 12:01 and stand in their organic chem department or I go to Patterson and have the back of the day with Pete Brouchette or whatever or go see Bill Rossi because it's just that I've got to do 4 hours and 1 minute somewhere every time I visit my sister just to make the IRS happy. 

Shelly: We would love to spend a half hour with you just picking your brain, listening to you. It would be great fun. 

Howard: I've talked to Bill. I've talked to you, the dental assistant. You've got hygienists that work for you. You've got a lot of people. I want to interview every one of them. I also think that the best marketing that you guys could do is start putting some courses up. Shelly, if you just got on Dental Town and started a thread and all you did was post all your forms, which every one of them is amazing, that would be the best marketing you guys could do. Consider that versus buying a full page ad in Dental Town Magazine, which costs actually one kidney. It costs os much money because it's a 125,000 circulation. When you have an ad, that’s 125,000 pieces of paper printed for color, postage, mailing lists. You could be posting these things for free on Dental Town. 

You know what no one's ever done ever, online continuing education is exploding. All these major dental meetings, their attendance has been drifting down. Meanwhile University of Phoenix Online is exploding and now all the colleges are doing online. Everything is moving online because it's faster, easier, lower cost and it's higher quality because if you miss something … If you got to go the bathroom, you just pause it. You don’t have to go to the bathroom while you're missing the lecture keep going. If you watch a lecture and you think, "Oh, I wish my assistant would have heard this." Well then your assistant can watch it.  

Of the 350 classes we've put up, they've been viewed over half a million times but most people approach everything as a one-hour course. I just don’t know if you can take a kid out of baby dental school and in one hour teach him practice management. I think this: I think it's very counter-intuitive. When you put up a whole curriculum … No one's done a curriculum practice management. I think it would take 25 hours just to teach them A to Z. Most consultants won't do it because they'll say, "If I do that, then they won't need me." Number one, you can sell that so you can make money doing that. 

Number two is this, I believe that all the consultants getting the most business … You know when you go to restaurant, you're looking at a menu. Do you want steak? Do you want chicken? Do you want lasagna? Don’t want to buy a mystery consultant. When they see everything that you're going to do and now they can do it all themselves, what they realize is that I ain't ever going to get it done. I ain't going to implement it. I'm going to actually pay you. I know you sell lasagna and you don’t sell chicken. I'm going to pay Advanced Practice Management to come in and deliver lasagna and I want you guys to deliver. The consultants that are the most transparent and tell you everything you're going to do, eliminates all the fear so that my homies say, "God that would be nice if our office did all that. I'm going to write you a check."

Shelly: Yeah, yeah. You know, one of the things about us is we are as far from a canned program as you could possibly get. We tailor everything to the practice based on the practice philosophy. Because we're on-site with hundreds of practices every single day, every single year, we see what's really working and what doesn’t work so we're able to tailor it. The interesting thing about what you said earlier, putting your stuff out there and being afraid that people won't hire you or won't work with you, I find that hilarious because one of the things that we know, we have clients, 250, 300 offices that we work with on an ongoing basis. The average client stays anywhere from 12 to 14 years with us. We see them it could be twice a month for a half a day. Everything we do is usually a half a day in length. 

We've found that that’s about as much information as anyone can or wants to hear from us. We do it in stages. We might meet with you twice a month. We might meet with you once a quarter. Some of our clients we meet with once a year. I think that it's the ongoing support and management that’s a process. You can have all of my checklists. I will put them all out there for you. I'll put anything you want out there. If it's going to help practices understand and start to see the value of the behavior side of dentistry, not just the clinical side. I will give them any information they want and help them interpret it. No problem. 

Howard: You're an assistant by background. I'm a dentist. There's hygienists, front desk. Who's the craziest one in the office?

Shelly: Usually the dentist. 

Howard: Oh, I thought since I was a dentist, we'd blame it on the hygienist. You're saying it's the dentist. 

Shelly: They're crazy but, yeah, it's the dentist. 

Howard: You know what the interview I want the most is that maybe one of my homies out there listening can hook me up. Consultants are talking and they're going in there and trying to build the barn. I want to find a therapist, a psychologist, who's worked with a lot of dental clients to first, let's talk about the head. Reframe stuff. How you see this person needs to be reframed this way. How you see life needs to be … I've always believed that if a psychologist, a therapist, got them seeing more normally, more functionally, less dysfunctionally … Do you know of any psychologists or therapists that have worked with your 3,000 dentists?

Shelly: You know, there is a psychologist up in Duluth. I heard her speak at the Minnesota Dental Association meeting, oh boy, it was probably 4 or 5 years ago. I will do some checking. I can't remember her name. Dr. Bruce Christopherson, Christophersen. I can't remember. He's spoken for us a few times. He is a psychologist. He is awesome. You've probably heard him. He's got tapes out there. He does speaking specifically for dentistry and other areas. He's good. He makes it fun. He gets it. 

Howard: Do you know him?

Shelly: He's spoken for us a couple …

Howard: I sent him an e-mail and he never replied. Maybe he didn’t know who I am or whatever or have this podcast. Maybe he's not aware of it. Can you e-mail both of those people and cc me, 

Shelly: Absolutely. 

Howard: When you say you heard them speak, that’s really code for that's your personal therapist?

Shelly: Yeah. I could use one as my personal therapist. 

Howard: Shelly, it's been an hour. I think I've gone the longest with you of anybody I've podcast. An hour and 23 minutes. Thanks for all that you do for dentistry. I'm your biggest fan. Your clients are so lucky. What states will you go to, to one of my listeners out there?

Shelly: What states? We go anywhere. We primarily focus on the upper Midwest, Minnesota area. We have clients all over the country. 

Howard: Last question is, seriously, have you ever stuck a dentist in a wood chipper?

Shelly: No. I wanted to. 

Howard: Okay, Shelly. Again, I hope our listeners can log onto Dental Town. We have 51 forms, root canals, fillings, crowns; one of them is practice management. It would just be so rocking hot cool if you logged on and started posting all your checklists because they are just amazing.  

Shelly: I'll do that. Absolutely. 

Howard: Thanks Shelly.

Shelly: Thank you. 

Howard: Tell my bald buddy Bill I said hello. 

Shelly: I will do that. He says hello as well.

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