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VIDEO - DUwHF #924 - Neil Gajjar
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AUDIO - DUwHF #924 - Neil Gajjar
Dr. Gajjar lectures on managing medical emergencies in the dental office, has been a lecturer of oral pathology and clinical instructor at the Canadian Academy of Dental Hygiene, and has served as a clinical instructor in the Oral Diagnosis and Emergency clinics at the University of Toronto, Faculty of Dentistry. Dr. Gajjar is a Master of the Academy of General Dentistry, a Fellow of the Academy of Dentistry International, a Fellow of the Pierre Fauchard Academy and a Fellow of the International College of Dentists. He has served on the Disciplines Committee, QA Committee, as Councilor, and currently serves on the PLP Committee of the Royal College of Dental Surgeons of Ontario. He is a Clinical Examiner for the NDEB, President-Elect of the AGD, is certified in IV sedation and serves as the official dentist for the Miss India Canada Pageant and Suhaag Publication Group.
HOWARD: It is just a huge honor for me today to be podcast interviewing Neil J. Ghajjar, DDS M.A.G.D., all the way from Masagua, Ontario Canada. Dr. Ghajjar lectures on managing medical emergencies in the dental office, has been a lecturer of oral pathology and clinical instructor at the Canadian Academy of Dental Hygiene, and has served as a clinical instructor in the oral diagnosis and emergency clinics at the University of Toronto Faculty of Dentistry. Dr. Ghajjar is a master of the Academy of General Dentistry, a fellow of the Academy of Dentistry International, a fellow of the Pierre Fauchard Academy and a Fellow of the International College of Dentists. He has served on the discipline's committee, QA, committee as counselor and currently serves on the PLP committee of the Reall College of Dental Surgeons of Ontario. He is a clinical examiner for the NDEB, president-elect of the AGD, is certified in IV sedation and serves as the official dentist for the Miss India-Canada Pageant and Suhaag publication group. Neil it is just a huge honor for you to come on the show today. How are you doing?
NEIL: I'm doing great and it's my honor and pleasure to be here, Howard, thank you so much.
HOWARD: So that bottom line is, you've been practicing almost 20 years, podcasters tend to be younger than me and you. I always tell them and I'm still telling them, “if you're out there, email me: email@example.com and tell me your name and how old you are and what you think of the show, or who you want to listen to.” And I'm shocked that 25% of the people are still in dental school. There's even a bunch of pre-dental and undergrad, but the majority are all under 30. Probably only once a week or once a month, some guy’ll say, “Dude, I'm as old as you. I'm 55 years old.” But what advice would you give these young kids today? Because they're kinda saying: “Oh Howard and Neil, you graduated in the golden years, and you didn't have any student loans, and now we're coming out of school with $350,000 of student loans, and there's corporate dentistry and insurance has switched from Indemnity to PPO.” What do you say to the young kids coming out of school today? Do you think they made a good decision going into dentistry?
NEIL: Oh absolutely. You know what, up until a few years ago we were number two behind vets as the most profitable and most likely to succeed. We’ve surpassed that now. We are the number one profession out there. It's harder to get into dental school than it is into medicine.
And I think for those those kids that are in dental school and those that are thinking of applying, this is a phenomenal field. It's a field that you're not limited to practicing one specific thing. You have a whole fortitude of things that you can practice. You can choose what you like and what you don't like, that's why we have specialists. And it's a challenge every day and it's a lifelong learning experience. Howard, I commend you on what you've done. You've taken what used to be getting together and talking about things, and learning from older people who have been in practice, learning from their mistakes so that we don’t make the same mistakes, and you’ve allowed that to happen from your living room, from your washroom, from the kitchen, from an airplane. There’s no better learning than learning from somebody else and especially somebody else's mistakes, where somebody else has positive effects that they gotten out of dentistry. So kudos to you Howard for what you’ve done.
HOWARD: Well, the one thing I've noticed in my 30 years, is the people who seem to be fulfilled and happy and paid back all their student loans and crushed it, always had the most continuing education.
Howard: Like your fellowship (ineligible 04:05) and I started thinking about this show. First, in 2004, I started saying, “let's do online CE.” because a lot of people are married, they got kids, they can't fly all around the country. So online CE just seemed faster, easier, higher quality, lower price. And then I thought, “my gosh, they're in a small town in Oklahoma and they're study clubhouse, one speaker a month and it's usually one of the five specialists in the county. My gosh, so I thought what would be really cool is to go get the greatest dentist I can find and do a podcast so they can listen to that once-a-month study club on the way to work. And then they can listen to another once-a-month study club on the way home from work. And in a small town in Oklahoma, they're never gonna get Neil Ghajjar to come in all the way from Canada to speak, and now they get to hear you speak. But you mentioned learning, what was going on in your mind to make you commit to getting, not only your FAGD, but to go onto your MAGD? First explain what it is, cause the kids in dental school might not know what that means. So talk about what FAGD and MAGD mean, and why did it mean so much to you to commit so much time, resources and money to achieve that.
NEIL: Well initially when I started off, I was a CE junkie. I love CE, strictly because not only if you go to an implant course or an endo course, what you learn specifically regarding those procedures, how you can be more efficient at those procedures, how you can recognize early failures, and know when to refer and know when you're over your head. But more so than that, it's the small pearls that you learn from being in a room with other dentists and other speakers. Perfect example: a couple weeks ago we were in Chicago at a meeting and one of the new dentists that were starting off an office had a question of whether he should buy a Panorex. And my answer to him is: “you'd be crazy not to buy.” It's expensive and what about my return? I'm gonna to be paying out more debt. Panorex is a gold mine. It's literally a machine to put the patient in, and like an ATM, it spits out money. Not to say that it's all about money, it is good ROI and it is something that every dentist should have in their office, specifically because of the diagnostic information that comes out of it. Just a couple months ago in our office, we found an Ameloblastoma. On top of that, one of our orthodontist on staff here, diagnosed on an 8-year-old juvenile arthritis by degeneration of the conducts.
A $60 pan is worth its weight in gold at that point from patient health and treatment. So not only is it a good thing to have for a dentist, it's a great thing to have for the patient. And as such, that dentist walked away thinking that, “you know what? This is one thing I should invest in.” I think back to the fact that this profession is so great. There are companies out there paying eleven times EBITDA for a dental office, and then you hear people talking about, “Well you know what, I'm gonna sell and I'm gonna get into real-estate, and I'm gonna buy some apartments and rent them out.” Every business has its problems, but this is the most profitable business out there. With more money, there's always more stress. But hopefully you will love this profession and you love what you do and then there's no stress associated with it. So I would encourage everybody to concentrate on what they’ve been trained to do and do it well.
HOWARD: Okay, my job is to ask the questions that I think they're thinking right now, and I know you just said EBITDA, and that flew over a lot of heads. EBITDA: earnings before interest, taxes, depreciation, amortization. That means: say your business is at a dollar and you made 10 cents. Now you still would have to have depreciation, interest, taxes, amortization. But that's true, and a lot of dentists are crying and whining that the average dentist in America only makes $175,000 a year. What percent of the United States and Canada, what percent of the people would just think making $175,000 a year was mind-boggling.
NEIL: I think a big chunk of it.
HOWARD: Oh yeah.
NIEL: And I think we take it for granted.
HOWARD: Oh wow. 95% would trade for that any day,
HOWARD: And usually the guys doing that have three day weekends.
NEIL: That’s right.
HOWARD: To make a $100,000 a year usually gotta be a workaholic salesman working twelve hours a day seven days a week. But you're absolutely right about the CE junkies. The CE junkies always seem to do the best.
NEIL: Yeah. Because they do more procedures. And this is a field where when you move your hands, you make money. And the more you moving your hands, the more money you're making.
HOWARD: I want to ask you a big controversial thing about the AGD.
HOWARD: So, this young kid goes and takes an endo course and thinks, “my gosh, that was really cool. I want to try that.” And the next patient comes in and needs a root canal on a second molar, and she's like, “I'm really motivated. I want to tackle that.” But then her endodontist making her feel bad and say, “well, you should put the patient first. And I'm an endodontist and I should do that second molar and you should not do that, that is over your head.” So the bottom line is, the endodontist, were they born with a hundred second molars under their belt? Did a endodontist ever do their first, second molar? How do you justify the ethics of the really motivated who says, “well I know it's impacted wisdom teeth. I really want to try to do it myself.” And then the associate in the same clinic saying, “Oh come on, you can't pull that. You need to refer that over to Neil. He's been doing this for 20 years.” So how do you reconcile the ethics of that situation of wanting to try something that's probably over your head and referring?
NEIL: You know Howard, it's called practicing dentistry for a reason. And that's what we're doing, we're practicing every day. Even though we're trained to do the simplest filling, we learn something different every day. We learn a different way of doing it, we learn an easier, more efficient way of doing it. Working on kids, we learn different ways of doing it. When you go and do a course, your level of education, awareness, understanding becomes higher. And as such, you should have the confidence to tackle something. I'm not saying tackle something you think that’s way beyond your scope. Take baby steps. Learn, gain confidence. You'll be surprised. When implants first came out, “oh, you can't do thes, you can't do these.” Who's knocking in the majority of implants right now? It's general dentists.
Things are going to change down the road, And it's our job as dentists to stay current with continuing education, to learn new techniques. That's what we're trained to do. To learn new techniques and deliver them to our patients. And yes, there is a need for specialists, but that doesn't mean every single extraction has to be referred out to a oral surgeon.
That's not justice to a patient either, to be sedated, to pay extra for the higher level of training that a general dentist can potentially do. And so there is a lot of ethical questions. And if you're in a small town where it's gonna take four hours to fly out to see a specialist, what do you do when your patient comes to you and says, “Doc I can't afford to see a specialist. I know you told me, I want you to take the best attempt, otherwise that tooth is going to be extracted.” What do you do Howard? What's the best thing for the patient?
HOWARD: So what are you most passionate about today? What are you out there lecturing on? What makes you wake up and want to run twenty red lights on the way to work?
NEIL: Especially here in Canada, the practice of dentistry has become very competitive, especially in large cities. There's a dentist on all four corners of every intersection. And that interests me. And on top of that, you have turf wars. The endodontist thinks that they should be placing implants because the implant looks at the root. The periodontist thinks they need to place the implants because it’s in the gums. The surgeons think that they need to do it because it’s drilling into bone. The prosthodontist thinks it's load bearing so now they need now full control over it. And then the general dentist is there thinking, “you know what, we do all of these things, so we’ll take care of everything in-house.”
It's what differentiates one practice over another. Why is there a line-up outside Practice A, and nobody's being seen at Practice B? These are the things that motivate me. I've taken a number of courses that you’ve promoted. I signed up for a Jay Geier series for instance. And we’ve learned an incredible amount of information, just from recording the phone calls from the front desk. We have a receptionist pick up the call and say, “hey, somebody goes, do you have an appointment for a cleaning today?” “No, not today,” and hang up the phone. No callback information, no contact information. Make room for the patients. So be it if a hygienist has to stay an extra hour at the end of the day.
These are the things. I see offices out there where I'm calling my friends and nobody's picking up the phone because everybody's on lunch from twelve to one. Have one person out there answering the phones. You're losing patients before they even come in the door. So small things like that. And I have a passion for telling people what they can do better. What we've done wrong, what we've learned from it, and how potentially it will help you. And that's my drive. My drive is to make dentistry better, for both dentists and patients.
HOWARD: So you're talking about Jay Geier of the Scheduling Institute, and he has been doing it about 20 years in Atlanta and now he has an Institute in Phoenix right here in my backyard. What I liked the most about that FAGD is, when I was a young baby dentist, I got out of school at 24 and I signed up for that only because I thought the best role-model dentists that I had met, they all had their MAGDs. So I said okay, I'm going to be like them. They force you to take these courses in like 16 different areas. And I was arguing and saying, “well, I don't want to take classes in implants and ortho cause I don't do that.” And these older people say, “Yeah, but you need to learn that.” And I said, well it's a waste of time to learn that if I didn't do that. But they were wiser than me and I was humble, so I did it. And the funniest thing about the implant deal is I was so mad because I had to take all these hours and the only way I could… I found this course, I don't know if you ever heard of this guy called Carl Misch?
HOWARD: And I could go to his institute and knock out all of my requirements. So that's the only reason I signed up for it. I went out there and my god, it was love at first sight. I fell in love with Carl in like 8 seconds. I told people, it was like I discovered this new continent called Africa or Asia by being forced to do that.
And the other thing is business. I'm trying to lead these dentists in the business cause the scheduling institute. They don't realize that three people have to call your office before your receptionist can convert one to come in. Well hell, that's a huge funnel. Your practice could be three times bigger if she could convert them all to come in. But dentists they don't usually like to think about that but that's schedulinginstitute.com, and I was even bad with that. My dentist buddy that I met at Creighton University in 1981 was a dentist across the street from me (inaudalbe: 00:16:39). He told me for five, six years, “Dude, you got to go to the schedule institute.” And finally he said, “if you go, I'll go with you. I've been doing it.” So I went down there and that's where I met Jay Geier and that just changed our whole practice. The guy who is doing the best root canal doesn't necessarily have the best, busiest office.
NEIL: It’s what patients think of you. They don't know the technical aspect of dentistry. They know you. Did you hurt them? Did you care about them? Did you take care of them? That’s the bottom line. It's bedside manner, chairside manner.
HOWARD: Yeah, no doubt. So what are you lecturing there? What are you lecturing on these days?
NEIL: So I do medical emergencies in the dental office. I do CPR training. And as well, we do wellness for the offices up here because that's the requirement by health and safety and all dental staff need to be trained in it, so I concentrate on the kind of bread and butter things that dentists need.
They don't want to go to long, extended courses and make it applicable to dental offices. So when lecturing, we go on a lot of the sides and speak about things like, “not everybody needs to take a lunch from twelve to one. If you don’t have a pan, get a pan. If you're not involved in the AGB, get involved in the AGB. Increase your knowledge on a broad spectrum of things.” Like you said, the fellowship is basically you have to take so many hours of lecture in so many disciplines for a total of five-hundred hours. On top of that you have to take an exam. And then after that, you can become a master of the academy which is another six-hundred hours and a big chunk of those are in hands-on participation courses; so you actually get your fingers wet and actually do live treatments on patients and mannequins and models. Having a masters is definitely setting yourself aside from the crowd. You’re doing a lot more and your understanding a lot more. Even if you're not doing a lot more, at least you're giving your patients more options.
HOWARD: You lecture about something that is, to me, is actually frightening. You lecture on medical emergencies, and you're certified in IV sedation, and that is the one thing that, going 30 years ago I just wouldn't do because it seemed like whenever dentistry made the news, somebody died. And if they died, it was usually related to IV sedation, and I used to always think to myself, “I can do a crown, and maybe worst case scenario it doesn't fit. I could do a filling maybe worst case scenario, it’s sensitive. But gosh darn, I still won't do IV sedation.” So, what do you think of dentists doing IV sedation, and how does that tie into your medical emergency training? And would you recommend some young baby, twenty-five-year old who just got out of dental kindergarten, do you recommend that she should learn IV sedation? Is this something you think should be a goal for her or not?
NEIL: I think any education is good education, and the fact that if you learn IV sedation, even if you choose not to practice IV sedation; you can practice oral sedation, because you have a higher level of training, and that will help you with oral sedation- mild to moderate sedation. Nitrous Oxide, you've learned pretty much everything less than the general anesthesia aspect of it. And it's that training that hopefully will prevent any medical emergency from even arising. And so I think even if you practice or don't practice, it's good training to have. The problem is not the actual IV sedation, but the dosages, the multiple drugs that are given. In Canada, in Ontario specifically, we're limited to giving one drug for IV sedation and typically that’s Versed (Midazolam).
In certain U.S. states, you start adding multiple drugs to the formula. And that's sometimes when you get into problems. I know there's a lot of changes, and there have been a lot of changes, in what's required for monitoring and IV sedation which is a good thing. But more so than anything, it's controlling what drug and how much of it you give.
Touch wood, local anesthetic, Versed, is a phenomenally safe drug with a huge therapeutic window. But like anything if you abuse it, then you find yourself in trouble. So there’s a time and place for it. Is it applicable to kids? That's when you start changing the dynamics and you have to be very careful. You should have more training before you start taking on sedation routes for kids. Because people think that kids are a small adult, but they are not a smaller adult, their physiology is completely different, and as such they need to be treated differently. When an adult starts crashing they would thrive to live and they'll come back; when the child starts crashing, when that pulse oximeter hits 90, you're in trouble. You've got to recognize that and you better be ready to treat it and know what needs to be done. It is more challenging.
HOWARD: I think one of the most interesting things is I like to really, really study the only three corporate dental chains on Earth that are publicly traded, cause that's a very sophisticated game and there are none in the United States or Canada. There's only two in Australia, 1300Smiles and, is it Dental Pacific Smiles? Pacific Smiles Group in Australia and 1300Smiles. And then what's the one in Singapore, HM, H&M? Q&M. What I found entirely fascinating about them, is in order to get through the investment community and Wall Street and all those people, they're not allowed to do IV sedation on patients under twelve or over sixty-five, because when they look at the paradigm risk; you just were talking about pediatric dentists work where they don't have the lung reserve capacity that you know a twenty-one year old would have. So their lawyer said, “no, you can't do under twelve or over sixty-five.” But did you just say that in Canada, when dentists do IV sedation, they’re are only allowed to use one drug and that's Versed?
NEIL: Typically one drug is what you're allowed, typically the drug of choice is Versed, and that’s for a general practitioner. We also have a specialty of dental anesthesiologists, they are not limited in the in the drugs of choice.
HOWARD: What about oral surgeons and periodontists?
NEIL: They about oral surgeons, is they're not limited in how much drugs they can drop or the number of drugs that they qualify to use.
HOWARD: So the only one drug at a time is only for general dentists, and the specialists and dental anesthesiologists can do whatever they want?
NEIL: Dental anesthesiologists and oral surgeons, yes.
HOWARD: Oh, just dental anesthesiologists and oral surgeons? So not periodontists?
NEIL: Not periodontists.
Howard: Wow. And so, to you, what is the pro and con versus- me, if I want it, I will just have a dentist anesthesiologist come in my office; versus these kids listening to you today saying: “learn it yourself.” What would your advice be on that?
NEIL: Well, we do have a dental anesthesiologist that comes to our office and that's predominantly to treat kids. It's much safer for them to be under general anesthesia with an anesthesiologist, and in Canada, like I said, we have a dental anesthesiologist, that's a specialty and we're lucky enough to have a dental anesthesiologist come sedate kids while we treat our pediatric patients. To those that are looking at IV sedation- it's a fantastic tool to learn. Whether you will practice it and how much you’ll practice it, that it's up to the individual operator. But I'll tell you one thing, when I did the IV sedation course at the University of Georgia Medical School, the one thing I learned more than IV sedation was extraction of complicated wisdom teeth. And when I came out of that two-week course, I was pretty much extracting 98% of the wisdom teeth that were in my office because I’ve seen it, I had the confidence and I learned it. So, sometimes when you go in for a course and you go in for a specific modality, you end up learning something completely different. So while IV sedation was great, and while I do have an anesthesiologist that comes to the office now and takes care of the kids, and very rarely actually practiced on adults because of that fact. What I learned from it ended up turning it’s ROI multiple times because of the fact that we do so many extractions.
HOWARD: And that is what is so great about joining an AGD, is that you're always going to be a summary of the five people you spend the most time with. So if you're out there golfing on weekends with three dentists who flippin' hate dentistry, that's going to drag you down.
And I thought the coolest thing about the AGD, is that every time in Phoenix I went to an AGD course, it is the same people. And you're right, you could be listening to a course on red while the guy next you is saying, “my god have you seen blue. You got to see, you gotta do this.” But you were just always hanging out with people who had a positive attitude. They say the most valuable real-estate in the world is the six inches that lives between your ears. And if the guy sitting on each side of you is whispering the hottest stuff into your hottest real-estate, you're just more fired up, you know, hire on attitude, train for skill. And I thought the best thing about the AGD was the social side of it. Just running with people who were going for it. I remember when I was learning implants and my friend was already doing all on four and I'm like, “damn, I'm a year older than him, I'm baby stepping into an implant and he's doing it all on four. You just really realize how much you could go. Besides Versed, what would be the next most common one-drug use at a time?
NEIL: For oral surgeons it's typically Propofol, but for general dentist, in lieu of Versed, it's Fentanyl.
HOWARD: It’s what?
HOWARD: Oh Fentanyl. And that's the most abused drug, Oxycontin and fentanyl, that's crazy. I always thought that was weird that Michael Jack..., of all the drugs in the world, that Michael Jackson got addicted to propofol, isn't that kind of bizarre?
HOWARD: I mean, that’s just bizarre. And a big shout out: yesterday we lost Tom Petty that was so sad. So he went into cardiac arrest. When you lecture on medical emergencies, what's the low hanging fruit to talk about on medical emergencies? What do you think is the biggest things they should think about.
NEIL: Most of all it's getting good medical. There's always doubts about whether a procedure can be done because the patients on blood thinners and so on and so forth, those are typically the questions. And you know what? So be it. To have a good INR of 3.5, you go ahead, you do the extraction, and you run into a situation the patient’s not bleeding. We as dentists sometimes panic and that's the biggest thing. And rightfully so.
Usually never happens to us and when it does, we kind of freak out. We put the gauze in the patient, and then 30 seconds go by, lift it up, and, oh, it's still bleeding. Put the gauze in there, wait another minute to lift it up. Just put the gauze in there, put it under pressure, leave it for five to ten minutes. Don't touch it.
It's the panic situation. We're trained to do the procedures. We're trained to handle medical emergencies. Here's the biggest thing that dentists, and I never, never understood this: We give the most injections of any profession out there, and when it comes to dropping epinephrine into somebody, all of the sudden we panic because it's outside the mouth. “Where am I gonna do, how do I deliver this, I’m going to inject somebody in their arm or somewhere else?”
If you feel safe in somebody’s mouth, then jab that needle in somebody's tongue. If that's where you feel comfortable, then that's where you feel comfortable. But that's the biggest hurdle when we’re teaching people. We see, “well, I've never given an injection outside the mouth.” It's harder to give one inside the mouth. And so I think that's when you're building confidence and you're telling people, “okay, its epinephrine, nobody’s allergic to this, you're not gonna kill anybody with it. Go ahead.” Worst case scenario, the chances of it interfering negatively, ie..- raising up the blood pressure and somebody who's about to stroke out. Fair enough. But for nine out of ten emergencies you're gonna be safe giving them epinephrine. Likewise, oxygen. The only time you're not gonna give it is when somebody has COPD, where their drive for breathing is based on the carbon dioxide level in their blood, in their lungs. So, apart from the small exceptions to the rule, and that's we want to kind of teach, is the exceptions, but for everything else- go the standard. And have cue cards ready. I don't know why we think that we need to have everything memorized. If you have anaphylactic shock, have a cue card ready that has one, two, three, four, five, six steps on it. So when it does happen, you open up your medical kit, and you got the card in front of, you just run through the steps.
Pilots fly planes every day, they have a checklist, and we’re expected to know everything by heart? No, nobody expects it. By all means, simplify your life as much as you can. And these are things when you can tell dentists and they say, “oh, I didn't know you can do that.” You can. And just making life easier, and hopefully we deliver that message when we go out and teach.
HOWARD: It's funny you nailed it on the head when you talked about pilots, because if pilots had a 99.99% success rate, four major airlines a day would crash in the United States. They have to have ninety-nine, point, then six nines to have their safety record. They all work from list, and they have a list for everything. And you go into a dental office and they have five operatories, and there's something different in every drawer of every operatory, unlike United, where they standardize operations. You watch a dentist do a routine filling, and the dental assistant has to get up and leave the room twice, and then they have a medical emergency and they don't even know where the box is, or what's going on and who's supposed to do what. And if dentists would steal all the best ideas from the Fortune 500, make every operatory a Boeing 737, like Southwest Airlines, they’re the only airline where they only fly one airplane. Make every drawer the same, standardize everything, and every time the assistant leaves the room, you call the office manager in the room and you write it up. You say, “okay, I'm doing a root canal like I always do, and she had to leave the room.” And then the office manager finds out, “well we only have one of these.” Okay, well we have eight operatories. So if that's a problem buy eight. Because my costs are the docs 35%, the staff twenty-five, the lab bill nine, the supplies six, the facility five. Why did I have to stop my operation to go get some slow-speed because someone else use that an hour ago? And then you go do a hygiene check, and Neil's in there and he has just a little bitty M0 on number three. And you say, “Hey Neil, you're a busy guy, do you just wanna do it now?” And then you say, “yeah, let's just do it right now.” But the hygienist says, “oh, well you have to, you have to leave my room and you have to go to another room because this is my room and I don't have what you need in here.” It's like, “no,no, no, no, no, every room’s the same. You go start in the next room.” And nine times out of ten the hygienists say, “but this is my room, and I can’t leave my room;” and you're like, “are you kidding me? Are we patient-centric or dental-centric.” Crazy, crazy, crazy. So you also talk about marketing. What interests you in marketing?
NEIL: When we started 20 years ago, the marketing was Yellow Pages. You had to have an ad in there, and that's how people would find you and look you up and call you and get an appointment.
Well, no disrespect to Yellow Pages, but Yellow Pages is straight to the mailbox, it’s a blue box, there is no need for it. And there's no need for Yellow Pages online either because everybody's doing Google searches. If not doing Google searches, then doing searches on rateMD or Facebook or other types of social media. So the dynamics have changed on how people are finding you (ineligible 34:36) and you want to make sure that your presence on there is mobile friendly. You want to make sure that you have the right information on your site and on your Google listing and everything else, so when somebody is standing outside their door looking for a dentist, they're not pointed down the street to somebody else.
And in fact, if you want to capitalize on that, that there are somebody elses down the street, they’re pointed towards you and not the towards the one that's closer. So, we try to keep up with that. We try to advocate the dentist with what's worked for us, what hasn't worked for us. TV was big at one time and now we're finding a full 360°, that radio is incredible. People, like you said earlier about the podcast, people are spending a lot more time in their car and what are they listening to? They are listening to the radio. And then you hear, when their spots go on the radio, then all of a sudden their phone starts to ring because we have tracking numbers associated with that specific ad. And that's another thing that we do, specific tracking numbers for every ad we run. So if we do something in a magazine, in a bridal magazine, or city magazine, we know that that phone call came from that ad. And then we can kind of cater our advertising to go towards the more beneficial ones for our office. And we found that radio is very successful. Same reason people want podcasts on their ride home. The dynamic has changed. People thought print matter was completely out the door, and it was for a while, but now you're bombarded with so many emails and stuff, that sometimes something sitting on your desk does catch your attention. So, we personalize those with birthday cards, and anniversary cards, or you're getting, “congratulations, your son graduated from school,” just to stay in people's face because this is a business of repetition.
You don't have to tell people that you need a recall appointment, sometimes seeing a birthday card on your desk or seeing a, “congratulations because your son finished university.” “Oh, such a nice guy, let me go, it's been a while since I've seen him, I think I need to make an appointment.” And small things that are thinking different and out of the box are what's working now.
HOWARD: I went to lunch a while back with one of my lawyer buddies and he's complaining about how marketing is going down, down, down, and he's got the back cover of the Yellow Pages, he's got billboards, he's got TV, he's got radio, he's got all this stuff, but he's obsessed with his eight-hundred number and he just doesn't get it. And it's like, “okay, so when someone calls your eight-hundred number, how do you know they came from your billboard, the back of the phone book, a TV, a radio, a direct mail?”
And he goes, “but everybody knows that number.” I'm like, “dude, yeah everybody whose dad was a Tyrannosaurus Rex and their mom was a Brontosaurus, but that aint how it works anymore.” I mean the number one search on Google now is “near me”. So no matter what they want: dentist near me, attorney near me, personal injury attorney near me, and they're not doing the one-eight-hundred number.
NEIL: No. And the sad thing about marketing is that 50% works. The sad thing is, is that you don't know which 50% works.
HOWARD: That's so funny, I just told Ryan that quote this morning. That was from the father of advertising. What was that guy's name? He was he was my idol back in the day. Father Ogilvy. What was his first name? David Ogilvy. David MacKenzie Ogilvy, and that was his famous quote he says, “half of my marketing works perfect, the other half doesn't work. But I never know which half is working.” And that's why everybody is pulling out of all the traditional print, because they can't track it. But when you put an ad on Google or Facebook or on your Web site and they click that, you have a receipt. And a lot of times the young marketer says, “well, I tried a Google ad and it didn't work. I tried a Facebook ad and it didn't work. I put up a website, it didn't work.” Maybe you know you should tinker with it? I mean if you put a Google ad, it doesn't work, maybe your ads don't work. Maybe it's your price, maybe it's your loca..., maybe there's something with that ad. And then the other thing Ogilvy taught me so well was that he said, “the number one marketing mistake is for someone to change a well-working ad.”
And I'll never forget it. I learned that and the next thing I knew I was talking to this dentist and he felt bad because he said, “I love to do implants and I have this little dollar bill size ad in the weekly paper that comes to my small town and it just says: dental implants 999.” And he says, “you know that damn ad gets me one to two patients a week. But I feel stupid because I've had the same damn ad for like 15 years.” I'm like, “dude, rule number one: you put a little ad in there and you get two new patients a week who want implants? Do not touch that ad.” Rule number one. But humans have a need to always want to tinker something. I tell these young dentists, they'll say, “well do you think I should switch from polyether to polyvinyl, or polyether to oral scanning,” and the first question I want to know is, is something broke? If its not broke .....Dentistry, there’s so many things you have to learn, the last thing you should start doing is changing everything that ain't broke. You know what I mean?
NEIL: Yeah. I agree with your point. I’ve run the same ad for like 10 years and one of the marketing guys have come up to me and said, “Well you know what? That ad, after a certain period of time, becomes part of the furniture and people start ignoring it.” But it's on the front page, on the top right-hand corner of that newspaper, and it still generates patients based on my tracking number, and I refuse to change it. It's working. How much better is it gonna work?
HOWARD: Right. And then what happens if you have it and then it doesn't work. You also talk about starting up, what do you like to talk about when you talk about starting up?
NEIL: I think with the prices, the way dental offices are being sold and the exorbitant amount of dollars that are being asked...We started from scratch and it is a learning curve, there is no cash flow from day one. But I think the profession is good enough and if you have enough confidence in you, then start from scratch. The savings are huge. You build an office that's catered to you, to how you want to treat patients, to how you want to staff it. You're not inheriting anything bad or anything negative. I think, you know what, when you're ready to make that leap, by all means make it. Don't be afraid of it. You are in a good profession, you will do well. And then small things, don't blow your brains out making an office like the Taj Mahal. You're going to intimidate patients the moment they walk in the door like, how expensive is this guy. Now again, it depends on your environment. If you're in Dubai and you’re dealing with actors and actresses and seven figure salaries, then by all means. But if you're dealing with bread and butter patients and that's what your backyard is, and it is my backyard, then you know what? You have to make sure that your office is welcoming and approachable to them. We have dentists up here that have rainforests in their office. And they have problems of frogs taking off on them. Again, if that's your patient base, then by all means, but be conscious of the fact, it has to be a warm and welcoming environment.
And again, when it comes to spending money on equipment, take a look. Sometimes it's worth spending that money. A pan will pay for itself in under two years. What better piece of equipment can you have in your office and a better service for your patients. People get carried away, let me buy a CEREC and this and that. Start with the basics, make sure you capitalize on that and then when you see the need and you have the patient flow to actually sell additional treatments, then by all means work out the return on investment, and then if it's something that's right for you, it's right for you and your office.
HOWARD: You said buy a pan. How much about is a pan, a pano?
NEIL: A panorex is about eighty-thousand Canadian, so what’s that? About sixty-thousand US?
HOWARD: Okay, so then the same question, what if they're asking you, you're saying, recommending a pano, eighty-thousand Canadian, sixty-thousand US; What about even more expensive? A CBCT?
NEIL: And again, a CBCT has its place. Are you going to subject every patient to the level of radiation that a CBCT gives? Do you have the training to read it, to make sure you don't miss anything? Sometimes the liabilities that come with having far more diagnostic equipment than potentially we're trained to do. And if you're trained to do it, by all means, another good investment. Radiologists do extremely well with the CBCT units. And again, if you feel comfortable, and that's your forté, then absolutely, there's definitely a return on that. Specifically I don't know the return on a CBCT, but I'm sure it's good because I think a CBCT out here, for eight centimeters, is about $250, $220. So the return is there and the CBCT is what, about two-hundred thousand Canadian, hundred and fifty US? Is that correct Howard?
HOWARD: Yeah. So here's a big deal when we were talking to the kids, they say, “okay, I came out with like $250,000-$350,000 of students loan. Two-hundred and fifty to three hundred, you see it all day long. They got married, had kids in school they could be four-hundred. If they went to a specialty school and became an endodontist, periodontist, pediatric dentist, you see them come out with $500,000 in student loans. And they see these CBCTs for one-fifty, your point about that, but the next one is the chairside milling that's another $150,000 deal. So I know they're wondering, “okay Neil Ghajjar, you got your MAGD, do you do chairside milling or do you use a dental lab?”
NEIL: I use a dental lab. I don't have a milling machine in my office. And for me, the economics just doesn't make sense. I can get a full-seat crown out and back in my office for $120, $140. It just makes sense for me to prep the tooth, temporize it, bring the patient back and see if the crown… When it doesn't fit, so be it, which happens one out of fifty times. Core impression or core pick up or whatever it may be, but the numbers don't make sense. I think the way a milling machine would work, in my opinion for whatever that's worth, is that the block costs you, I think, twenty bucks, the machine is about two-hundred thousand Canadian or two-twenty Canadian, or whatever it may be. If I were to have that machine, I would literally put up signs around town and say crowns for $250, and just mill-out patients. Volume. I think if you have volume then that machine makes sense. I think if you're still charging what you're charging for a crown and expectations are high, people want anteriors, people want aesthetics and so on and so forth. I think those machines still sometimes fall short of that. And as such, it wasn't something that would work in my office. Not to say that it doesn't work other offices.
HOWARD: When you talk about chairside milling, you said CEREC machine, by name, and that's owned by Dentsply Sirona, what did you think yesterday when the Chief-executive...
NEIL: Oh, resigned?
HOWARD: Yeah, The chief executive Jeffrey Slovan, executive chairman Brent Weiss and Chief Operating Officer Christopher Clark all resigned. What did you make of that?
NEIL: I don't know, but it seems a little beyond coincidence.
HOWARD: You know what I thought of it? You know what the first thing I thought: you could talk about anything right now? So if I called up Neil and said, “Hey Neil, what do you want to talk about?” And you say, “My God is your wife driving you crazy, or you have marriage ...” I know that was the issue. When a advertiser says, “there's two scoops of raisins in every box.” You know they don't have any raisins. When you look at car advertisements from cars from Japan and Germany, they never talk about a warranty, and bumper to bumper warranty, cause their cars are made right. But whenever an American’s trying to sell you a Ford or a Chevy or Chrysler, “And we have a hundred thousand mile warranty, we’ll cover anything.” So whatever they say, they're selling their weakest spot. And the press release is pretty interesting, and it says, “Monday, sweeping leadership changes. Chief Executive Jeffrey Slovan, executive chairman Brent Weiss and Chief Operating Officer Chris Clark have all resigned. The dental product maker said in a statement that the resignations were not related to any issues or disagreements regarding the company's financial disclosures, accounting policies and practices.” So what does that mean? That's the only thing it's regarding. They didn't say it was because these guys are Americans, and that the Germans wanted to try their style of man…, they could have talked about… If they said “this has nothing to do with the culture of German businesses or American business”, you know it would be that. If they said none of these three men have been charged with sexual harassment lawsuits, it would okay, it would be that. Whatever the hell they say it's not, that's what it is. That's how monkeys work. Humans are nothing more than wild, savage Homo Sapiens, and they're so damn predictable. Just like when you're grandaugh… I got a grandson- when you see someone go out in the backyard and they leave the backdoor open, you see your grandson sit up and look at that open door, you know what he's thinking, “oh my god, that door's always closed. I wonder what it leads to.” I mean you can see him thinking outside their brain, and someone better shut that damn door. Somebody did something, I assume, with everything they said it has nothing to do with.... That's why we call it dentistry uncensored, because if every person that's his story, another person says: “that guy is an idiot.” But, so you also talk about organized dentistry and volunteering. What would you like to tell the millennials about organized dentistry and volunteering? Cause a lot of them say, “Neil, I have $300,000 student loans, I don't want to join the AGD or the American Dental Association or the Canadian Dental Ass... I'd rather take that money and spend it on something else. What do you say about organized dentistry and volunteering?
NEIL: First thing, I wanted to address is that student debt thing, and I think, I know it's a high student debt, but don't forget that we're not the only profession, because when we go to lobby for student debt in Washington on behalf of the students, we've come to realize that it's not only dentists and dental students that have this extraordinary amount of debt. There are lawyers out there. There's medical practitioners out there. There's the whole spectrum of professions that have a large amount of student debt. And I think the big education part here is, guys remember- you are in the number one profession out there. So I know it's a huge debt. Your programs in the United States are phenomenal in the sense that your government will give you loans without a credit check. You will get the loans required to go to school. And on top of that, you technically don’t have to pay, you can pay back a portion of what you make. So if you're making a smaller percentage than the regular dentist, then your payback is a percentage of what you're making. And so you can still live, and function.
And on top of that your government has a 20-year forgiveness program, in which you could technically, you ask for forgiveness of debt after 20 years and just pay the tax liability of it. In the United States, we do have a good program for debt. And one thing I do want to tell students is that don't let it consume you. There's many programs out there that are going to help you get through it and the profession itself will help you get through it. But with that said, to these students and new Millennials coming out, one of the biggest things is get involved, get active. You'll meet great guys like yourself Howard, or other AGD members who have taken tons of continuing education, will tell you what courses are good, what courses are potential courses that you know what, you won't get any decent takeaway messages, which are very rare. I think anytime you sit with a group of dentists you do learn something.
But at the same time, you'll get to learn from each other. Like I said, a course maybe on implants, but you may learn something about marketing, you may learn something about not putting an ad in the Yellow Pages or spending money on radio and so on and so forth, what to look for, how to track it. There’s so many things that come out of taking part in continuing education and being a part of AGD. And giving back to the community, giving back to the profession, helping dentists, teaching them, making them better at what they do.
Getting together and venting, that my friend is the biggest, biggest benefit of being involved with a group of dentists. It's good to know that, you know what, when that patient comes in yelling and you're always putting on your fireman's suit, putting out fires at the front desk, that you're not the only one doing it. That everybody is doing it, even after 60 years of practice. And how to handle it and not let it get to you. Today, patient expectations are the highest we've ever seen in this world. And we're all dealing with them. And it's good to know that we're not the only ones dealing with it. And forget even dentistry, other professions are dealing with it as well. We cannot make these patients happy there. They wanna complain. They may even sue you. This is just part of practicing dentistry. Do what you're supposed to, do it right, have good communications, because communications is the answer to not getting yourself in trouble, 99% of the time.
That 1%, you're not going to do anything about. You're not going to be able to rationalize or reason with this person and so be it. But it's good to be involved with them, and it's good to give back, it feels so good. It feels good to learn that you're not doing this by yourself, that everybody's in the same boat. It feels good to help people who need help, whether it be a dentist or whether it be a patient. And by doing so, I guarantee you, you will learn so much, and your life will become much more enjoyable knowing that we're all fighting the same battle.
HOWARD: Another question that I'm hearing a lot in the dental schools is, you're in dental school or you're working for an associate, yet you haven't tied and committed, you haven't bought a practice. And now they've fallen in love with someone in your country, Canada, or maybe they're Canadian, they fell in love with someone down here; how fungible is a dental degree from the United States and Canada? If I have a dental degree from Canada, and now my lover’s in the USA, how hard is it to get licensed in America and vice vers? I'm living in North Dakota and the girl I fell in love with lives across the county line and now I gotta go be a Canadian. How fungible is a dental degree from the United States and Canada?
NEIL: So I studied at Howard in Washington D.C.
HOWARD: Which was named after me. Did they tell you that?
NEIL: Okay, perfect.You know what, I knew we had a close relationship with someone (inaudable 00:55:26)
HOWARD: Just keep spreading that rumor that Howard University was named after me. Politicians taught me one thing, no matter how many times you say the lie, eventually everyone will believe it.
NEIL: Believe it. Absolutely.
HOWARD: So you studied in the United States?
NEIL: I did, fantastic school, loved it, learned so much from that school. I owe my life to that school. The beauty coming back to Canada, because of the reciprocity agreements between ADA and CDA and the joint commissions - the only thing I had to write was the written exam very similar to ADA part one and part two. It's a one-day exam and basically you can apply for licensure after writing that Canadian equivalency exam. On top of that, movement, under NAFTA, let's see how far that goes. But dentists are one of the professions that are included in NAFTA. And as such, that if I move to the U.S. and start working and show that I can earn my own living and pay for myself while I'm there, they'll give me a work NAFTA visa so I can work and eventually I can apply for a green card. And likewise in Canada you can come here and do the same.
HOWARD: So do you remember who Howard University was named after?
NEIL: I don't know who Howard university’s named after, our school itself was the Russell Lake Dickson College of Dentistry, named after one of the pioneers there. But...
HOWARD: It was all Oliver Otis Howard, General Oliver Otis Howard, a civil war hero, who was both the founder of the university and at the time commissioner of the Freedmen's Bureau. Howard later served as president from 1869 to 1974. But I think they should update that, and just name it after me, so.
HOWARD: Yeah. I mean come on, that was a century ago, 1869. And again, volunteering, why do you think volunteering is important?
NEIL: I think, you know what, likewise, God is giving you a phenomenal profession to practice in. You've been trained in it, you have the ability of changing lives. I see the ads for the Smile program where they have world surgeons and dentists go across the world and treat cleft lips and cleft palates, you change people's lives. You bring them back to function in normal society.
And I think as dentists we can do a lot. And I think we should be involved. And it doesn't mean going out of your country to do so. We have enough people in both our countries that need help and we can give that help in however way you want to give it. Whether it be dental camps or oral screening sessions, and education. We have so many parents that come here that their kids have milk bottle carries, because nobody has educated them that you know what, this is what could happen by giving your child a milk bottle at night time. So small things that can lead to huge strides in prevention.
And I think that's our job, and it does bring a lot of a lot of enjoyment to me and I'm sure it will to everybody that when you see a child twenty years later, thirty years later, you arrested that carries. After speaking to them, they've taken good care of their oral health and they have beautiful smiles and they thank you for it. It is a good feeling. What you learn from it Howard, remember, when you're interacting with other dentists and you're treating people that are underprivileged or need dental health or dental care, ultimately you learn tips and techniques from the guy you're working with. You learn things about his frustrations in his office or her office. And I think that's something that the reward from helping somebody and the reward from learning something. You get them both when you give back. So I cannot stress it anymore.
HOWARD: And congratulations. You're the president-elect of the Academy of General Dentistry. Wow. Tell us about when are you the president?
NEIL: So I'm currently the vice president, in November I will take on the president-elect position, and then the following November I will become president. It's a line position serving as the VP, president-elect, and president.
[01:00:03]HOWARD: Okay, so say that again. Right now you’re President-elect
NEIL: Vice president.
HOWARD: Vice president-elect and then at the meeting in October, where’s that meeting at?
NEIL: The meeting in November will be in Chicago where I'll be sworn in as president-elect.
HOWARD: So in Chicago you'll be president-elect, and then the following year in November where will that meeting be at?
NEIL: That's in Chicago as well. We separated our annual meeting from our scientific section.
HOWARD: Say that again.
NEIL: We originally had both the annual meeting, The House of Delegates and the scientific session combined. This year was the first year we separated it. We had our annual scientific session in July in Las Vegas at Caesar's, and we have our annual session with the House of Delegates in Chicago every November now.
HOWARD: Wow. What was the thinking behind that?
NEIL: The thinking behind that was, predominantly, we had so many delegates that would want to take part in continuing education and be a part of the scientific session that weren't able to do so because of their duties at the house. But now this would open up a window for them to do so.
HOWARD: So your last year's meeting was in Las Vegas?
NEIL: Our meeting this year in 2017 was in Las Vegas, at Caesar’s, yes, in July.
HOWARD: And where will it be in 2018?
NEIL: In New Orleans.
HOWARD: It's pronounced “Nawlins'”.
HOWARD: Nawlins. Only people who are not from “Nawlins'” call it New Orleans. Well, man, congratulations on that. And how much they pay you a year to be the president-elect?
NEIL: I think the president-elect comes with a stipend of, I think it’s, if I'm not mistaken, $40,000.
HOWARD: Oh well, that's good. That’s good. But how many hours for how many decades did you volunteer for free before you became the vice president-elect?
NEIL: Technically we still volunteer for free. It takes a lot of time out of the office.
HOWARD: I know.
NEIL: And, but, it's not the money, it's literally a stipend to kind of cover some of the costs.
HOWARD: But does $40,000 cover all the lost time in your dental office and travel and expense?
NEIL: No, it doesn’t.
HOWARD: I remember back in the day, you would not do a $10,000 day to go lecture for $1,200. And I keep telling people that if there’s a lecture on the stage you could make more money at home. And right now with the ADA, two out of three dentists are members. And a lot of people say they don't want to pay their dues. I’m like: “Dude, not only are like two-thirds paying your way, but all those guys in the ADA.... She should be going home after work, she’s guilty, she wants to go home and help her children with their homework and cook dinner. They give up so many free evenings and so many free weekends trying to make the profession better. And two out of three pay, and I don't know what percent volunteer, but then there's one third who never pay, and so to justify their guilt of not paying, what do they do? They're always bitching the loudest on Facebook. When they're bitching real loud, what they're saying is: “There's no raisins in raisin bran. There's two scoops of raisins in every box. This piece of crap Chrysler will last as long as a Lexus.” And what they're basically saying is they're guilty for not paying their way because you got to have parents. And I remember the ADA, and AGD (ineligible 1:03:45), and many other ones. Just the fact that I want as many people up there at Washington D.C. and all these state and local lectures. There are so many issues, and the best way to have your profession destroyed, is have no one representing the dentist, and just have it be represented in Washington by insurance companies, and all this stuff like that, and you're just gonna hand your diploma away. When I graduated from dental school my mom cried. When I got my FAGD, she cried again. When I got my MAGD, she cried again. And you're not willing to support just a couple of institutions that are up there fighting on your behalf, all day, every day, year round. A lot of the presidents that I know, that make it to the president of AGD, ADA, they sell their practice. They're like, I basically will miss a calendar year, so I'm going to sell, cause I got patients, I guess. So they sell their office and go up there and fight full time. I was talking to the president of the ADA yesterday - he's been home five days a month for the last year. And so, gosh darn, if you want your grandchildren to graduate in dental school and have their parents cry, you better keep fighting for this profession.
NEIL: Yeah, and again, Howard, I'll bring it down to the simplest thing, and I'm sure this happens in the U.S. as it does in Canada: You do an occlusal filling on somebody, all of a sudden you get a letter from the insurance company who want more information on this filling. How many people you think actually filled that form out and send them back and get remunerated for that? There are many different avenues to avoid payment. We work hard and somebody does need to protect us. Whether it be government regulations or whether it be insurance tactics, I think somebody needs to keep an eye open for these things. Whether you're a member or not, you're still getting the benefit. But at least you know what's happening and hopefully you think it's a good cause to be a part of.
HOWARD: The ADA and AGD, they're like your parents. Your parents are’nt perfect, but they're the only parents you got. The bottom line is, I'm just honored that there's these two great professions that have been around over a century, fighting to make this the sovereign profession that it is. And congratulations on becoming the vice president-elect, and good luck on becoming president-elect, and god help you when you're the president. And I hope when you're done, you will not say, “That was crazy. I'm going to learn how to say no. Next time someone asked me to volunteer for anything, I'm going to run out of the room and yell fire.” Thank you for all that you've done for dentistry. Thank you for all that you've done for the Academy of General Dentistry, and it was a honor to podcast interview today.
NEIL: Well Howard I just want to say, thank you for what you've done for dentistry. You know the community that you've made is a God's gift to dentistry. It truly, truly is. Allowing everybody to interact, allowing people to learn from each other, allowing dentists to vent, making the profession better for both dentists and the public. You couldn't have done a better job about that. And a heartfelt congratulations to you and many God blesses for that.
HOWARD: Well, on that note, thank you so much. And a big shout out and thank you to Ryan for making podcast possible, because Dad could not have technically done it without him. But I hope you have a rocking hot day.
NEIL: Thank you so much.