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AUDIO - HSP #189 - Nareg Apelian
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VIDEO - HSP #189 - Nareg Apelian
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Patient-centered care means something different to everyone. Nareg Apelian, DMD shares exactly how he does it the right way!
Graduated in 1996 from Universite de Montreal.
Worked in a low socioeconomic demographic for 19 years.
Hired by McGill University in 2014 to take care of the clinical courses of the 3rd year students and directing the CE program.
nareg.apelian@mcgill.ca
Howard: It is a huge honor for me today to be interviewing Nareg Apelian who is not only a dentist in Montreal but dude, you have 6,300 posts. You've been a townie since 2007. I feel like I know you like a brother but I only know you on text and I think so many townies are going to just love meeting the human behind all those amazing posts that you've been posting since 2007. Thank you so much for sharing so much information on Dentaltown.
Nareg: Thank you. The honor's all mine.
Howard: Now you're sharing information in the dental school. You work in dental school.
Nareg: Yeah.
Howard: Was that like just wanting to give back like you do on Dentaltown? What made you get into dental school?
Nareg: It started a couple years ago. I decided I wanted to do a masters and then I started to do the masters and it turned out I enjoyed the environment here at school so I figured you know what, I want to spend more time here. When some positions opened up, I applied for them and next thing I know, I'm 4 days a week now at McGill University. That's in Montreal, yeah.
Howard: 4 days a week teaching.
Nareg: 4 days a week, yes.
Howard: Teaching what?
Nareg: I do 2 things. I'm the director of the continuing education program here, and I teach everything clinical to the third year students. Every time the third year students are in the clinic doing anything, it's under my course.
Howard: Wow. One of my friends is a very successful dentist and he decided ... He didn't work Fridays, so he decided a couple years ago that he was going to go back to dental school and just teach on Friday. When you talk to the guy, he almost never talks about his 4-day work week. He's always talking about exciting stories in dental school. I know he just loves that 1 day a week more than the other 4.
Nareg: I think as dentists, we're so alone in our offices and in the dental school, we're so surrounded by students and other teachers and people we get along with and everything. The environment is really nice, so it's very satisfying from that point of view to work in a dental school, at least for me. I know some people have a horrible experience in the dental schools but I seem to be enjoying it. Mind you, I'm new. It's only been a year in a little bit so maybe that's why I'm so excited. I don't know.
Howard: You teach clinical for third year students.
Nareg: Yeah.
Howard: That's at McGill University in Montreal, Canada.
Nareg: Yeah.
Howard: Then you're bilingual. You speak French and English?
Nareg: Correct.
Howard: Is that the only 2 languages?
Nareg: Armenian.
Howard: Armenian, so you speak 3 languages.
Nareg: I speak 3 languages.
Howard: That's amazing. I can barely do English. I don't know how you guys can do 3 languages. You teach clinical, but what's the other part that you teach?
Nareg: I teach clinical. The other part is in administrative position. It's the continuing education so I run their program, basically. I put together events, I contact speakers, I book the speakers, we negotiate the fees, that stuff, come up with a program. That's what I do.
Howard: Seriously, for your 6,310 post since 2007, if you ever want me to speak, I'll waive my honorarium. I'll do it for free just for my bald buddy on Dentaltown. I will. I mean that sincerely.
Nareg: It's recorded. Everyone heard it.
Howard: I know. I'm dead serious. How many hours do you think it took you to post 6,310 times on Dentaltown?
Nareg: A while ago, I calculated how much time I was spending on Dentaltown and it was close to ... Oh, I don't know. It was in the thousands, I think, [crosstalk 00:03:39] points, yeah.
Howard: For me to give 1 day back to you, that would be the smallest return gift. I'll be like giving you a chocolate man after you fed me Thanksgiving dinner. This is my beef with dentists whining about dental school. Dentists always say, "You know in dental school, they didn't teach them this or this or this." I'm like, "Dude, I'm in dental schools a lot. You're taking a hundred kids off the street and 4 years later giving them a license to do whatever they want." I said, "They are completely overwhelmed and you just can't ..."
These dentists always forget that they've been out of school 10, 20, 30, 40 years and I just don't think they can remember going back to what it's like to walk ... I could remember 1 of the first root canal lectures in dental school and my roommate says to me, goes, "What is endo?" I'm like, "Dude, your dad's a dentist. How do you not know what a root canal ..." People just assume well, your dad's a dentist. You know how to do a root canal. No, there were kids there in class that didn't know what a root canal was and their dad was a dentist. What are the challenges of teaching kids in 4 years from A to Z?
Nareg: That's exactly what it is. I'm doing the third years. The thirds years are their first experience in the clinic. I know that my instructors, they forget like you said that they've never done freezing before. We call it freezing instead of anesthesia. They've never numbed. Is that what you guys call it?
Howard: Yeah. You guys call Septocaine articaine, don't you?
Nareg: Well, yeah.
Howard: Septocaine is a French company. They started in Paris, France and they went to French Montreal, Quebec, right?
Nareg: No. In Paris, France, I don't think Septocaine markets Septocaine here. I think it's marketed as articaine. [crosstalk 00:05:31], articaine is the real name of the chemical.
Howard: Yeah, but when they went to North America, they went to Montreal, didn't they?
Nareg: Oh, possibly. I don't know.
Howard: Yeah. I remember that.
Nareg: I don't know. Those kids haven't even done anesthesia on patients, let alone all those complicated concepts. It's hard for the instructors just to step back a little bit and say, "Okay, one step at a time. We're going to hold your hand and you're going to be okay." There's a lot of human teaching, give them the confidence so that they can go ahead with it and not worry too much about the dentistry at this point, get them used to going from their simulated plastic teeth to real people, how that changes things. Those are mostly the challenging parts because dentistry, we're all comfortable doing dentistry but then transferring that information to students gets a little bit more tricky.
Howard: I can still remember my first freezing, as you call it with ... It wasn't articaine. They didn't even invent articaine back then. That would've been 1984 as a freshman, so it would've been '85, '86 and obviously, I was way too high. I was so high I was out of sight because the person started getting ... Their eye was getting numb and they started getting blurry vision. My lab partner, I'm going to throw her under a bus, I hope this never gets back to her, it was [Deedee Richards 00:06:48] and she starts panicking like, "Oh, my God. Oh, my God. What's wrong with his eye?" She's like, "God." I'm like, "Okay, I'm too high. Everybody just settle down and relax. This will wear off in 2 hours." The instructor came and everything.
These dentists are complaining that they got out of school and never did veneers and ortho and they never placed an implant, blah, blah. The list goes on and on and on. It's like, "Dude, relax. They got to get out and do a filling, a cleaning, an x-ray, a crown. Are you doing continuing education for students or you're doing it for alumni, too?
Nareg: Alumni. Yeah, like dentists.
Howard: Not to ask you a dumb question ...
Nareg: [crosstalk 00:07:30] of Dentaltown, I'm the [inaudible 00:07:32] of McGill, basically.
Howard: You're the [inaudible 00:07:33] of McGill?
Nareg: Yeah.
Howard: I'm sorry to be ignorant but most of your courses in Montreal, do you have them in French or do you have them in English or do you have them both?
Nareg: We have them in English because we're an English school. We have 1 course in French. We're starting to dabble in that but there's a French university here also. It's the Université de Montréal. They do the French courses, we do the English courses because we're the English university, they're the French university. There's 2 universities in Montreal that does [crosstalk 00:08:01].
Howard: 2 dental schools.
Nareg: Yeah, 2 dental schools.
Howard: 2 dental schools in Montreal or 2 dental schools for all of Quebec?
Nareg: No, 3 dental schools in Quebec. There's another 1 in Quebec City called Université Laval but in the Montreal itself, we have 2 dental schools. We have UdeM which is big school. I think they have 80, 90 students. We have 35 to 40 students. We're much smaller class dental school. We're considered one of the top schools in Canada. It's a decent school, McGill.
Howard: Do you miss private practice?
Nareg: I'm still doing private practice once a week and I'm also doing the faculty practice here at the university so yeah, no. I would definitely miss it. I think it's part of my identity. I can't just get rid of that. I would feel empty and I just couldn't do it every day because it was starting to get boring. I guess I reached a point in my practice where I needed more challenge or maybe more people. I'm not sure exactly what it was.
Howard: I think I know what it was. You're a natural sharer. You're just a natural sharer. If you learn something, you get excited and you like to share. I followed 6,000 of your posts. You learn something, you just naturally want to share it with your friends and colleagues.
Nareg: Possible. Possible.
Howard: You always talk about patient-centered care and my beef with dentists is that if you ask a dentist with a straight face, you say, "Do you think you're focused on the patient or do you think you're focused on the dentist? You think it's all about you or the patient?" "No sir, it's all about the patient." I'm like, "Hey, what are your hours?" "Monday through Thursday, 8 to 5." They really believe they're focused on the patient then you go through a checklist of 20 things and they maybe click off 3 things. They're just not patient-centered. You're talking about 7,000 dentists and probably almost all of them are townies that are big. They miss your post. They must not have turned on the right website. What does patient-centered care mean to you?
Nareg: Patient-centered care is one of those terms that's hard to define because it's understood differently by different people. If you're a surgeon, you might understand it differently. If you're a dentist, you might understand it differently. If you're a dentist and doing aesthetics, you might understand it differently. There's no universal definition for it. The closest I can come to it is doing care that takes into account the patient's views, feelings, and if there's 1 word that can stick to it would be more healing instead of curing. It's all about this concept of we need to heal the person. How do we heal the person? Well, we can't just look at the disease part of it because dentistry is very good at just looking at disease. We're like disease, disease, disease. We don't look at what does the patient really want? Maybe the patient wants something else that's not disease or disease but wants to fix it in a different way. Patient-centered care is a way to integrate that into the treatments, basically.
Howard: Whenever you say those types of words, feelings, healing, things like that, a lot of patients are thinking ... I hear patients a lot. I had a person ask me in the swimming pool this morning, "Well, do you do any holistic dentistry or alternative dentistry?" What do you think the consumer is thinking when they hear terms because I know dentists on Dentaltown, if they hear the word holistic, probably 98% are like, "Oh, brother."
Nareg: Yeah, exactly.
Howard: They think, "Okay, there went the science and the math and the gravity and now it's all feelings." Consumers, what do you think consumers are thinking when they hear holistic or alternatives?
Nareg: I think the consumers are attracted to holistic anything, medicine or dentistry, because of the human aspect. It's not because of the treatments they're doing, in my opinion at least, but the fact that those holistic practitioners spend more time, they speak to the people, they listen to the people, they really get the people, they connect well with the people. That fact that they do that, the people get attracted to that because there's value to that. There's healing value to that to connect to the people.
Since the other side, the more traditional medicine or dentistry, if you want to call it, we've forgotten that aspect of it so it's become 2 camps, the holistic dentist who do those touchy, feely, hug trees type of thing. Then the other dentist or medicine who does not do this, so it's become 2 camps. However, things are changing now and we want to incorporate all that listening and bringing the patient back, the human side of it into dentistry. I think as medicine goes into that direction, the whole alternative, non-alternative thing might not be an issue anymore, I think. The whole holistic dentistry would not exist if we do the interesting part of holistic dentistry integrated into regular dentistry.
Howard: You know what the physicians and the dentists don't want to hear? They don't want to hear the realities that when you're listening to people on the street that you live with and work with and shop with and everything, they have really lost faith in the medical model of you go in there, you're sick and they either surgically cut something off or they give you a lotion, potion, pharmaceutical pill. The pills all have side effects and they all know people that have started taking up pill, the next thing you know, they have leaky bladder, they had other symptoms or side effects. They're starting to look at physicians, "Well, you just go there and he's just going to cut something off and give you a pill and I don't want to start taking it. I don't want to go to the pharmacy every week and be on some medication the rest of my life."
The truth of the matter is would you rather cure your blood pressure through diet and exercise or a pill? Would you rather lower your cholesterol through diet and exercise or a pill? I think the pharmaceutical people, they are losing ground and I think the holistic people and I think you described it well. They're better people, they're better listeners. I've saying that I think the average dentist could double their income if they got a part-time weekend job as a bartender or a waiter just to learn how to just be with people and just talk with people.
Nareg: That bartender is doing a lot of healing behind this. Yes, there's the booze but there's also the whole listening part and this is not invented. This is well established, written, studied in medicine. This dates back to the '70s where they said, "You know what ..." they came up with the concept of the doctor as a drug. The doctor who listens is the treatment. That has therapeutic value and for whatever reason, it's been lost throughout the years. We haven't latched on to this but it's changing.
Howard: I love that. The doctor is the drug. Wow, that is profound. You don't get a drug at a pharmacist, you get a drug by talking to your doctor. It's just so amazing how these dentists are technicians and they think that the only way to be successful is to get a laser and a CAD/CAM and digital radiography. It's like, "Dude, the people doing the most amazing practice, they know the fluffy, touchy, feely, talking, chemistry, listening. They know the people." Once you get that relationship with people, they don't care we have digital x-rays or film. They don't care if we have a CAD/CAM or a lab. They don't care about any of that crap.
Nareg: Yeah. Talking about relationships, you have to connect at a human level. It's humanizing. The moment you dehumanize, I think that's when we start getting problems. It's not the dentist's fault. I don't think it's the dentist's fault. I think it's the university's fault and I think it's the teaching. We teach very axed on anything biomedical. It has to have a disease component to it and it has a human component. Oh, we get scared in dental schools and we go, "No, no, no. We don't want to touch this. This is humanities. We don't do humanities."
We've been urging the universities to integrate humanities into the dental curriculum because it's important. We're dealing with people. We need to understand people. In order to understand people, we need to delve into the humanities and it's a hard sell because there's years and years and years of tradition of looking only at diseases and not looking into the human aspect of things.
Howard: Explain what humanities is and what are courses in humanities and talk about that.
Nareg: Humanities could be anywhere from art interpretation, anthropology, sociology, anything that deals with learning about how to be with people. The art departments are doing a very good job creating subtleties. When you interpret arts, there's no one right answer. There's many different answers. It brings people together. It shares, you listen. You tend to listen more critically. You learn all these skills that are so important in communication yet when we go into dentistry or medicine, we've nailed communication down into a specific science where it's like smile 3 times, shake hands, check, check, check. That's not how you communicate.
There's more to communication than with using it to a bunch of steps. In the arts, they get this and when you do interpretation, you understand this and then you can put things in context. You create bonds, new relationships, and I don't think you can do this with more of a reductionist way of teaching.
Howard: You know Joyce Bassett, the first woman dentist, president of the American Academy of Cosmetic Dentistry? You know ...
Nareg: No.
Howard: She had a dinner party at her house last night and she had the most amazing artist deal. It was a bunch of cigarettes shaped as a hand smoking a finger.
Nareg: Cool.
Howard: I thought when you said art interpretation, I just thought last night, I just took a double look at that painting. I'm like, "Wow, that is a wild painting." You're so right. Humanity is everything and the problem is the dental schools and the school rankings. I remember when I got my MBA, they were saying the number 1 complaint with MBAs from the S&P 500 is that you sent me this person and has MBA but she doesn't work well with others, she doesn't work in a team, he doesn't get along with others. They're trying to do all these team exercise. Half your homework had to be a team [inaudible 00:18:14] and I was sitting there thinking, "No, you guys don't get it. You only accept people who make straight As. They live in libraries. They don't have lives. They don't have girlfriends. They weren't in frats or sororities. They didn't have a part time job as a bartender. You only accept these 4.0 geeks because you want your rankings and you want to say well, we had a smarter interns class than this other school."
It's natural selection. You accepts all these freaks and then their only skill set was acing calculus, physics, and trig, and then you turn them loose into a business like dentistry where we sell the invisible. Nobody knows what a root canal is and these people don't have the skill set to explain what a root canal is.
Nareg: It's even more than that. Those who are getting really high marks are go getters, ambitious, really able to focus. Not only it's not a good strategy, it's the opposite strategy. Yeah, but that's changing. Now for example, just an example as of last year or 2 years ago, to go into McGill, you do MMIs. MMIs are Multiple Mini Interviews so you're put in this simulated room with an actor and there's 10 different stations. The actor, for example one of them could be a homeless person and they want to see your interaction with the potential applicants, interaction with a homeless person and then they see how it's interacting. Then there's an interview asking why did you ask this way or how come you acted that way. Then they want to capture their human side of it and if they don't see the human side, no matter what your GPA is, you're cut off. Now they've ...
Howard: Wow. I've never heard of anything like this. When did they start doing that?
Nareg: Well, we annexed with medicine and medicine's been doing that. We're using the same admissions process as medicine and medicine clued into this a while ago. We're just hopping on to that bandwagon. I think it's a great idea. It's a superb idea.
Howard: It's 10 interviews. The students got to meet 10 different people and they're all actors?
Nareg: Yeah. It's a room with a mirror. You know when they do interviews in movies with the police are watching from behind the one-way mirror?
Howard: Yeah.
Nareg: That's how it is. You have 3 or 4 professors looking in and then you have an actor inside the room or 2 actors sometimes. Sometimes you have someone who gets angry and upset and then they want to see the reaction of the student, potential student. Then there's a little analysis after of what did we see and what happens and they want to check how well you perform under stress, how empathy you have, how much can you connect with people, how charismatic you are. All these things can be evaluated through those ... Well, ideally could be evaluated through these multiple mini interviews. They have their own issues but I think there are much better way of doing things than the traditional interviews.
Howard: What part did you play, Nareg? Were you the homeless guy or were you the guy that lost his temper? What part did you play on this?
Nareg: I'm a terrible actor. I'm not included in the admissions process.
Howard: Well, that's great.
Nareg: The actors are real actors. They're acting students from acting department who get hired to ... They use this for interviews but they also use it to train medical students. Actors act out let's say somebody has cerebral palsy and then the teachers go behind the mirror and then the students enact let's say an encounter with someone who has cerebral palsy and then they come in. They say, "Okay, you do it this way. Try doing it that way." They go back out. It's a teaching tool also. The simulation center is not just for admissions but they can be used for admissions also and they are being used for admissions.
Howard: You know what? Most of my dean friends also tell me they're looking for ... They're afraid of the person that's going into dentistry because they want to make a million bucks. What they're looking for, did the person do any volunteer stuff and the secret to at least 5 deans that I know close, if they don't see volunteer work in the St. Vincent de Paul or the CASS homeless shelter or these different [guilds 00:22:11], they want to see that you just love helping people save their teeth regardless of there's money associated with it.
Nareg: I don't have anything against dentists who want to make money. I think there's nothing wrong in making money but it doesn't mean make money at the expense of the patient's health. Don't cause harm so that you can make money. As long as you're doing good and you make money, I have no problem with that. That's fine. That's great. I'm convinced the dentist who's more patient-centered will make more money because patients will love them. Patients love practitioners who connect at a human level. Everything goes better, they're happy, they go home, they say, "Wow, this guy's amazing." They tell everybody they know. You have to go to this guy because nowadays, there's much less dentist who do this than they don't do this. Those who do do it, they shine among their peers.
Howard: Let's talk about the success of that. They're more patient-centered.
Nareg: I guess so.
Howard: I believe they're more into continuing education. It seems like everybody I know that just rose to the top was always doing a hundred hours of CE a year. Do you believe that?
Nareg: I believe that. I think so.
Howard: They love to learn. They're lifelong learners. They didn't walk out of school and say, "Oh, I got my diploma. I graduated from McGill." They're just always in student mode. I don't care if they're 65 years old. They're still doing a hundred hours a year. They're always in learning mode.
Nareg: I'm not sure it's the CE stuff that makes this or it's the type of people who would pursue hundred hours of CE are the type of people who have some kind of a passion and it's the type of people who have some kind of a passion who ended up being more attracting more patients, being better at their jobs. There's the whole package deal. I have trouble saying, "Oh yeah, because they took the CE, they're like this," but more like it's the type of people who do this are also the type of people who tend to be successful maybe.
Howard: Man, you're a smart critical thinker. I see that with a lot of studies and they're just so biased. Obviously, I'm not a pro smoker. I'm anti-smoking and all that stuff but a lot of the smoking data is so skewed because well, if you're a smoker, you're more likely ... You don't exercise. If you're a smoker, you're more likely to drink. If you're a smoker, you're less likely to eat vegetables. That smoking is a tag of a whole basket of bad behavior. You're just tagging someone who doesn't care. You know what I mean?
Nareg: Yeah, totally. Dental science literature is full of these problems, full of these problems. A lot of things we know in dentistry, maybe they just go up together. We don't know one causes the other. As dentists, we're very quick to say, "Oh, yeah. This causes that because there's something in our brain that wants to make connections and it's just hard to just step back and say maybe there is no connection. Maybe they're just together.
Howard: Well then, that's a red flag for the evidence-based dentistry movement.
Nareg: Well, the evidence-based dentistry movement started with a very good ... Evidence-based medicine started with very good intentions. They wanted medical practitioners to be more skeptical about what they read. They wanted to teach them science methods, methodologies and all these things so that we get better doctors. However, somewhere along the line, it turned into a guidelines thing. Oh, this is evidence-based so it must be true and then we swayed away from this whole idea that let's be more critical to whatever we're reading. Let's be more naïve when we see something and then look at it with naïve eyes basically and then be able to analyze it without bringing on baggage into it.
However, that's not what's going on today. Hopefully, it's going to go back to somewhere more balanced. Right now, I'm a bit scared about the idea that we do half our studies that are not really well-designed and then we interpret from that conclusions that are very strong like, "Oh, yeah. This causes that obviously," whereas that's not what the study said. This was against what evidence-based movement was about. However, that's not the reality now. I'm a bit skeptical about the whole evidence-based. I'm all for evidence-based but I'm skeptical about the quick conclusion, jumping to conclusions based on the evidence.
Howard: I always think government should benchmark against other governments and governments should benchmark against other industries like private sector, non-profit. You look at the healthiest companies out there and they'll spend 3 to 5% on R&D. Then you look at the American healthcare budget, they don't even spend a half of a percent on research. When they go spend a trillion, 700 billion, it's all on drilling, filling, billing, surgeries, pills. It's like, "God, don't you think 5% of all that money should go on with studying about all these surgeries and pills you're handing out? Wouldn't that just be a much better use of the money?"
Nareg: Yeah.
Howard: They just pay for every surgery and every pill and then they don't have any money to study that stuff. It's [crosstalk 00:27:20].
Nareg: All right. You should come to Canada. You should be Canadian.
Howard: I should be Canadian? I love Canada. I really do. I live in Phoenix so it's a perfect winter but the summer is ... I need to figure out how I can be a Canadian in the summer and a Phoenician in the winter. I don't know if you know this about Phoenix is you're more on the east side of Canada but they say 10% of Phoenicians are Canadians. 1 in 10.
Nareg: 1 in 10?
Howard: 1 in 10.
Nareg: [crosstalk 00:27:48].
Howard: I've seen that number ... I've lived down here since [inaudible 00:27:54]. I've seen that number every 5 years or 10 ... Every 5 years the whole time and it's amazing because they come from Alberta and Saskatchewan and all these places. Yeah, they just love the winters in there. If you ever go down to Mexico in those retirement communities, it seems like they're all Canadians.
Nareg: That didn't surprise me. I was just surprised about Phoenix.
Howard: What else did you want to talk about? There's so many things we could about with you.
Nareg: Pick, just pick something.
Howard: Well, let's go back to you're trying to make these people successful and you're talking about patient-centered. We talk about being life-long learners but you said something very critical, which came first, the chicken or the egg? Was it the type of person who's doing the CE? Was that why they're a better dentist or did the CE actually make him? What else do you think are you telling these kids will be deal breakers and forks in the road to make them be better dentists over their long career?
Nareg: My approach to teaching and I'm not sure if this is going to be popular or not in the university because it's a little bit different to the other ones and if they kick me out eventually because I'm making too much trouble, that's fine. Other than the human approach to things, I think we're dealing with human beings and we can't ignore that human part. Traditionally, being a professional has ... You think of professional, you think of someone whose detached, whose emotions are in check, everything that's not human basically. I'm trying to change that concept of what is a professional. I don't mind, somebody wants to get angry. That's fine, get angry but then apologize and say, "Sorry. I lost my nerves and it's okay." Show that vulnerability.
We have an issue as professionals to show vulnerability, and I think that's a bit of an issue. If we want to be more human, we need to show our vulnerable side. We need to show our human side and I think the moment we show our human side, we'll be able to connect better with our patients because our patients are human. They come to our offices, obviously they don't feel like they're top of the world. Something's wrong with them. A lot of them have a broken tooth. They're worried, they're wearing their teeth. They're thinking about how they're getting ... All the teeth don't look good. There's these thoughts inside their mind. They're not feeling like super humans and they go to this office and this dentist acts like a superhero with perfect everything. I'm thinking, it's hard to connect this person. To be able to connect this person, I need to see someone who's might be going through the same things that I'm going through as a patient.
I think as a step towards humanizing dentistry, it would be to start humanizing our concept of what a professional is. We need to redefine this identity of what is a professional. I think that would be one big step. We talk about patient-centered care, yeah patient-centered care is very important but in the back of all this, it's humanizing. It should be an experience where it's a very human experience to go get fixed by someone, healed, cured, or anything you want to call it. It's as human as it gets, yet we do it in a very sterile, non-human environment in a non-human approach and I wouldn't be surprised if that has contributed towards not doing as good as we could've done as a profession. I'm talking about dentistry but it could extend to medicine also.
Now medicine is changing, dentistry is not changing. Most dentists don't even know what patient-centered means. Most dentists haven't even thought about the things we do. For example, the things we do, the approaches that we have. You go into the office, what do you do? The first thing you do, you fill up a medical questionnaire. Why? Why is the first thing that you do is you fill up this completely non-human, yes and no answer of what's wrong with you from a disease perspective. To me, that makes no sense.
In fact, some of the experiments we did in my office with a colleague of mine from Toulouse in France, we started giving the medical questionnaire in the middle of the appointment. First the patient comes in, we say, "Hi, how are you doing? What's going on?" Whatever, we have a little conversation. Then once that conversation was finished, then we do our exam and then we ask the medical questionnaire and boy was a huge difference. The people started giving more information. The medical questionnaire was better filled, and it didn't become a barrier to that rapport. Something as simple as placing the medical questionnaire at a different time in your appointment could make such a big impact. The problem is nobody's ever thought of these things. Nobody's thought of why are we doing the things the way we're doing them?
I looked back, I looked into all the medical literature and everything. There's nothing written on dental approaches. There's nothing that's been analyzed, there's nothing that's been thought about. Dentistry has never had the reflection on the sequence of things we do, the way we do it, the approach we have, nothing. It's zero. It's uncharted territory. That's got me excited about doing ... That's why I started doing a master's. I wanted to look into this. I find this interesting. It's weird that a hundred-year profession has never been reflective on it's own approaches.
Howard: Nareg, I'm a new patient. I just walked into your dental office. What do you think the sequence will be? I just walked in your office. Is this Dr. Nareg's office? Am I in the right place? What would be the sequence be?
Nareg: Yeah. I'll be like, "Hi, how are you?" Like, "I'm fine." I usually would ask them, "So how come you're here?"
Howard: Because you're bald.
Nareg: Perfect. It's the bald people association.
Howard: I only deal with other bald people because I know our brains are so big that it killed all the hair roots, and that's why we're bald.
Nareg: Humans evolved when they stood up and they stood up because their head started getting hotter so more blood went to their heads, and that's why the brain got better in this whole homo sapien thing. I think being bald is the next step in that evolution where you lose your hair, more sun goes in, more blood goes to the brain, and the brain gets even more developed. Anyway, that's my little insight.
Howard: My thoughts are you know how the people who go bald from the front are thinkers and the people who go bald from the back first are lovers. The people who go bald like me, front and back, we just think we're lovers.
Nareg: Nice one. [crosstalk 00:34:14] the back of my head.
Howard: What would be your perfect sequence to make it more humanitarian, more anthropology, more socialistic, more human?
Nareg: Not socialistic, not humanitarian, but more human. This is not about helping the poor. Yeah, it works well with poor populations but I think it would work with everyone. I think people go see their medical practitioners, whether dental or medical to talk about their health. That's what we do. You come in, you sit [inaudible 00:34:47], I'm like, "Why are you here? How come you decided to go see the dentist?" Well, they will say, "I'm worried something happened here." Okay, then we start the conversation. We talk about that, we explore everything that needs to do about their health and whatever they think ... They think about their health, how they feel about their health. While you said you lost a tooth, how does that feel you lost a tooth. Do you feel getting older? Does that bother you? I'm not afraid of going into that and then exploring all facets of anything that has to do with dental health or oral health.
Once all that conversation is done, it comes to a finish, then we can go over the medical questionnaires and do the whole yes, no answer. Why do I ask and delve into the feelings and everything? I don't necessarily delve into the feelings all the time but if I see somebody needs to talk about it, I let them talk about it. That's why I can't recipe book the approach but I can say that the idea behind it, the philosophy behind it is to let the person express themselves. If you see someone really is anxious, they have something to talk about, as healthcare professional, I need to be sensitive enough to that to be able to make them talk about it and not be an ass enough to cut them and then say, "No, no, no, no. That's stupid." I don't impose my medical models on to them.
I think what we're teaching the dental students hopefully is to listen to patients even if they have absurd ideas, try to understand them. It's all about understanding the other person. Does that help? I know [crosstalk 00:36:20].
Howard: Yeah. No, I could listen to you all day, dude. I love your post. I always love reading your post. I love reading about you. You know what, I actually ... They say history repeat itself. I don't think anything's ever changed since the original medicine man. Go back 10,000 years. You go to a witch doctor and he used all these lotions and potions which is now Walgreens and your local pharmacist or they take out a knife and they cut some body part out. It's lotions and potions and magic and voodoo. Then my 2 older sisters went into the Catholic nunnery straight out of high school and so our family was crazy Catholic. We had to go mass every single day. We had to say the rosary every single night.
My favorite priest was Martin Luther because he knew that's what the priests were 500 years ago. It was all voodoo and because the Germans couldn't read the Latin Bible. He was the first Catholic priest to translate the Bible into common German so the common people could read it and here 500 years later, you still talk ... You're a dentist talking, "We have irreversible pulpitis and you'll need endodontic therapy and you'll need [inaudible 00:37:32]. Do you have any questions?" It's like, what was that? Latin? Greek? What the hell was all that about? Then if you talk English, they're too arrogant.
I want to go to this. I want to ask you this question. I'll let you do the dentist but I routinely ask people. I'll say, "What were descriptive words coming to mind when I say lawyer?" They almost always say arrogant, prick, liar. Say with politician and what do you think ... When I say what about your physician, your MD? They still say, "Well, you know, arrogant, know it all, [inaudible 00:38:14] down, condescending." We saw the death of the male gynecologist because the women didn't feel ... Well, how do you even know what's going on? You never had a baby. You never had a period. Don't tell me it's all in my head. What words do you think Canadians use to describe if you said, "Describe a dentist." What do you think would be the first 5 words that come out of their mouth?
Nareg: What would I like it to be or what it actually is?
Howard: What it would actually is.
Nareg: I wouldn't be surprised if they say crook at some point, somewhere in that list. I think there's a distress of dentists that's been growing more and more and more. I would like them to say they're very human. I would like them to say that, "Oh, he's my buddy, my dentist." I don't think they say that. I don't think I would be able to come up with 5 words to be honest.
Howard: Now you're hearing lion killer. Did you remember that?
Nareg: Yeah, I got the lion killer, yeah.
Howard: The Cecil the lion, the lion killer. Somebody in the swimming pool told me that. Anyway, yeah.
Nareg: What do you think [inaudible 00:39:21] would be the 5 words?
Howard: Well, I think this. I think about this all the time and right now, if you go into Dentaltown ... When I got out of school, the big boogeyman was ... First it was OSHA. Dentists thought they're all going to jail for an OSHA violation and then later, it was HIPAA. Then back in the day in '87, it was this capitation where instead of paying you money per procedure, they were just going to give you $10 a month and you just fix up the patient and all that stuff.
I've lived through 28 years of different boogeymans and monsters that are supposedly always living under the bed and they're always going to come out and they'll get you. They never do and nothing ever changes. Right now, the big one is corporate dentistry. I think it's laughable because at 28 years of practice, I can't find anybody who stays at their same dentist. I know the lady I swam 2 and a half miles with, we did the 4,000-meter, 159 nine laps or whatever, she's been to 3 different dentist this year getting different opinions in this. She's gone to 3 in 1 year. The corporate dental chain, a lot of these corporate dental chains, they can't even keep their dentist employees for 1 year. Their average dentist doesn't even work for them for the year.
Nareg: They have a high turnaround.
Howard: Yeah, and the patients are just revolving door. You could also explain this incapacity. If a hygienist works 40 hours a week, 50 weeks a year, that's 2,000 hours a year. She could clean a thousand Howard and Naregs twice a year. She could clean a thousand people twice a year. You go to a dental office 30 years ago, how many hygienist? You got 1. 10 years later, how many hygienist? They got 1. 20 years later, how many hygienist? They got 1. They've never changed their capacity. Then you say, well how many new patients you get a month? They say 25. You say, okay well every 33 months, you should have added another hygienist. Nobody ....
Nareg: [crosstalk 00:41:14] at the same time.
Howard: The corporations can't keep a dentist and this is why when I got out of school, orthodontics centers of America's on the New York stock exchange or the billion-dollar valuation, the whole thing collapsed, everything, because they couldn't keep their orthodontist. There are [inaudible 00:41:30]. Then they all collapsed. They disappeared for 10 years. Now they're back, same red flags. They can't keep their dentist. As far as not keeping their patients, it's not just corporate, it's everybody. I don't see anybody's capacity. I don't see practices that are getting 25 new patients a month growing a third every year, on and on and on. They're always the same size. 20 years later, they're the same size. 30 years later, they 're the same size.
Nobody can keep a patient happy. What you're talking about ... My big beef is what you're talking about is whenever you start talking about this subject, they're all, “That's flop. I want to learn about bone grafting. Shut up, Nareg. Do I need bone morphological protein. Do you like autogenous graft?” They want to talk [crosstalk 00:42:17]
Nareg: Which is very important.
Howard: It is important but they want to be engineers. They don’t want to talk to people. They don’t want to talk to people, they don’t want to relate to people, they don’t want to relate to their staff.
Nareg: Well, there's talks, talks that maybe dentistry should split into 2 and part of it should merge into medicine and the other part should become a technique. These are ideas that are being thrown around at university levels, I guess, to see what is dentistry. Are we doctors? Are we technicians? I’m not sure we have a clear identity on this because we like to call ourselves doctors but we act like technicians.
We need to come to a conclusion on this. As a professional, we need to sit down and say, “Okay, we are doctors. Okay, if we are doctors, then we better start acting this way. If we're technicians, then we need to act this way. If we're a bit of both, then we need to figure out exactly where that line stands." Right now, I think there's a bit of confusion when it comes to dentistry, self-identity. If you ask most dentist, I think they see themselves as technicians and most dentists are proud. “Look how nice my prep is. Look how nice my filling is.” We barely mention about look how happy she became after seeing me type of thing or how well her life was improved. [crosstalk 00:43:36].
Howard: I think the best education is going around the world. When people have debates about healthcare models, everybody has an opinion and they've never gone to another country. When you study the 206 countries around the world, 180 at the United Nations, you can see the difference in healthcare systems and all the stuff. I think that the Soviet Union did it better where their dentists were a stomatology. All the medical students, 4 years undergrad, and the reason why I'm so ... It has to go back that way. It's separated in Baltimore in about 1890. It was separated by architects because a dentist needed a sit up chair and the physicians needed a lay down bed, and because of a stand up, sit up chair, and a lay down bed, that's how we got separated.
The Soviets left them in place so the 4-year med school is the same, the 2 first years of med school. Then you do a rotation. It could be in dermatology or gynecology or stomatology. The reason I think that is so critical, not just oh, the oral health system, it links and all that stuff, but the deal is physicians, 90% of them don’t have to work with their hands. They don’t have to do surgery. If you're a cardiovascular surgeon and you're losing your eye-hand coordination or you're just not good with your hands, you can just be cardiologist. I think that dentist would be a lot happier and a lot less stressful is that they start losing their eye-hand coordination or they weren’t good with their hands. I can say, “You know what, I could just go back to med school and I’m going to do a rotation in dermatology or ophthalmology. I’m going to do something non-surgical where I’ll just use my brain and not my hands.” I think it's one of the biggest curses in dentistry that you force these people that they always have to work with their hands.
My analogy to that is how many times have you seen where this person goes to school and gets a degree in painting and then you meet your 12-year-old niece with no training and she's a better painter. At the end of the day, there is natural ability. Some people have gifted hands in painting. Look at singing. I had 4 boys and I used to think that singing was cultural preference, right? I’d be rocking my little 1-year-old baby and I’d be singing and they'd reach their hand up, put on my mouth and say, “Daddy, no. No.” I think, "Oh, my God. A 1-year-old knows I suck. How does a one year old know I can't sing? I thought I could fool this guy." There is natural ability in singing and hands and artist and painting and the medical model of stomatology, like the Russians do, would be far better.
Nareg: Well, maybe. It's something that could be considered. More and more schools are trying to annex their beginning years with medicine. In Canada, that's popular. We have at least 2 schools, maybe 3 schools. McGill is 1 of them where the first 2 years is with medicine, so they do 2 years of med. Then once they finished doing 2 years of med then they go into dentistry and they continue the dental part of it. Except it's so crammed, the 2 years of dentistry, that it becomes difficult on a curricular level, so maybe should we add another year. I don’t know. Those are all questions that they need to figure out. At the more essence level, we need an identity and we don’t have that identity. In my opinion, we don’t have that identity. There's no clear identity of what is a dentist.
Howard: I know the main identity dentist have. I think most of them believe they're rock stars because I look at their living expenses. I know a dentist that was going bankrupt, and he had 5 cars. Are you the lead singer for the Rolling Stones? How the hell did you think you should have 5 ...? In dental school, they're taking cruises, they're going to the Caribbean, they're world travelers. It's like, “Dude, are you a rock star? Do you have an album I didn’t hear or I missed?” Their overhead is that I think they think they're rock stars. It's amazing. I’m 53 years old and my car is a 2004, the 115,000 miles. Then you drive either way to these 2 dental schools and half those kids, new cars, 30,000 dollars. They only get 12,000 miles. It's like, “Why is your car 12,000 miles and you have 5-year payments, and mine has a hundred and fifteen thousand miles?” Yeah, I think they're identity is rock stars but I have [crosstalk 00:47:56].
Nareg: You are a rock star, Howard.
Howard: What's that?
Nareg: You are a rock star.
Howard: No, I’m only a legend in my own mind. I’m only a rock star in my mind. Hey, I want to ask you another question since you are trilingual. You said you had a colleague in France.
Nareg: Yes.
Howard: France has a ... It's part of the EU and is their official language English in Brussels?
Nareg: The official language of France Is French.
Howard: No, the Brussels for the EU or European Union. What do they do all their legal work in?
Nareg: In what language they're doing it? I have no idea.
Howard: I was wondering when you talk to your colleague in France, do you speak in French?
Nareg: We speak in French, yeah. He barely speaks ... He speaks English but he struggles with it. I don’t struggle with French that much so we communicate in French.
Howard: Do you ever get on ... There's a French Dentaltown called Eugenol. Have you ever gone on that?
Nareg: He goes on that. I haven't but he has shown me excerpts of Eugenol.
Howard: That lady is so cool. I started Dentaltown in '98, she started Eugenol years later. When she started Eugenol, I was so proud of her. She flew all the way from Paris, France to Phoenix to talk to our team about ideas.
Nareg: Oh, really? Wow.
Howard: I just thought ...
Nareg: [crosstalk 00:49:13]. Cool.
Howard: I just thought I was so humbled that she was so ambitious that she would fly all the way from Paris to Phoenix to talk to little old me and our team at Dentaltown and just the sweetest lady in the world. I haven’t seen her since so I was wondering if that's still going. We were talking about you want these people to be successful. You're talking about patient-centered and you talked about vulnerability. I always talk about parodying what Harvard Business Review is always saying. They're always saying the number 1 trait they see in the most successful CEOs is humility. Humbleness, humble, humility. What else do you think they need?
Nareg: Well, we came up with a model of what does it mean to be patient-centered. Our model, it says there's 2 sides, so to understand everything you need a model which is a higher level and you need an approach, which is more of the recipe thing. Our model, we said that in order to be patient-centered in dentistry, before that even, we said dentistry goes through 3 things that are different from medicine. We try to understand, we take a decision, and then we intervene. That intervention is different from medicine.
In order to understand to be patient-centered, we need to understand not only disease but we also need to understand illness. Disease is the actual disease, and illness is the experience of the patient of that disease or of anything. Illness is an experience thing. We usually don't explore illness the way we explore disease. We're very good at exploring disease which is not very good exploring illness. Adding exploring illness would be important to become patient-centered.
When we're doing decisions, so when there's decision making, to be patient-centered, the decision making has to be shared. It needs to be a shared decision making. It's not you decide as a patient, it's not me that I decide as a dentist, but we decide together what would be best for you. In order to do this, we need to let go of the idea that there is an ideal treatment plan and everything else is a compromise because then we're not doing a shared decision. To do a shared decision, we need to understand that there's multiple ways of doing things. We need to figure out together what you need and what I can do for you, and then let's put those 2 things together and then figure out what's the best for you. What's the best for you could be very different from what's the best for somebody else presenting the same situation.
Finally, in interventions we said that in order to be patient-centered in interventions, we need to go at the pace of the patient. We need to include the patients and their expectations into our outcomes. It's not just about getting that x-ray that looks perfect, it's all about, “How do you feel? Are we comfortable now?” That is as important as that x-ray that looks like that white line is all the way to the tip of the apex. Who cares? We care, right?
This is the model we came up with. As an approach, we said that for a dentist to be able to do this, they need 3 characteristics. Humility was one of them. Hospitality is another one because you can be humble, as humble as you want. You can open the door but it's not enough to open the door, you need to invite people in. You need to attract the attention, attract the questions. You need to say, “Ask the questions.” Your whole demeanor has to be very welcoming. That's very important, I think, that hospitality.
Finally, we say we need to be mindful. Mindfulness is the new buzz word in medicine now. Mindfulness is the ability to be present. When I’m talking to you, I need to be mentally present. We need to make contact, we need to connect. I shouldn't be writing something and looking, washing my hands, and then while you're explaining to me your life story. That's not being mindful. Mindfulness is in the moment right there, like we're connecting. When you're working, we need to be mentally present while we're working. Not chitchatting with our assistant about how the weekend was while I’m doing some work. That's not being patient-centered to me. It's a little bit insulting for the patient.
Those are the 3 attributes we said that the dentist needs to have. Then how they do it, it's up to them because we cannot say 1 way fits everyone but as long as you have these attributes, each dentist, based on their personality and the patient's personality, they're going to have different recipe books on doing things and that's fine. I don’t think 1 way needs to be ... You can't just tailor 1 thing and then apply it on everyone. You like big words, the big word for this is constructivist. This is a very constructivist way of looking at things. That means reality is constructed by different people's construction of reality. As supposed to a positivist view of health, a positivist view says, “This is the right way. This is a wrong way, and we can clearly measure what's right, what's wrong.” That used to be the old way of doing things, the positivist you and more and more the tendency is going towards a constructivist understanding of health.
What does it mean to be healthy? It's different for you, it's different for me. I might have a different idea of what it means to be healthy. Don’t impose your values of health on me when I have completely different values of health. Maybe for me, aesthetics is more important than an infection in the back tooth. I don’t know. It's my health, it's my body. That needs to be taken into account. Sure there are some limits we can't cross, legally mostly, but I think we need to at least acknowledge that the construction of each person does of health is important. Yeah, I’m done.
Howard: I swear to God, I’m just going to start calling you the Socrates, Plato, Aristotle of dentistry. If you and I know this is 10 times more important than which implant system to buy, why don’t you build an online e-course on Dentaltown on this, the patient centered practice, and cover all of this because they need it more than anything. They come out with $250,000 on student loans and they think they can't be successful unless they spend a hundred fifty thousand on a CAD/CAM, 75,000 on a laser, and a hundred thousand on a CBCT 3D x-ray machine. I can give you the names of a hundred massively successful dentist just because they don’t have any of those things but they're just humble and have humility and mindfulness and vulnerability. You know what I mean? Why don’t you do that?
Nareg: I thought of it a while ago. I discussed it with Howard. I thought there would be no interest back then. I don’t think people are interested. If they're interested, I’ll be more than willing of putting together some kind of ...
Howard: They will be very interested, and I think it would be far better if when you presented, it was for the team, the office watch desk in the patient waiting room. They put Nareg up there on the screen and get into the zone together because they're not laboratory techs. When they come in, everything you're talking about is the most important. Then when I talk to my peeps, they're like, “Oh, that's flop. I want to talk about which bonding agent do you use.” I'm like, “Who cares?” See, that doesn’t even matter.
Nareg: [crosstalk 00:56:04] those. Well, it'd be more interesting for dentists, but if dentists are interested or teams are interested in anything like that, I'm more than happy. I have tons of courses I’ve already done here at the university. It's easy to turn this into an online CE thing. It's not that difficult.
Howard: Yeah, let's do that. You might even do a series. I read something very interesting on mindfulness that with 1 technique you massively raise the score of the patient thinking that you are listening if you just repeated some before you go to the next question. If I ask you a question, you answer, and I’m a doctor, we have reading comprehension, we got it, we go to the next question. They don’t think you're listening. If you just paraphrase, summarize over the few words then go to your new question, they're like, “He's listening.”
Nareg: They understood it.
Howard: Yeah, so you got to repeat.
Nareg: I'm not a huge, huge fan of those recipes per se. They're great. However, the intent has to be behind it, and I’m scared some people who don’t have the intent, they just repeat it automatically. I think patients can tune in to that. Some patients can tune in to that. I can tell when you're just repeating what I'm saying just because you repeat what I say as opposed to you actually you're there in the conversation.
Howard: Nareg, the secret ...
Nareg: The secret is mindfulness.
Howard: The secret to success is to be able to fake sincerity.
Nareg: That's right.
Howard: That was a joke. No way [inaudible 00:57:30]. Also you said in the middle of France and Canada, is everything you're talking about different in Paris than it is Toronto or Detroit or Chicago? Do you sense any of that?
Nareg: [crosstalk 00:57:53] level. The universities around the world, I think, are at the same level, at least France are. However, there seems to be they're faster to change.
Howard: Who's faster in change?
Nareg: Their patient centered techniques are being implemented with much less resistance in France as we're having here in Canada. People seem to be a bit more resistant here. Maybe it's the way the universities are, maybe we were much more conservative. Maybe they're less conservative in France, so they're like, “Yeah, let's change. No problem.” They're more risk takers when it comes to teaching students, approaches of teaching students. Maybe that's what it is. I don’t know. My colleague's having a much easier time implementing patient-centered techniques and invested to lose [inaudible 00:58:35] than we are here.
Howard: Is Paris one of your favorite vacation spot?
Nareg: I've never been to Paris.
Howard: You're kidding me. You speak French, you've never been to Paris. I have to fly you there myself.
Nareg: I went to Toulouse south of France was one of the beautiful places in the world. I highly recommend. You can buy amazing wines for 2 Euros, 3 Euros straight from the manufacturer. Amazing cheese, amazing food, beautiful scenery. It's in south of France. It's a paradise.
Howard: How politically incorrect can I get [inaudible 00:59:07] Paris. How many people can I offend?
Nareg: You can't offend French.
Howard: I’ll tell you the truth about Paris. They are far more serious about their food, the way they look, the way they dress, the way they smell. You go to Britain and Germany, and you meet a 60-year-old man or woman and they don’t really care how they dress, their food is bland, they'd have no cologne or perfume. A french woman at 70 is still rocking it. She's sitting there with her purse, her shoes, and there's garnishes on it. I think it probably is the most cultural town in the world.
Nareg: Yeah, France is weird. On 1 hand, they're very liberal, on the other hand, they're so stuck on their rituals, their social rituals. In France, you have “tu” and “vous,” it's the plural you and the singular you. Then other respect you call people who you haven’t met before or you don’t know them well as the plural you. In today's age, this is all gone but in France, you have to stick to this. It's a huge deal for them. For a society that's so liberal, it's weird how they have all those social etiquettes that are so stuck. The way you're saying ,the way they look, about their food, their rituals of eating, pairing wines with their food, it's so ritualized. They're very stuck on those which is weird because they're so [crosstalk 01:00:37].
Howard: Maybe that's why. Now it makes sense because he asked me if I was born in a barn. Maybe I was doing something wrong. Hey, I got to ask you a last question since you speak French. The father of dentistry is Pierre Fauchard. Did you ever read his book? I think it was written in 1780 or whatever.
Nareg: I have not read his book.
Howard: We're having Dentaltown ... We started in '98 and then in 2004 we had the online CE. Then we've added a podcast. The next feature coming out is audio books. I'm going to read that book. I’m going to try to find someone in French to read it. If you could ... I know you're a busy man, but if you could find me a French dentist. I going to have the audio book. I’m going to have the Pierre Fauchard's book in French and then English. Then I’m also going to do the American's father of dentistry, G.V. Black, which is about a hundred years later than Pierre Fauchard and do that in English.
Nareg: That's a cool project. I can try and find someone.
Howard: You can find someone French?
Nareg: I'll keep you in mind, don’t worry.
Howard: Yeah. Find one because they'll have to do a dental terminology, I assume. Hey, Nareg, seriously dude, this was the most fun hour I’ve had all week. Now I’m your hugest fan. You're just a great guy. You shared so much, and I just think you're great guy. Thank you so much for spending an hour with me today.
Nareg: Thank you. It's my pleasure.
Howard: Any time you want my free services in Montreal, dude, I’m there for your countless, gazillion hours you spend on Dentaltown.
Nareg: Thank you so much.
Howard: All right, bye.
Nareg: Bye.