The 5 Tenets of Practice Success by Brad Guyton, DDS, MBA, MPH and Carolyn Ghazal, DDS

Dr. Guyton's start
The day I arrived in Nashville, Tennessee for my first morning of undergraduate orientation, I believed I had entered a brave new world with limitless opportunity to grow and explore. By that evening, my new oyster already started smelling a little fishy.

For many of us, that day was spent with our parent(s), moving crates into our dorms and walking around campus looking at the 40 different ways we could get involved in campus life. But that evening was different.

We filed into the stadium to hear the chancellor speak to the incoming students. His first statement was, "Welcome to our campus. I ask you to look at the student to your left … (long pause) … In four years, at graduation, one of you won't be here." Ouch!—the sucker punch. Opportunity just flipped over to responsibility. Reality hit home.

Fast-forward nearly 25 years. I am no longer a young student or a new dentist. I have been blessed to own a couple of practices and learn from some world-class mentors, and through my jobs in dental consulting, industry, and education, I have had the opportunity to hear from hundreds of dentists about what makes them successful.

Dr. Ghazal's start
My experience has been a little different, as I have been in the Pacific Dental Services-supported environment for almost 25 years, but in that time I, too, have witnessed (and coached) hundreds of dentists on success and clinical excellence. In 1991, I had been practicing for just one year and had quickly become discouraged. Dentistry was not what I expected. Luckily, I quickly recognized how dissatisfied I had become in my job and took action.

A month into my search for something better, I was hired by a doctor who ultimately became my mentor and had a significant impact on my career. He taught me the basic building blocks of becoming successful and the value of becoming a lifelong learner. My success today is due in large part to my mentor; he was unique because he was genuinely interested in my development. My confidence grew, and I became a mentor to others. Today, while I spend a great deal of my time coaching others, I still find myself humbled by how much I learn from those I teach.

Our consensus
The two of us recently sat down and outlined the five tenets to business success in dentistry. If we master these five practice-management tenets, nothing short of bad luck will stand in our way. We believe that they are so important, every dentist should cut them out right now and tape them to their car dashboard. Try a new one each day this week. Here they are:
  • Monday: Prioritize excellence, while becoming excellent at prioritization.
  • Tuesday: Build systems to decrease stress, instead of stressing about decreases.
  • Wednesday: Focus more on increasing revenue, and less on decreasing costs.
  • Thursday: Be better, not cheaper.
  • Friday: Be willing to take what others are willing to give and give what it takes.
Of course our clinical culture, operational excellence, technology, team morale, and a slew of other factors are important, but not until we have mastered the five tenets.

Let's take a closer look at each one.

Tenet #1: Prioritize excellence, while becoming excellent at prioritization.
At the core of what we do as clinicians should be a firm commitment to clinical excellence. This is even more important than operational effectiveness. When we survey dentists, 91 percent respond that, "When we retire we will be most proud that we have helped other people." However, 82 percent of young dentists claim they are in dentistry to make a good living. There is a great disconnect between what we will find satisfaction in later, versus what drives us today.

If the fundamentals for a good team and business model are in place, and if we focus on making the lives of our team and patients better every day, the money will follow. One of the first dental journal articles I ever read stated that success in dentistry was typically due to steady growth, a focus on the patient, and "underpinnings in exceptional clinical skills."

Dentistry affords us a luxury that few professions have: we see the direct and immediate way we improve people's lives. Sister Irene Kraus entered her religious order in her teens during WWII, served as an operating room supervisor, earned her MBA, directed six Catholic hospitals, and was the first president of the Daughters of Charity National Health System, which was in charge of more than 80 hospitals and health-care facilities. She is given credit for having coined the now well-known phrase, "No margin, no mission."

In other words, strong fiscal management is necessary to accomplish our mission, vision, and goals. We must remind ourselves that while the margin feeds us, it is the mission that keeps us fed.

Dentistry has few shortcuts. It is almost impossible to build trust based on profit. However, prioritizing patients over profit builds trust. Trust enhances case acceptance. And improved case acceptance equals profit.

As a complement to prioritizing excellence, we must be excellent at prioritization. As former UCLA basketball coach John Wooden said, "We must never mistake activity for achievement." Here comes the understatement of the article … wait for it … dentistry is a busy profession. Most of us know all too well what it is like to run around the office all day with a fire hose. And we go home drained from filling far too few teeth and far too many emotional bank accounts.

Success comes when we learn to build trust with our teams so that we can delegate even the high-value tasks of the day. If we train and delegate appropriately, we simplify our lives so that we can focus more on the significant tasks and less on the survival ones.

William James said that the art of being wise is the art of knowing what to overlook. Planned neglect, as you move up the chain of command, is critical.

We never want to mistake being busy for being effective. Take the time to prioritize the projects that are most important and focus on getting them done in order—no one ever poached a perfect egg by scrambling it. It can be daunting to build a checklist and then order it in terms of priority, but if we delegate effectively we can achieve remarkable results over time.

"The best thing about the future is it comes only one day at a time."—Abraham Lincoln

Tenet #2: Build systems to decrease stress, instead of stressing about decreases.
The top three stressors consistently observed in the dental office are: conflict among team members, understanding practice financials, and marketing the practice. Ever wonder:
  1. Why, when we arrive home after a long day at the office, we sometimes feel like it takes every ounce of effort just to make it to the couch?
  2. How other dentists seem to have boundless energy and are off running marathons and traveling the world?
The common solution to these challenges may often be found in the adoption and implementation of business systems.

Business systems are the fundamental building blocks of our success. They are repeatable processes that are designed to achieve a desired, consistent outcome in our practices. Business systems pervade every aspect of the office from when our doors open to when they close, and range from formats for effective meetings to patient retention processes and perfecting the patient experience.

Operating without systems means we are either gambling, or working harder than we need to be. Systems allow us to provide greater value to our patients because our outcomes are predictable, measured, and consistent. It is often the systems that are the highlighted keys to success in the most popular business books like In Search of Excellence (T. Peters/R Waterman), The Tipping Point (M. Gladwell), and Good to Great (J. Collins). While imperfect (occasionally highlighting companies or examples that were relevant at the time, but may no longer hold true), these "success story" books challenge and motivate us to be better, and to think in terms of systems. When we implement systems in our practices, we not only reduce stress, but we also often work less and make more.

While financial fluctuations do occur in dental practices, our energies are best spent focused on systemizing office procedures versus staring blankly at spreadsheets, wondering what went wrong last month. This is a classic example of taking a proactive role in your practice as opposed to a reactive one.

Once created, successful implementation of systems is dependent on the cohesion of the team. Successful teams are very clear on the goals and priorities of the practice and are cross-trained in other roles of the office. Each team member must be aware of what his/her contribution must be in order to achieve office success. Accountability plays a significant role in achieving results.

When we have systems in place, we are able to hold team members accountable. This leads to having systems in place that are effective, because they are implemented consistently. And personal success must align with office success—not just at the end of the quarter or year, but at the end of each day.

An added benefit of having systems is that when something goes sideways, we can evaluate our process and identify where the breakdown occurred. This allows for rapid course correction and risk mitigation.

Tenet #3: Focus on increasing revenue, not decreasing costs.
We need a balanced approach to revenue enhancement and cost-control focus. And the scale should tip toward increasing revenue. When we spend too much time on decreasing costs, we begin the vicious spiral of chasing the wrong target. Would you rather have a $1 million office with 70 percent overhead, or a $700,000 office with 65 percent overhead?

Remember in 2009 and 2010, when most doctors panicked during the Great Recession? Most of them discounted fees, prolonged patient payment arrangements, and tried to cut costs everywhere they could. For most of them, this didn't help much. What did the dentists who excelled during that period do instead? They focused less on decreasing costs and more on increasing revenue. They invested in three specific areas:
  1. A commitment to expanding skills through clinical education
  2. Expanding in-office procedural mix (they referred fewer procedures out and instead kept them in house)
  3. Case presentation and sales skills
Did we just say "sales skills"? Yes, we did. Those two may be the least favorite words in a dentist's vocabulary. How about "case presentation and patient acceptance"? Does that sound a little better? How about "patient education"? Ahh—you just exhaled a sigh of relief, right? The bottom line—regardless of what we call it—is that we are helping patients understand their options and enabling them to pick the best option to address their needs and wants. These are the keys to driving patient satisfaction while simultaneously enhancing practice success through increased revenue.

No matter what we call it, getting patients to say "yes" to the treatment they need is the lifeblood of our practice. We would go as far as to say that it's more important than new-patient flow and even patient retention. In business, we use the term "churn," which can easily be visually defined by the concept of pouring water in a bucket that has a hole at the bottom.

Think of new-patient flow as the rate at which we pour water into the bucket, and patient retention in terms of the amount of water that remains in the pail—which directly corresponds to the size of the hole at the bottom. The hole is the churn. They both definitely matter, but if we want to boil water in that bucket, what matters—even more than the flow and the hole—is the heat. The heat is the "sale," and we can't cook without the heat. Given the assumption that no good dentist will ever sell a patient on treatment that is either not needed or wanted, then sales is merely a result, a by-product, of a relationship built on trust.

Revelation #1: Sales is patient education and patient acceptance.
Revelation #2: Trust drives sales.
Revelation #3: When trust drives sales, sales drives revenue. Period.

For those of you who came out of the recession stronger, better, and more profitable, was it really the cost cutting that made the difference? Was it cutting the monthly team lunches or counting cotton rolls? Or was it a line-item farther north on your balance sheet?

In the April 2013 edition of Harvard Business Review, M. Raynor and M. Ahmed summarize their research findings from studying more than 25,000 companies over 44 years. They conclude that there are only two common threads for success:
  1. Compete on differentiators, before you compete on price.
  2. Always prioritize increasing revenue over reducing costs.
They found that everything else was a distant second to these two critical tenets. To be exceptional, dental practices don't become great by killing the coffee bar or switching impression materials. Instead, we earn our way to greatness by investing in ourselves, our practices, our team, and our patients. When we do this, we learn new service delivery verticals so that we may expand our scope of practice. Not only are we improving service, but we may also be cutting costs at the same time. By investing in our teams and patients, we empower others to live up to their full potential. Revenue focus does not supersede the other four tenets. Revenue focus is about differentiating yourself from other dentists so that you no longer need to compete on price, you invest in the right team, technology, and techniques, and you practice the way you want to practice.

When we learn to serve patients instead of feeling like we deserve to be served by our profession, we win. Profitable practices depend on revenue enhancement and cost control with emphasis on revenue enhancement.

Tenet #4: Be better, not cheaper.
It is as simple as the Montage Hotels versus Motel 6. Just as in the hotel business, there will always be dentists who compete on price. As healthcare practitioners, most of us would prefer to compete on service and quality of care.

We believe the choice to have a high-tech practice with digital X-rays and CAD/CAM technology in our offices early on helped our practices survive the economic turmoil of six years ago. Our choice to invest in education and commit to offering the best solutions for our patients allows us to improve quality and enhance margins.

It seems obvious that the dentists who win are dentists who get better every year. The best dentists commit to a goal of at least 100 CE hours every year, rather than just the state minimum. The learning does not stop with us, the dentists; the teams that engage in learning are the teams that reach their full potential.

In his book, Better, Atul Gawande explains three components of being better: diligence, doing right and ingenuity. He begins with the question, "What does it take to be good at something in which failure is so easy, so effortless?" He makes the case that avoiding failure and being better takes hard work, prioritizing people over profit, and creativity. He also asks, "What if you turn out to be average?" By definition, you probably will be. He encourages health-care providers not to settle for average, but to be better and not just take the path of least resistance.

In most communities today, it is becoming more difficult to hang a shingle as a solo practitioner. We must get our minds off the dental assembly line and instead be innovative and ingenious in order to be better than our neighbors. In his recent book, Imagine, Jonah Lehrer emphasizes, "Although we live in an age that worships attention—when we need to work, we force ourselves to concentrate—this approach can inhibit the imagination." We must give ourselves time to think and imagine what could and should be, not just what was and is. Success most often follows those who work hard, but we need to reserve adequate time to reflect, imagine, and explore new possibilities. Being mindful of the need for self-reflection, continuous evolution, and growth potential is paramount. Reinventing one's self is a must for long-term success.

Tenet #5: Be willing to take what others are willing to give and give what it takes.
Look at this as a willingness to mentor team members (especially associates) and an openness to being mentored. Dentists learn best by shoulder-to-shoulder coaching. This applies to clinical competence and team leadership; we learn from leaders around us. We then incorporate our prior experiences, reflect on and learn from them, and execute our strategies.

This is what leads to growth and maturation as a leader. In watching the San Antonio Spurs rise to win another championship last year, multiple team leaders spoke about learning from painful experiences in their past, how they rose to the challenge and ultimately became better. These players credit and define their level of talent and play as executing their "best over a long period of time."

We gain confidence and competence most effectively from our best mentors. We each have personal mentors who have been helping us for many years and owe much of our career development to their guidance and leadership. We identified dentists who are some of the best clinicians in the country and sought to practice alongside them. Even after so many years beyond dental school, we still learn something each day when practicing together.

We all have to show some vulnerability and remain open to improvement. Continued growth over the course of our careers is necessary for evolving in a positive way. When a leader is open in such a way, he or she is better received by the team members he or she is trying to lead. In return, the team members will follow and even step up to lead by simply following the example that we set.

As Phil Harkins suggests in his article, "Ten Leadership Techniques for Building High-Performing Teams," being confident, genuine and dependable, while listening and defining a clear picture of expectations, is the catalyst for others to follow.

We finish with the importance of being willing to give what it takes. Tenacity, training, trust, and a focus on serving others are what make doctors successful and satisfied. No matter how successful we might be today, tomorrow is a different day. We must be humble and hungry at the same time. Self-actualization in dentistry is defined by simultaneously being a student, a promoter, a servant, and an instructor.

Each of us has what it takes. Prioritize excellence, invest in systems, focus on revenue, be better and be willing. When we focus on these five fundamentals, we discover success.

And once we discover that success—we can look to the left and help your neighbor find success!

Dr. Brad Guyton serves as vice president of Clinician Development for Pacific Dental Services and dean of the PDS Institute. He is an associate professor at UCSDM and practices dentistry in Denver, Colorado. He can be reached at

Dr. Carolyn Ghazal was the first Pacific Dental Services-supported owner dentist, is currently a multiple-office owner/doctor, and is chair of associate development for PDS Institute. Dr. Ghazal can be reached at


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