Second Opinion By Rick Kushner, DDS

Second opinions are common in healthcare; whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dentists to share their opinions on various topics, providing you with a “Second Opinion.” Perhaps some of these dentists’ observations will change your mind; while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.
–– Thomas Giacobbi, DDS, FAGD, Dentaltown Editorial Director

Maybe you remember me. For more than 15 years I lectured on my “Lean and Mean” practice management philosophy in every major and minor city in the US and Canada from the early ‘80s through the late ‘90s. My wife Cindy and I sometimes visited as many as 50 cities per year to talk to dentists. More recently some of our partners and I published three years of our classic print masterpiece, The Simple Truth newsletter. Ultimately we have talked to tens of thousands of dentists, most of whom are smarter than me. The scars on my head from beating it against the wall are nearly healed now that I have retired from arguing with dentists.

I now set my appearance fee just higher than anyone can or will pay and am always just a little too busy to write an article for or speak to anyone other than my partners (the one exception is in a dental school). What with 83,000 new patients and $64 million collected in 2005, growth potential so great I can’t build dental buildings fast enough, ever increasing numbers of partner candidates needing me to create Comfort Dental opportunities for them, 100+ current partners earning triple the national average for dentists in the US, I can stay as busy and successful as I want to be by cajoling our partners, the greatest people on earth, into the Lean and Mean style of practice and philosophy. Ours is the largest entirely-dentist-owned organization in the world.

All of my material is still available in audio, video and print mediums. It is at once ahead of its time and absolutely timeless, and I might add, the greatest material ever compiled for practice management success in the history of our profession. But in the end, you see, very few listened. Oh, those few and my partners here at Comfort Dental in Colorado have prospered beyond their wildest dreams as a result of listening; and don’t get me wrong – we’ve made hundreds of friends around the country and we are still in touch regularly with many of them, including Howard – but again, you see, in the final analysis, very few listened.

You’re hearing from me now for the simple sole reason that Howard asked me as a personal favor. I’ve refused him many times over the years. As he works to get back up to full speed, I’ve agreed to do an article for him. By the way Howard, permission to edit this article in any way is hereby denied, and yes, this is part of the article. So, I don’t argue anymore. I don’t debate. I’m supremely confident that we got it right. Right for our patient population, right for us here at Comfort Dental, right for 99% of all dentists, but they don’t/won’t listen. Maybe it’s a good thing or we wouldn’t be who we are.

Over these many years, I have preached continuously about what a dangerous threat elitism is to the mainstream profession. Dentists have been made to feel embarrassed, inferior, inadequate, and less than a full dentist if they do not raise fees exorbitantly and perform only big-ticket cosmetic services. Dentists are shamed into not admitting they perform what we believe to be the ultimate ANSWER to serving our communities and fulfilling our financial goals as the professionals we are: that is, performing bread-and-butter dentistry such as amalgams, extractions, immediate dentures and the like. Impressionable dental students and younger and dumber dentists can only conclude that the only proper way to practice dentistry is in an elite cosmetic boutique spa practice. What with the barrage of continuing education hype virtually all geared towards big fee cosmetic services, elite gnathological and cosmetic dentistry “institutes,” big dental product suppliers and manufacturers, and equipment salesman all thinking they can lead the young and dumb around by their you-know-whats, I’ve warned all who gave me a forum and many who didn’t to wise up. I’ve lamented the shame and sorrow I feel for all solid bread-and-butter dentists like us Comfort Dentists, who can’t or won’t beam with the pride they should feel for what they do because others look down their nose at them.

Very few listened. Elitism has run rampant and, to me, has no end in sight. Elitism has a place: for around 1% of our market. The profession has priced itself out of huge segments of the marketplace; a marketplace that is extremely BROAD –– regardless of how hard the elitists try to narrow it. It is a market that stupid dentists think dentists control. Dentists do not. Patients control our market. It shames me to admit that the profession has literally and figuratively turned its back on most of the American patient base. We prove it daily by the way our ordinary working class patient base flocks to our offices. As an example, we recently opened a new office in a small resort town with 10 or 12 dentists all working the same patient UNfriendly hours, same fees (high), same plans (none). They were quick to point out that there was no room for more dentists in this community. Of course I ignored the warning, we opened and experienced our largest, most successful first year, by far, in our history. Now we target much smaller markets than we used to for all the reasons above.

We should be proudly offering and performing AFFORDABLE extractions, single-unit crowns, one-visit endos, non-surgical perio, dentures, and amalgams. Yes, AMALGAMS. Amalgams are fine restorations and those who claim they are harmful to patients are hucksters. If you do not do amalgam and you are not in the top one-tenth of one percent in people-skill and clinical talent and you do not practice in one of the extremely rare upper-class communities in the US, you have been grossly misguided. I have only amalgam and gold in my mouth and in recent years had a 30-year amalgam replaced…with another amalgam. I’ll do it again when necessary. Do not feel ashamed to do strong, durable, serviceable amalgams. Learn to do them fast and good. Lots of ‘em. Tons of ‘em.

I preached overheads in the low 40 percents and taught how to achieve it so we could make informed decisions on managed care and other discounted fee plans. Elitists taught how to “beat” managed care. How’d that work out for ‘em? Here at Comfort Dental, we can accept any dental plan we choose to and profit from it because all of our overheads are under 50%; quite a few under 40%. Very few dentists believed. They got used to 75+% overheads and now dental students are taught to expect it.

Speaking of dental schools, I preached that they actually do a decent job if they don’t try to do too much. I was worried that students don’t get enough procedure “reps” and that instructors need to be cautious of their tendency to impart an elitist mentality to students…dental students for goodness sakes! I said that dental school was not to be taken too seriously. That it should be considered a right of passage, a place to get your ticket punched and that the focus should be on getting maximum reps in bread-and-butter procedures. Nobody listened and a few schools graduate dentists who can’t do endos or extractions and therefore aren’t even real dentists. (They can do posterior composites, though.) Others graduate dentists with an elite bent that retards them financially for years until they finally figure out they were sold a “bill of goods.” Some never do.

The result is a continuing plethora of bankruptcies. If you are not aware of a dental bankruptcy, you need to get out more. At any given time, I’m aware of at least 10. See: Utah. We have a young superstar partner who was awarded “dental office” of the year by a large supply house two years before he went bankrupt in Utah. They sold him everything under the sun because he couldn’t practice without all of it. Thankfully he found us and now sees the light. He’s an immensely talented guy who simply got sucked into the elitist bottomless pit. He is one of a precious few elitist rats to have successfully accomplished jumping the elite ship.

I preached and preached collection policy as the number one factor in low overhead. We taught thousands of dentist how to collect 100+% of their production without sending statements. We taught the painful steps necessary to achieve overheads in the low 40 percents. Very few listened and most simply didn’t believe us.

We talked about the Recall Myth: That is, the false security that nearly all dentists think results from a big recall system. I told what you get from a big recall system: big overhead. Show me multiple hygienists and I’ll show you 80% overhead. Security doesn’t come from big recall. It comes from big NEW PATIENT flow.

I showed how to handle the new patient. I taught how to open the telephone and front office gates to allow hundreds of new patients per month into the practice. We demonstrated how new patients should and could be invited into the practice same day or next day from the initial phone call. We taught why and how to NOT schedule new patients in hygiene, how NOT to do first-visit prophies and how it results in complete-case dentistry…better for our patients and better for our success. Very few listened because it was hard. That’s the catch. What we do is hard. So most dentists do things the way they always have and think the way to increase income is to raise fees. The best way to increase income is to find a way to help more people and the best way to meet more people is to hold the line on fees.

Maybe my best preaching of all was concerning our Lean and Mean Group practice concept. It allows the senior doc to recapture the equity in the practice in multiples through growth and the sale of partnerships. It also resulted in reduced overhead via the expanded hours that are mandatory in today’s market along with the other economies of scale that maximum usage of the facility provides. I conveyed my heartfelt belief that solo practice is an antiquated concept and only suitable for a tiny few percentage points of elite-leaning dentists. I warned dentists against taking their solo practice downhill into retirement. Very few listened and what we have are multitudes of retiring dentists closing their doors because no one will buy their practices. Retirement is not what they hoped it would be.

I spent eons teaching how important location is to dentists and that proximity (or not) to other dentists is NOT a factor. I ranked the types of locations from best to worst so no dentist who listened could possibly locate in anything but a good location. Very few dentist paid any attention and I still see dentists who look like they are hiding their offices from their patients.

For all these many years, I preached that a traditional one-patient-per-hour hygiene practice was a failed ideology that drove overheads ridiculously high and didn’t meet the needs of our patients or the practice. Most hygienists reacted with all too typical knee-jerk venom, refusing to own up to their role in the fiasco and refusing to learn how they could serve more and better for our patients while earning better for themselves as well. We taught accelerated hygiene practice in our Lean and Mean hygiene series and our hygienists prospered and served our patients well. We talked about such things as no hygienist “nesting” meaning no specified hygiene rooms creating all-same treatment rooms, no first visit hygiene scheduling, no new patients scheduled with the hygienist, and doctor diagnosis of perio disease. Very few listened and enough dentists are fooled by the ancient ideology and have now accepted 75+% overhead. In my geography, we suffered through a horrific hygienist shortage in the late ‘90s so by necessity we learned to do without hygienists and we learned well. Nobody believes me, but I love hygienists and they are NOT overpaid; however, they could do so much more. In our system, they must do it our way or they’re not with us. Mostly, they’re not with us.

Surprisingly, on the rare moment when I look at a professional periodical most often filled with nothing but mindless drivel, elite CE hustles, and gadget/product huckstering, I occasionally see messages similar to mine espoused by a respected colleague. I appreciate it. It gives me hope. Make no mistake though: I said it first, I said it best and I still do. It would be nice if they mentioned my name now and then. I’m no longer the irreverent smart-@#$ punk you used to know disrespecting my elders and the institutions of the profession. I’m a smart-@#$ elder-statesman disrespecting everyone who doesn’t see it my way because we got it right.

To be sure, Cindy and I have been humbled by the tragedies of life in general, but our passion for how we know dental care should be delivered to the dental patients of this land has never wavered. We are more confident of our righteousness than ever. We have taken our lumps from the profession in every way imaginable as you would expect to happen to someone who elects to swim upstream for an entire career. Dental politicos, dental school instructors, elitist traditional soloists, et. al. consider us fair game for pot-shotting and perpetually in season. This is to be expected; however painful, as we are dealing with, after all, well…dentists. (And I don’t mean that in a good way.) We have found too many dentists to be jealous and hypercritical of their own kind all the while being non-confrontational poster children for passive-aggressive behavior. Translation: Embittered, backbiting cowards. Such is the price we pay for our success. We carry on anyway. Every arrow in the back that I suffer determines and emboldens me even further to grow our wonderful organization throughout this country.

So, Cindy and I spend our time with our sons, caring for our Comfort Dental Partners (you see, they DO listen) investing in real estate, and entertaining our partners in Colorado and around the country (often in our own jet and in our own resorts). I wanted to be able to bring you new practice management techniques and tools for this new millennium on my first effort after these past few years. But there aren’t any. I wanted to bring you a new message. But there isn’t one. Maybe this time, you’ll listen to the old message. It just doesn’t get any better.

My best to all of you.

Editor’s Note: What do you think? Discuss this article on the Dentaltown.com message boards. Dentaltown » Dentaltown Magazine this month... » May 2006 » Very Few Listened by Dr. Kushner

Rick Kushner, DDS is the founder, president & CEO of Comfort Dental. The first Comfort Dental was opened in 1993 in Denver, Colo. Since then, the company has expanded to include many offices in the Denver area, plus six Comfort Dental Braces offices, and additional offices in Colorado Springs, Ft. Collins, Pueblo and Glenwood Springs. Each Comfort Dental office is independently owned and operated by dentists. Unlike solo or chain dental practices who get paid hourly or on a production schedule, all Comfort Dental doctors are owner/partners in their own practices. Their mission is to provide affordable, high-quality dentistry to patients. For more information Dr. Kushner, can be reached at: Rick Kushner, DDS, Comfort Dental Inc. 9990 W. 26th Ave. #300, Lakewood, CO 80215 or RAKUSHNER@aol.com.