My Casebook

The Excellent and Effective Dentist

       The Excellent and Effective Dentist






Introduction                                              p1




Chapter 1.    Introduction to "In Search of Excellence"   p9

Chapter 2.    A Bias for Action                          p11

Chapter 3.    Close to the Customer                      p19

Chapter 4.    Autonomy and Entrepeneurship               p25

Chapter 5.    Productivity through People                p33

Chapter 6.    Hands-On, Value-Driven                     p41

Chapter 7.    Stick to the Knitting                      p48

Chapter 8.    Simple Form, Lean Staff                    p52

Chapter 9.    Simultaneous Loose-Tight Properties        p54




Chapter 10.   Introduction to "The Seven Habits of Highly

               Effective People"                         p60

Chapter 11.   Be Proactive                               p65

Chapter 12.   Begin with the End in Mind                 p71

Chapter 13.   Put First Things First                     p79

Chapter 14.   Pardigms of Interdependence                p85

Chapter 15.   Think Win/Win                              p95

Chapter 16.   Seek first to Understand, then to be

               Understood                               p101

Chapter 17.   Synergize                                 p111

Chapter 18.   Sharpen the Saw                           p122


                   SECTION 3: THE PRACTICE


Chapter 19.   Introduction to the "Practice"            p131

Chapter 20.   Primum Non Nocere                         p135

Chapter 21.   Total Dedication to Service               p147

Chapter 22.   Listen to the Patient                     p161

Chapter 23.   Provide more Quality, less Quantity       p172

Chapter 24.   Do more to create Win/Win                 p185

Chapter 25.   Inform before you Perform                 p198

Chapter 26.   Be an Independent Entrepeneur             p228

Chapter 27.   Build a Loyal Team                        p237



To my wife, Ingrid, without whom it would not have been possible.



Everything I am is by the grace of the Lord Jesus Christ.


My wife and childhood sweetheart, Ingrid, who supported, encouraged and loved me through good and not so good times.


My late parents, Louis and Dythea, who taught me the principles of honesty and integrity.  My father told me, at the outset of my professional career, "Forget about the money you want to make, just concentrate on doing your work to the best of your ability."  Sound advice, which spoke of remarkable foresight.


My uncle, the Rev Dr Johann Fourie, who led me to the Lord.


My friend, orthodontist dr Piet Botha, for many years of support and advice.


My teachers and friends; the late prof PC Snijman, the late dr John Leppan, prof Hannes Nel, prof Hannes Pretorius, prof At Ligthelm, dr Peet van der Vyver, prof Maryna Ferreira, prof Piet van Vuuren, dr Jan Steenekamp and prof Manfred Dannheimer.


My friends and spiritual mentors, dr Bertus van Niekerk, the Rev dr Danie Dreyer, the Rev dr Ferdi Clasen.


My staff, especially Marlena Nel and Theresa Morkel who helped me to achieve all my goals.


Dr Richard Manning, of Newbury, Berkshire, England, for whom I worked for two years, for his hospitality and kindness and from whom I learned good business sense.


The specialists, Jennifer de St George, Cathy Jamieson, dr Gordon Christensen, dr Omer Reed and dr Burton Press who taught me the technical knowledge of practice management and marketing.


Stephen Covey, author of "The Seven Habits of Highly Effective People" and Tom Peters and Robert Waterman, authors of "In Search of Excellence", whose combined ideas and works finally led to the crystallization of my own ideas and the production of this book.







             The Excellent and Effective Dentist






                          JT Marais




















We have but this one opportunity at life.  This is our one and only attempt at life. Langenhoven, that famous Afrikaans author and philosopher, once said: "To live successfully is not so easy, even the best of us have difficulty in achieving it.  To die is easy, even the worst amongst us, manage to get it right."


It is with a sense of great urgency that these pages are written.  I am writing this for the benefit of the entire dental profession and with a fervent hope that it will contribute to that very elusive goal - excellent and effective dentists around the globe.  Many dentists believe that it is impossible to be a happy and a successful dentist at the same time.  My first hand experience of the South African and British dental scenes has left me with no doubt about the problems of unhappy, unsuccessful, depressed, self doubting, remorseful and embittered dentists.


Whatever their motives, young dentists enter the profession starry-eyed and with great expectations.  They have spent many years and a great deal of money, laboriously studying the art and science of dentistry.  Very often also, a young dentist entering professional practice, has to spend even more money putting up a practice.  So it is with a justifiable desire for some form of recognition and compensation that the young dentist embarks on his or her career.


The tragedy is that this eager, excited young dentist wakes up one morning, several years down the line, frustrated, disappointed, disillusioned and very unhappy.  Uppermost in his or her mind are a number of doubts and questions. "Why am I so unhappy?  Why don't I like my patients and why don't they like me?"  I know because I was there.  It all happened to me.


I graduated from the University of Pretoria in 1979 and went straight into the South African Defence Force to do my two years compulsory military service.  In 1981 I went into private practice starting up two new practices simultaneously, from scratch.  The one practice was in Cullinan, a small diamond mining town 40 kilometres from Pretoria and the other practice -right in the middle of Pretoria's central business district.  From the start I wanted to be the best dentist in the country.  I didn't know why but I just wanted to be the best, most probably for the glory of it.


The mine in Cullinan gave me premises to practise in - for more or less nothing, but on one condition, that I treat all the mine's employees on a contracted-in basis - that is at a very regulated, relatively low fee structure.  Even then this irritated me and after a year I sold the practice.  I wanted to concentrate all my efforts on my grand Pretoria practice, my flagship.  Whereas the Cullinan practice was only very basically equipped, I spared no expense on the Pretoria practice.  I bought only the best and most expensive equipment, a decision I still regret. 


In the first few years things went rather well, or so I thought.  I was making a little money and the practice was quite busy.  From the start I operated this practice on a contracted-out basis - that is a private practice.  I did not send my accounts directly to the medical aid schemes because I charged more than the regulated fees.  My patients had to pay me and then claim back from their medical aid schemes. But in those days I knew nothing about communication and I made no effort to inform my patients about their obligations.  I sort of surprised them with an account at the end of the month and then waited for the cheques to arrive in the mail, which they often didn't.  I guess I was doing dentistry of a reasonable quality back then.  I still see a few of my patients of those early days and most of my craftsmanship is acceptable, but I had more than my share of spectacular failures as well.  I really thought I was good then and I didn't hesitate to do even extensive and expensive crown and bridgework.  A few of these cases really came apart, I have to shamefully admit.  And it was my fault.  I did not have the experience and expertise to handle them properly then.  To my defence I can only say that these failures really humbled me.  I still feel very ashamed of the harm that I may have caused any patient by my search for glory and money. 


After a few years, things started to deteriorate. My accounts receivable increased and so did my overdraft.  My tax burden skyrocketed.  I began to panic.  At the same time, for some reason, I experienced a shortage of patients.  I think I responded by doing more dentistry for the patients I did have and maybe this put them off even more.


Finally I responded by starting to do some work on a contracted-in basis, that is for the medical aid schemes, at their rates. Very quickly I had a full practice again.  I had been lured into the trap of the "easy money" of the medical aid schemes.  My practice became very busy.  By this time the quality of my dentistry was a little better.  I was working very hard but I wasn't seeing any real financial rewards. Everything was going into the overhead costs, overdraft interest and a sky high porcelain laboratory account. Also the medical aid schemes were in no hurry to pay me.  So I became the disillusioned dentist who woke up one morning, embittered because I had to work so hard with so little to show for it.  Why did my patients not understand me?  Why was there such a lot of unhappiness in my practice?


And then a strange series of events turned my life around. The landlords of the building in which I practised decided to refurbish the building.  They in fact demolished everything around me, even cutting off the practice's water, electricity and telephone for long periods.  This led to a court case which I won and I decided to relocate to another building.  This move hurt me a lot, in more ways than one.  Emotionally I was drained and I sold my practice, in 1990, and I went to England with my wife, Ingrid and two small children, Soekie and Gunther.  I did not sell my house, because I knew exactly what I wanted to do.  I wanted to come back to South Africa to put up a new practice at my house.  And this would be a cash practice, I said, way back then - like a supermarket.  Never ever was I going to send out accounts, either to individuals or to a third party. 


Since the very early days of my professional career I attended a few practice management courses by people like Burton Press and Omer Reed.  I even tried a few of their selling and marketing techniques, with very little success. One day, about eighteen months before I left for England, I went on a hunting trip with my friend, Piet Botha, an orthodontist.  We always talk a lot about dentistry and people and communication but it was on this trip that I really decided to do something about communication with my patients. I came back and I really made a big effort.  I created a lot of informational material in the form of books and models and I scheduled post examination conferences with my patients where I presented their cases and my treatment plans to them.  I used all the marketing techniques taught by Burton Press and Omer Reed and all the others. But it just didn't seem to work that well.  Today I know why.  This is what this book is all about.  About why certain things does and doesn't work in a dental practice. 


We spent two very interesting and relaxing years in England and made wonderful friends over there.  I learnt the workings of the National Health System and I saw that it was even worse than South Africa's medical aid system.  In England I also attended a few courses, notably one by dr Gordon Christensen of Clinical Research Associates of America.  And then I came back to South Africa to try once again. I came here to set up a low overhead practice at my house and I was determined to make this a cash practice. By this time I had finally learnt a few things.


It worked.  I started out on a part time basis because I took up a position at the University of Pretoria.  Today the University  post is part time and I enjoy my involvement in research, teaching and publication very much.  But my prime interest is my private practice which has grown out of all proportions. In South Africa, more than 90 per cent of dentists still work on a contracted-in basis.  My practice is strictly contracted-out and I demand and get cash payment for my services.  This is unheard of in South Africa.  Yet it works for me, wonderfully.  Patients come from very far, Botswana, Mozambique, Cape Town, the Free State and even from abroad, because they get good service.  And they don't mind paying.


This book tells how it was done.  In September 1995, six months ago, my friend Bertus van Niekerk gave me a book, "The Seven Habits of Highly Effective People" by Stephen Covey.  By this time my practice was already well established and successful.  I started reading Covey's book and slowly it brought into focus for me, the reasons for my success.  As I was reading Covey's book I realised that I had already done almost everything that he wants his readers to do.  A few weeks later I bought a copy of "In Search of Excellence" by Tom Peters and Robert Waterman and I read this also.  I became very excited because I started to see the parallels between my own success, Covey's 7 Habits and Peters and Waterman's principles.


The 7 Habits is a recipe for personal success. It is a book written for individuals, to teach them how to become highly "effective".  On the other hand, "In Search of Excellence" describes how America's most successful companies got that way.  It is a study of success in corporate life.  I came to see the great similarities between success in personal life, corporate life and my own success as a dentist.


But what excited me most was to see the parallels and similarities between Covey's work and Peters and Waterman's work and another Book, the greatest Book on earth, the Bible.  None of the two former books are religious works, by no stretch of the imagination.  Yet as I were reading these two secular works, I became aware of how these two books contain all the biblical truths and doctrine.  I saw that everything that Covey and Peters and Waterman teach, was already written down two thousand years ago.


I knew all along that I owed my personal success to the Living God, Jesus Christ, but it was interesting to see that the christian principles and values which I hold dearly, have also brought America's best companies success and it also inspired Covey's 7 Habits.


And then I wrote "The Excellent and Effective Dentist."  This is my effort but I do not vaguely think that it can come close to the monumental works of Covey and Peters and Waterman.  Their two books have both reached cult status and spawned small industries of more books, tapes, and seminars.  There is no way that my book can compare.


I owe Covey, Peters and Waterman a tremendous debt of gratitude.  I drew a lot on their works and I wish to acknowledge and thank them publicly. 


The "Excellent and Effective Dentist" is written in three parts.  The first part is my commentary or interpretation of "In Search of Excellence

"as it applies to dentistry.  I have tried to analyze each chapter and each principle of the excellent companies' success, one by one, and to show its relevance to dentists and dentistry.  The second part of my book concerns "The Seven Habits of Highly Effective People

" and I tried to do the same.  I looked at each habit, individually and I attempted to apply it to dentistry.  I dealt with each individually, devoting a chapter to each.  The third part contains my own personal views consisting of eight chapters, each discussing the eight cornerstones of success in dental practice, as I see it and as I practise it.

                          Section 1


                          Chapter 1


          In Search of Excellence: An Introduction


The book "In Search of Excellence" by Tom Peters and Robert Waterman has been in print for almost a decade now.  It has been followed by more books by Peters and his name has become famous in corporate America.


Originally Peters and Waterman set out to find out what it was that made America's best companies so good.  On the basis of certain criteria they selected a number of America's top companies and then they conducted hundreds of interviews with the presidents, vice presidents, employees and customers of these companies. With time a picture of the excellent companies started to develop.  It was found that all these companies shared a few common characteristics.  These are described in "In Search of Excellence".  It is interesting to see what companies were looked at.  From the aeroplane manufacturer, Boeing, to the fast food chain McDonalds.  Other companies which are often quoted include Delta Airlines, IBM, Texas Instruments, Proctor and Gamble, Disney, Wal-Mart and 3M.  All these companies are multi-billion dollar industries and all of them are considered excellent.  What made them excellent can and will also make a dentist excellent. The first section of this book "The Excellent and Effective Dentist", chapters 2 to 9, deals with the principles which made the companies successful and it shows how these principles can be applied in dentistry.

                          Chapter 2


         In Search of Excellence: A Bias for Action


Tom Peters and Robert Waterman name the first principal characteristic of excellent companies as "A Bias for Action". They start out by describing the difficulty they have in putting into words what they actually mean by these words. They then use phrases like a "fine feel for the do-able" and "Do it, fix it, try it" and they encourage practices such as "Chunking" "Management by walking about" and "Testing" products and ideas.


What they are trying to get across is simply this - Let's stop talking, reading, learning, writing, theorizing, managing(!), planning, controlling and let's actually start doing something for a change. It is very easy to understand their difficulty in explaining such a simple, even stupid concept to their readers, but nevertheless they consider it as the first, very important step to success. Yes, it is also the first step to success in dental practice.  Even when you run a marathon you have to give the first step, and then the second one and so on.


Many companies stifle employees' innovative skills, enthusiasm and excitement about their work by too much bureaucracy, rules, regulations, organizational structures and autocratic style. 


It is the same in dental practices.  Dentists love routine and they hate to think.  Nothing is easier, for a dentist, than to grunt "Open wide please" and then to drill and fill and proceed to the next patient .  It is what comes naturally to a dentist.  Not only are dentists autocratic and bureaucratic in their attitude to their staff but also to their patients and even, very importantly, to themselves.


Dentists don't like change, especially mediocre dentists.  Far easier it is to stick to the tried and tested ways of doing the one medical scheme /NHS/ insurance patient after the other, no matter how much bureaucracy is involved.  Dentists are very reluctant, even to the point of being scared to death of actually sitting down and just talking to a patient and just telling them "Sir, I am going to ask you one thousand rand, in cash, for this treatment." 


They are equally reluctant to change in many other spheres of dentistry.  The task of changing and adapting seems so awesome that it is overpowering and so we just sit back and let it go.  We know we have to improve our waiting room/ reception area, we have to get new staff, we have to develop a practice logo, we have to go on a refresher course, we have to create new stationery (letterheads, visiting cards etc), we have to write letters to our patients, we have to clean up our private offices, we have to..... It is much easier to just go with the flow and to spend our energy on our hobbies and sport and recreation.  It is easier to stay with the old routines than to change and anyway the prospect of implementing all these changes is just too much.....


Peters and Waterman describe the process of "Chunking", that is breaking up big, seemingly impossible tasks into small, doable tasks.  They state that they believe that "the key success factor in business is simply getting one's arms around almost any practical problem and knocking it off - now."  They name the example of Exxon's success in Japan.  "They made each problem manageable.  Then they blitzed it."


In dental practice we should do the same.  Start out by doing something, anything, but just do it.  And keep on doing something.  Persist. Make mistakes even.  Allow yourself failures.


For instance take one patient.  Do not change your whole practice, yet, if you don't want to. But take one patient and decide for yourself - "I am going to treat this patient as a private individual and not as a member of medical aid society/NHS/ or insurance company.  I am going to sell my dentistry at my prices/fees.  And then do it.  Tell the patient "Sir/madam, you need a filling on this tooth and it is going to cost you one hundred rand/dollar/pound."


Or decide to do something about your waiting room or stationery or anything.  But start somewhere and do something.  And then keep on doing it. Persist.  If at first you don't succeed, sooner or later you will.  And success breeds success.  Nothing is more true than that.  Success really does breed success.  At some stage you will manage to get it right and you will sell your dentistry or your new look or attitude will attract a new patient.  It is amazing to experience the surge in self confidence once one has actually experienced a little success.


The famous dr Harold Shavell of Chicago told how he started out on his amazing success path.  Dr Shavell does not do cheap or inferior dentistry.  The technical excellence of his work is without parallel. He is also "expensive". When he started out he was a determined young man, not prepared to compromise his standards.  So he examined his first patient and presented him with his treatment plan and cost estimate, which the patient promptly rejected.  As did the next nine patients.  Eventually the eleventh patient did except his treatment plan and "outrageous" fees.  The rest is history.  Dr Shavell has achieved excellence in a way very few people have.


I can well remember the day I set out on my "second life" as a dentist in my second practice in South Africa.  For years and years I had planned this practice. For years I planned to break away from the chains of the medical aid movement.  I planned and planned and worked very hard at putting it all together. Eventually the big day dawned. Everything was ready.  Not only the new surgery but also my office and waiting room.  Most importantly my attitude was right.  This was it - my final chance at dentistry in the difficult circumstances of South Africa. I had long ago decided that it was going to be my last attempt at practising dentistry in South Africa.  I was going to do it right or not at all. I would rather clean the streets than fall prey to the medical aids again.


And suddenly I found myself sitting at my neat private office desk, face to face, with my first patient.  We small talked a little, and I steered the conversation to dental matters.  I enquired about the main complaint, dental history, medical history and finally the moment of truth arrived.  This was it. There was no escape from it.  I had to do it.  Now.  I took a silent, secret deep breath and blurted it out as best as I could. "Sir", I said "This is a cash practice.  We ask all our patients to pay us once we have finished and we then issue them with a receipt and specified account for claiming purposes."  Just like that.  I watched him intently.  "No problem" he said, "How much is it gonna be, Doc?"  The relief was almost overwhelming.  This was South Africa, where 95% of dentists work for the account of medical aid societies.  I had just conquered the world, I felt.

The patient did not get up and leave.  He did not decide to go and seek medical aid treatment elsewhere.  My confidence grew with leaps and bounds.  I had decided to do something and I did it and it worked.  Most often it does.  If only we would try.


Peters and Waterman also use the term of "Testing" when trying to decide what they mean by "A Bias for Action". What they mean with "Testing" is to try out any new idea on a small scale.  Do not wait.  Do not go into long term planning or wait for conclusive evidence before you implement something new.  Dental scientists are notorius suckers for so-called scientific evidence.  They want to see large samples and five year results and statistical analyses.  The excellent companies do not allow themselves to be bogged down by these rules of rational analysis.  They go out and try it.  If it works, they do it again, and again.  If it doesn't, they write it off as a valuable learning experience.  They do not fire their employees for failing. They know that without failure there is no learning.  They call these small ventures into the unknown "Testing".


Dentists should "Test" also.  Do it, try it, fix it.  This is true in dental marketing techniques as well as in clinical terms.  Obviously one should be responsible and a little cautious when trying out new clinical techniques, but not to the point where one ends up doing nothing at all. 


In the Bible James asks "What good is it, my brothers, if a man claims to have faith but has no deeds? Can such a faith save him?" (James 2:14)  Our inherent, natural, sinful laziness diametrically opposes the idea of a "Bias for Action".  Dentistry is extremely hard work.  We all know that and we pity ourselves.  We have such a hard time filling all those cavities and cutting all those crowns that the mere thought of doing one extra little bit is anathema.  God exhorts us to do something, to take action and not to merely think and talk about it.  In the parable of the Ten Minas (Luke 19: 11-26) Jesus clearly indicates that God wants us to use our gifts profitably.  Obviously He wants us to use our gifts for the benefit of his Kingdom, not for our own benefit.  But this in no way contradicts this book's message.  When we work for the benefit of God's Kingdom, ultimately it is also for our own benefit.  In fact there is no better way of achieving success than by seeking to do the Lord's will, first.  If we treat every patient as if on Divine orders, the way it ought to be, success will follow, inevitably.  If we live to honour, love and serve God and our fellow men, we must succeed.  But if we think of ourselves as small gods ourselves, ordained to be rich, to live successful and comfortable lives and if we use our patients towards that end, then the exact opposite will befall us. We might experience short term financial success but in the end we will pay the price.  We will become disillusioned and dissatisfied and what's more we'll blame it on the patients.  "They don't understand how hard it is on a dentist", we will then lament.  It is well to consider that God certainly did not intend for us to live lazy, comfortable lives of leisure.  We were made to work and to labour.  For Him. Not primarily for ourselves.  The irony is that if we do this - work for Him - we will achieve success, even in our own terms.  It is when we reverse the intentions, when we chase success for success's sake that we defeat ourselves.  "No one can serve two masters.  Either he will hate the one and love the other or he will be devoted to the one and despise the other.  You cannot serve both God and Money." (Matthew 6:24)  When a dentist chases money (Peters and Waterman term it "cost-driven", as opposed to "value-driven") he will ultimately fail.  He will fail in terms of his health, his family and his self-esteem.  But when we " first His Kingdom and His righteousness, ... all these things will be given to (us) you as well." (Matthew 6:33) So we have to take the first step on this exciting road to His kingdom.  And we have to take another step every day of our lives.


"Not everyone who says to me, `Lord, Lord' will enter the Kingdom of Heaven, but only he who does the will of my Father who is in heaven." (Matthew 7:21, emphasis added)



                          Chapter 3


In Search of Excellence: Close to the Customer


"So in everything, do to others what you would have them do to you, for this sums up the Law and the Prophets". (Matthew 7:12)


Peters and Waterman list "Close to the Customer" as the second characteristic of the excellent companies and they begin by questioning the need to write about such a basic principle in the first place. They answer that other companies talk about customer service, the excellent companies do it.


Maybe unwittingly, maybe for ultimate self-gain but in some or other way the excellent companies fulfill the Golden Rule. (See above - Matthew 7:12) The excellent companies simultaneously also manage to obey God's second Law: "And the second is like it: `Love your neighbour as yourself'.  (Matthew 22:39)


Being `Close to the customer' means loving and serving the customer.  It means fulfilling their needs, not yours.  It means giving the customer what he wants.  This is one of the great conflict areas in dentistry.  Dentists reckon they are the experts and they know best and therefore the patients should listen to them.  How wrong they (the dentists) are.


In the fields of clinical science, of course dentists are the experts.  But in the field of human science dentists are pathetic.  We know best and we like to let it be known to our `customers', our patients.  `Well madam, this tooth experienced a cusp fracture and I am going to have to place a crown.'  That's it. We give it to them straight.  Is it not better to say to the patient `Madam, as you know part of this tooth broke away and we now have to fix it in some way and I would like to have your opinion on the kind of treatment that you would like.'?  It is far better to name the alternative restorations (eg gold, porcelain, resin etc) and to discuss the advantages and disadvantages of each material and then to ask the patient to help you choose a material of his or her choice.  With modern technology it has become possible to virtually restore any broken tooth with any of the modern materials. Should we not involve our patients in these decisions?  The point is made in ISOE that the excellent companies seem to exhibit an obsession with customers.  An interesting example is IBM which is not noted for being a leader in technology but they look after their customers.  IBM is a dominant force in their industry and this dominance rests on it's commitment to service.


Another prime example cited is the legendary car salesman, Joe Girard, who sold more new cars and trucks, each year for eleven years running, than any other human being.  How does he do it?  Simple. He is close to his customers.  He sends out over thirteen thousand cards every month.  He delivers extra-ordinary after-sales service.  He intercedes on behalf of his customers.  He takes care of their problems.  Joe's 13 000 cards are not just another sales gimmick.  Joe seems genuinely to care!  How many dentists do?  How many dentists send out Christmas cards or birthday cards?  How many dentists provide after sales service?  How many dentists listen to their patients?  How many dentists will take the time to enquire about a patient's feelings or well-being?


Joe says, "When the customer comes back for service, I fight for him all the way to get him the best.....You've got to be like a doctor. " (He beats us at our own game!) "Something 's wrong with his car, so feel hurt for him."  How much hurt does dentists really feel for their long-suffering patients?


Joe cares about every customer as an individual. He says, "They are not an interruption or pain in the neck.  They are my bread and butter."  Dentists must accept this basic truth.


An ex-IBM employee is quoted as saying, "An IBM salesman always sells the cheapest product that will get the job done." Sadly many dentists follow the opposite line.  It is a tragic fact of life that far too many implants are placed, far too many bridges are placed, far too many crowns are done, all in the name of making money, serving Mammon.  With todays excellent adhesion techniques we can perform miracles with plastic (alloy and resin) restorations, if only we were prepared to spend the time.  We can and should charge more for such an excellent plastic restoration but it would still be much less expensive, less invasive, less traumatic and even less risky than a crown.  Before we rush in to do the next implant or bridge we should ask - "Is it really in the patient's best interest?"


IBM is customer-driven and not technology -driven. As dentists we should be the same. IBM salesmen are trained to "act as if they were on the customer's pay roll."  The cost-driven dentist will immediately argue that he will be cutting down on his turnover and that he will lose out.  He just has to do so much.  That is just the point.  No dentist has the right to do anything.  Everything we do is allowed us by the grace of our patients and God.  We are here to serve them not the other way around.  And if we do, the rewards will come.  Like it does for Joe and IBM.


Many dentists are technology driven.  Dentists are really suckers for technology. Examples are plentiful.  Cad-cam porcelain inlay producing machines, panoramic radiographic machines, intra-oral cameras are actually marketed, bought and used as revenue-generating machines.  The bottom line seems to be - "Will it make money?"  The bottom line should always be "Will it be in my patient's best interest?"  Very often patients are subjected to unnecessary investigations and treatments because their dentists happen to own one of these revenue - generating machines.  After all, the payments for the machines have to be kept up.  One actually shudders at the thought of what all the patients would really say if only they knew.


"IBM always acts as if it were on the verge of losing every customer."  This explains it very well.  In my own practice this has always been a key principle.  Especially in the earlier times, it was a reality, a fact of life. I really was on the verge of losing every patient.  Remember in the early days of my professional career, competition in South Africa was fierce. There was a gross overproduction of dentists and the overwhelming majority (95%) of dentists were contracted-in.  That means that they were virtually providing a free service.  All their patients got their dentistry for free, because their medical aid funds were picking up the bills.  This still holds true, to some extent, in 1996, but things are slowly changing.


Back then, and today, I was and still am fighting this corrupt socialist system.  I used to charge more, and I still do.  Patients had to actually pay me and today I go even further.  I demand cash upon delivery.  In the old days it did not really want to work, today it does.  What made the difference?  Being "close to the customer" did.  Back then I thought of myself as some little god. Patients had to accede to my demands, because I was so wonderful.  Today, I have found my true and rightful place in the universe, sort of.  This place is "close to the customer", amongst other things.


In fact once I came to the point where I did sort of lose every patient.  One day I found myself staring at a blank appointment book.  I had been in practice for a few years and my bookings had finally dwindled to nil.  It was a humiliating experience.  I responded to this by making a flawed decision.  I decided that with the next patient that would happen to call in I would change my principles.  I decided that I would start to treat this patient on a contracted-in basis - similar to the NHS in Britian and some insurance work in the USA.  In other words - there and then I surrendered my "Autonomy and Entrepeneurship "(See Chapter 4 and Chapter 26) to some unknown and faceless bureaucracy.  And slowly but surely the patients returned.  The trickle later on become a raging torrent.  I was still doing the same excellent high quality dentistry at half the fees that I had previously been charging.  I was totally overwhelmed by the demand for my services. And I was making a little money as well. At first I enjoyed it but soon the resentment started setting in and taking hold of me.  I was working faster and faster and harder and harder!  My overheads skyrocketed.  My tax burden also.  In spite of everything my overdraft took the same route.  I started resenting myself and my patients.  I lost my self-esteem and the esteem I held my patients in.  I became very unhappy.  A wide gulf had developed between me and my patients.  There was no communication.  I was rushing between 20 and 25 patients per day through my doors.  Misunderstandings and unhappiness over small incidents developed.


Where I found myself staring at a blank appointment book the one day - where I had lost virtually every customer - a few months later I was fully booked, but for the wrong reasons.  The bubble had to burst and it did.  I left dental practice in South Africa and went to England.  After two years I returned to South Africa to set up a new practice.  One of the cornerstones of this new practice was being "Close to the customer." This led me to become more successful than ever before. 

                          Chapter 4


In Search of Excellence:  Autonomy and Entrepeneurship


The excellent companies share another characteristic which is rather difficult to describe.  It is listed in ISOE under the heading "Autonomy and Entrepeneurship".  It boils down to fostering the innovative spirit of individuals, by allowing them freedom, by allowing them to be individualistic, free thinking, so called "Champions".  A "champion" is someone who is almost a zealot, a creative fanatic, a driving force and he is someone who believes in his product to the point where he becomes almost unbearable.  "Champions are pioneers, and pioneers get shot at."  Ask Paul and ask the other martyrs and prophets of the Old Testament.  Paul must be the archetypical pioneering champion.


The point is made in ISOE that all the presidents and most senior management people of the excellent companies were at one time of their early careers "champions" of some or other idea which eventually led to a success story.  They were people who hoped against hope and worked against all odds because they believed in something.


At IBM they have the "Fellow" program. "There are about forty-five of them, heralded as dreamers, heretics, gadflies, mavericks, and geniuses."  "There are less of us than there are corporate vice presidents," said one. A fellow is given virtually a free rein for five years.  His role is quite simple: to shake up the system."


At IBM these Fellows have massive support structures. They are allowed to do what they want. The favourite activity of at least one of them is - time with his customers.


Peters and Waterman comment "It's amazing, in fact, what one highly charged, crazy men can do."  I (Koos Marais) have personally experienced it myself over the past four years.  I have achieved success beyond my wildest dreams and I have achieved fame far beyond what I really deserve.  Patients come from the most faraway places, because they want to be treated by the so-called best dentist.  It makes me very proud.  Of my God, the Almighty God by whose grace I exist.  I am not proud of myself.  I know that the very minute that I become proud of myself, I will be back on the precipice of "losing every single patient".  (See Chapter 3)


One of the most important aspects of allowing an individual these freedoms of "Autonomy and Entrepeneurship" is the toleration of failure.  Even "champions" or "fellows" or super dentists are only human.  We all make mistakes, daily, ask every intelligent dentist.  So if we give an individual freedom to do what he likes when he likes, it is a fact of life that he will make mistakes  often.  At IBM and 3M and all the other excellent companies they seem to tolerate the mistakes of the "champions."


General Johnson, J&J's founder is quoted "If I wasn't making mistakes, I wasn't making decisions."  And Emerson's Charles Knight argues: "You cannot innovate unless you are willing to accept mistakes."  Making mistakes is a universal trait of mankind. "God looks down from heaven on the sons of men to see if there are any who understand, any who seek God. Everyone has turned away, they have together become corrupt, there is no one who does good, not even one." (Psalm 53:2-3)


We are all sinners, we all make mistakes, but in Jesus Christ these sins can be forgiven.  In Jesus Christ we can live a fruitful life to the honour and glory of God.


How does all this translate to dental practice? What does all this mean in practical terms, to the average dentist?


It is all in fact very relevant to dental practice, at least in South Africa and in the UK where dentists have for decades sacrificed their "autonomy and entrepeneurship" on the altars of the medical aid schemes and the NHS.  The situation might be the same in areas of the USA or it might still develop there in the form of some or other socialised dentistry.


In the excellent companies, the emphasis is upon allowing employees "Autonomy and Entrepeneurship".  It is about allowing employees freedom and tolerating their failures, encouraging innovation, encouraging them to try out new ideas, without having to fear retribution when something goes wrong.


In dentistry we cannot do exactly the same to our employees.  We cannot legally and we cannot, practically allow our dental nurses and hygienists and receptionists the same freedom as an IBM Fellow.  But we can and we must allow ourselves, the dentists, the same freedom. We must be autonomous and we must be spirited and free entrepeneurs.  We must break away from bureaucracy.  We must not allow our lives to be dictated by the rules and regulations of third parties.  Our business is our patients.  Nothing should be allowed to intrude into that.  We should jealously guard our precious close-to-customer relationship. - "What does the patient want?" - not "what will the insurance/NHS/medical aid allow the patient to have?"


Many practitioners in South Africa view their patients purely and simply as members of a medical aid society.  When a new patient reports, an immediate phone call is made to the patient's medical aid society to enquire about available benefits. The patient is only seen by the dentist once this information is available.  Sadly, the dentist then devises a treatment plan within these constraints.  This leads to gross, even criminal, over- or undertreatment.  These same dentists are then the guys who complain bitterly about their chosen profession, they are the ones who fall victim to alcohol, drugs, heart disease and marital problems.  If one makes a living out of daily cheating it will catch up with you, sooner or later.


"The evil deeds of a wicked man ensnare him; the cords of his sin hold him fast." (Proverbs 5:22)


The way forward depends on dentists recognising the fact that they are independent, small business entrepeneurs in the open market place.  We have got to take charge of our own destinies, or somebody else will. Dentistry is such an unique profession. It is extremely hard work, so much so that only proper remuneration can seem to motivate the practitioners of the art -and that includes me.


An amazing thing happens when a dentist takes charge of his or her life, when he or she confronts the fact that the contract is between him/her and the patient and not some or other third party.  The moment that the dentist looks the patient in the eye and informs him or her that he or she (patient) will be responsible for payment, a transformation occurs - in the dentist.  The dentist changes, he suddenly realises the responsibility that he has over this patient.  By being paid by the patient the dentist becomes the servant of the patient and he (the dentist) loves it.  Being paid by the patient, directly, is a very sincere form of  recognition and appreciation.  When a third party is responsible for picking up the bills, dentists often can't care less.  They reason that the patient got it for free and does not appreciate their tremendous effort anyway, why should they care.  The dentist escapes his responsibility towards the patient by failing to carry out after-sales service, by failing to provide proper preventative treatment, by failing to communicate with their patients and by plainly ignoring certain persistent problems.


A favourite line of "attack" by myself on difficult patients is: "Madam/sir, my fees are high because I adjust the fees according to the quality of the work.  I do not adjust the quality of my work to a prescribed fee."  These two well thought out and well rehearsed lines have never failed me.  I have had very hard-nosed patients succumb to it.  They had actually had the audacity to confront me face-to-face with my high fees and they ask me directly why I charge these ridiculously high fees. Invariably, they soften up at my equally blunt explanation.  Episodes of poor dental treatment are fortunately, or unfortunately very widely known and even the most difficult patient seems to understand my position, once I have explained it to him or her in these terms.  When a dentist is an Autonomous Entrepeneur, he will examine a patient, make a diagnosis and devise a treatment plan, and he will do the costing according to the amount of time and effort that he will put into it.  In other words, at the time of examination he will see that this is a difficult patient, he or she gags easily, has limited opening ability and is very scared.  The independent and clever dentist will have an idea of how much time he will need for the task at hand and he will also be acutely aware of his own overhead cost. He will then quote accordingly. It is not unreasonable to charge three, four or five times more than our colleagues, provided that our quality of work is commensurate with our fees.  And it is easy to provide better quality, when we spend more time, and time is money.......


It has been mentioned above that the excellent companies tolerate

mistakes, even almost up to the point of encouraging failures.  We must allow ourselves the same freedom.  When we set out on the road to Autonomy we are bound to experience failures. Some patients will not accept our new attitude and will turn away.  All dentists know how easily patients will change dentists.  On average it is thought that patients change dentists every five years.  When we introduce sweeping changes we have to accept that some people will reject us.


We simply cannot please everybody, all the time. The day I learnt this, I experienced a tremendous feeling of liberation.  Where previously I was constantly fearful and anxious of losing patients - as witnessed previously - I suddenly realised and accepted this basic fact: I CANNOT BE EVERYTHING TO EVERYBODY.  I suddenly found the freedom to accept the fact that a few people will reject my philosophies about dentistry and so be it. In fact these little failures, people who leave my practice, cannot correctly be described as mistakes. Mistakes I also still make, but I accept it and very importantly, I learn from them.


The one all consuming reason why the excellent companies put so much emphasis on Autonomy and Entrepeneurship is the inherent dangerous nature of big companies to form stifling bureaucracies.  Because they are good, they become big.  When they become big, they become autocratic, sluggish, dull, full of rules and regulations.  The excellent companies avoid just this last negative bit.  In spite of being big, they still manage to be good and one of the ways they manage to achieve it is by allowing and encouraging Autonomy and Entrepeneurship.  And they work very hard at being what they were when they were SMALL. The principle of SMALL IS BEAUTIFUL is emphasised over and over again.  And that is the beauty of it.  Our dental practices are SMALL.  There is no reason for us not to be excellent in this field.  We are small, we can change and adapt easily, if only we want to. We are what the excellent companies dearly want to be.  We have just got to exploit it.


                          Chapter 5


    In Search of Excellence:  Productivity through People


Excellent companies care about people.  They care not only about their customers, they care about their staff.  They really do.  Every dentist knows how dreadfully dependent we are upon good loyal staff.  It is plainly impossible to produce excellent modern dentistry, what with all the intricacies of bonding and implantology, without an excellent chairside assistant.  Now if they are so important, why do we treat them so badly?


It is amazing to see the lengths to which the excellent companies go to keep their people happy.  Why? Because they know happy people produce more.  In the final analysis the excellent companies want to make money.


We should treat our staff well because the Bible tells us to do so.  In the end, we will also make money anyway - if the Lord wants us to.  But we should treat our employees as our fellow human beings. We should love them as the Bible orders us.  We should not do it because we want to make money, like the excellent companies, but because it is the proper, christian, biblical thing to do.  Incidentally, it is also good business sense and we will also make money.


"Treat people as adults.  Treat them as partners; treat them with dignity; treat them with respect.  Treat them - not capital spending and automation - as the primary source of productivity gains.  These are fundamental lessons from the excellent companies  research.  In other words,if you want productivity and the financial reward that go with it, you must treat your workers as your most important asset.  In A Business and Its Beliefs, Thomas J Watson, Jr puts it well: "IBM's philosophy is largely contained in three simple beliefs.  I want to begin with what I think is the most important: our respect for the individual.  This is a simple concept, but in IBM it occupies a major portion of management time.  We devote more effort to it than anything else.  This belief was bone-deep in my father."


"There was hardly a more pervasive theme in the excellent companies than respect for the individual.  That basic belief and assumption were omnipresent. But like so much else we have talked about, it's not any one thing - one assumption, belief, statement, goal, value, system, or program - that makes the theme come to life.


What makes it live at these companies is a plethora of structural devices, systems, styles, and values, all reinforcing one another so that the companies are truly unusual in their ability to achieve extraordinary results through ordinary people.....  These companies give people control over their destinies: They make meaning for people.  They turn the average Joe and the average Jane into winners.  They let, even insist that, people stick out.  They accentuate the positive."


This quotation from ISOE is so full of biblical doctrine that it is almost amazing.  Just think what a difference it would make if we could implement it into our daily lives and our practices.  RMI is another company which is listed for its excellence.  At RMI "Big Jim" Daniell became chief excecutive.  He instituted his own program, described as "pure corn" by the Wall Street Journal.  RMI's plants are full of scmaltzy, sugary sweet signs and notices that say "If you see a man without a smile, give him one of yours" or "People rarely succeed at anything unless they enjoy it".  


"Big Jim spends much of his time riding around the factory in a golf cart, waving and joking with his workers, listening to them, and calling them all by their first name - all 2000 of them."  The result of all this is success, in a big way.


At Hewlett-Packard the company's people-orientated philosophy is called "the HP way."  It is "an expression of trust and confidence in people..." This trust is carried so far that the engineers are actually encouraged to take electrical and mechanical components home for their own personal use.  "Legend has it that Bill Hewlett visited a plant on a Saturday and found the lab stock area locked.  He immediately went down to maintenance, grabbed a bolt cutter, and proceeded to cut the padlock off the lab stock door.  He left a note that was found on Monday morning: "Don't ever lock this door again.  Thanks, Bill."


At another excellent company, Wal-Mart, all managers have to wear buttons that say, "We care about our people." The founder, Sam Walton, has become a legend for his caring attitude.  "According to the Wall Street Journal, "Mr Walton couldn't sleep a few weeks back. He got up and bought four dozen donuts at an all night bakery. At 2:30 am he took them to a distribution center and chatted for a while with workers from a shipping docks.  As a result he discovered that two more shower stalls were needed at that location."  Again, the astonishing point is not the story per se: any small business person could relay a host of similar tales.  The surprising news is that a top executive still exhibits such a bone-deep form of concern for his people in a $2 billion enterprise."


Another example of such people commitment is McPherson of the DANA company.  "McPherson's focus is always the same.  In casual conversation or formal presentation, he never wavers from this emphasis on people."  "McPherson is a bug on face-to-face communication and on discussing all the results with all of the people.  He required that there be a monthly face-to-face meeting between division management and every member of the division to discuss directly and specifically all of the detailled corporate individual results.  We see that time and again in the excellent companies. They are obsessed about widely sharing information and preventing secrecy."  "Another McPherson obsession is training, continuous self-improvement.  Classes are practical, but at the same time they reinforce the people philosophy."


If people are so important in the big excellent companies, they are even more important in our small dental practices.  We must learn to listen, really listen to our dental nurses, our hygienists, our reception staff, our laboratory people and even our cleaners.  And we must reward them, inform them and train them.


If big companies like DANA can afford to share the precious figures, like turn-over, losses and profits, we can also.  If our profits are so high, that we are actually ashamed of it, that we don't want our employess to know about it, then we really are in an excellent position.  We should tell them and we should share some of those profits with them.  The excellent companies do.  If our profits are not high or if we are making losses, our employees should also know.  How else can we motivate them?


Delta Airlines is an exceptional company as far as it's personnel relations go.  They don't lay off people when business is bad.  They have a true open door policy.  They really and truly care about their staff.  For instance, at Christmas time, traditionally, top management pitches in and help the baggage handlers.  Management spends an extraordinary amount of time just plainly talking to its people.


In dental practice there are many opportunities for improving staff relationship.  What is wrong with the dentist every now and then making the coffee, or pitching in to help with the clean-up and sterilization drills.  We all know or should know the importance of an early morning meeting - but how many dentists actually do it?


Do we listen to our staff, do we actively encourage them to talk to us and to voice their grievances and complaints? And how do we respond to them?


At McDonald's much emphasis is placed on training. They even have the hamburger university and it is no joke.  The details of running a McDonald's outlet and of making a hamburger is scientifically and meticulously taught.  Staff knows exactly how to treat customers - certain key phrases and sentences are learnt off by heart.


There is a big lesson in this for dentistry.  Does our staff know, really know, how to mix and dispense our materials?  Do they really know to respond to difficult questions - like "How much does your doctor charge for a crown?"  We have to train them.


Excellent companies also reward their employees. They reward in big ways and in small ways.  Some give plaques, some name "Workers of the Month/ Week/ Day/ Year", some give big rewards like holiday trips or money.


These small rewards are viewed trivial by some but it is amazing how well qualified people will treasure these little tokens. It is very easy to institute similar rewards in a dental practice.  It needs not to be in a structured way, but a box of chocolates, or a bunch of flowers at the right time can do wonders for the practice morale.


Informality is another characteristic of the excellent companies.  People call each other by first names.  Why shouldn't we?  Is the doctor title really so important?  Most probably not.  Formality builds barriers.  The excellent companies spend billions of dollars breaking down barriers.  That is barriers to communication.  Communication is the name of the game.  It underlines every principle in this book, in ISOE, in 7 Habits and in the Bible.  The excellent companies does not believe that "familiarity breeds contempt". The excellent companies thrive on open, direct lines of communication between management and workers.  And it shows in their financial results.


Dentists think that they are only earning money when their fingers are in somebody's mouth for eight to ten hours every day. Once out of that situation they are in a big hurry to escape as far away as possible to go home, to their hobbies, their sport, their alcohol or whatever.  There is precious little or no time for communication with staff.  This is totally wrong.  Communication is utterly important.  (Does it still need to be said.  Apparently, yes)  If it is so important TIME has got to be found, or created for it.


In the end, the authors of ISOE, concluded that the most important, one common characteristic of the excellent companies, is a value system, some call it the corporate culture.

At McDonalds it is Cleanliness, Service, Value and Quality. 

At 3M it is Innovation.

At Caterpillar it is Service.

Stephan Covey in 7 Habits prefers the term principles to values.  But the overall message is clear.  Excellent companies and effective people know exactly what they stand for and what they believe in.  We should let our staff know what we believe in.  They should know what we are living and striving for.  And this cannot be done in zero time.  We have got to get the message across.


I believe the best value system, the best principles, the best corporate culture is very clearly defined and described in the Bible. It is called the Jesus Christ way. But I have to make time to communicate this with the people  with whom I come into contact to.  And that means taking my fingers out of somebody's mouth every now and then.


The point is made once again in this chapter of ISOE that smallness is great.  "Small size is the prime generator of commitment" and "People can be themselves only in small, comprehensible groups."  Just another reminder that the dentist already has what the big companies crave, smallness.  We have just got to use it to our advantage.

                          Chapter 6


       In Search of Excellence: Hands-On, Value-Driven


Brief reference was made in the previous chapter of the importance of a value system.  It is reïterated in the opening paragraph of the chapter "Hands-On, Value-Driven" of ISOE

"Let us suppose that we were asked for one all-purpose bit of advice for management, one truth that we were able to distill from the excellent companies research.  We might be tempted to reply: "Figure out your value system. Decide what your company stands for.  What does your enterprise do that gives everyone the most pride?  Put yourself out ten or twenty years in the future: what would you look back on with greatest satisfaction?"


The point is made that most business people are reluctant or even ashamed to write and talk about such an emotional issue.  But nevertheless, the authors of ISOE ascribe the success of the excellent companies largely to the existence of a well-known value system within these companies.


Thomas Watson, Jr of IBM wrote an entire book about values.  He writes: "I firmly believe that any organization, in order to survive and achieve success, - must have a sound set of beliefs on which it premises all its policies and actions.  Next, I believe that the most important single factor in corporate success is faithful adherence to those beliefs.  And, finally, I believe if an organization is to meet the challenge of a changing world, it must be prepared to change everything about itself except those beliefs as it moves through corporate life."


In another book, Leadership and Administration, Philip Selznick writes:  "The institutional leader is primarily an expert in the promotion and protection of values......Leadership fails when it concentrates on sheer survival. Institutional survival, properly understood, is a matter of maintaining values and distinctive identity." He continues "Values are not usually transmitted through formal written procedures.  They are more often diffused by softer means: specifically the stories, myths, legends, and metaphors."


The importance of leadership becomes very apparent. Values are defined by the leading individual.  And he defines it not with mere words, but with action.


Dentists who want to be successful have got to lead by example.  They need a strong value system and they have got to live this value system.  They have got to believe in their profession, their products, their abilities and their staff.  This is all made easier, better and more practical when they believe in the Lord, Jesus Christ.  Christ is the foundation of the best and most influential value system of all history. He promises "And surely I am with you always, to the very end of the age."  (Matthew 28:20) He invites us to go to Him and to learn from him. "Whoever believes in me, as the Scripture has said, streams of living water will flow from within him." (John 7:38)


This also has very real, practical meaning for our daily lives as dentists.  There is no better value system for our practices than Christ's way.  The excellent companies know the importance of a value system.  Stephen Covey knows the importance of living a life based upon a firm set of principles. Without it no man can achieve real success, Excellence or Effectiveness.  Many companies struggle to get to grips with it.  They struggle to create mission statements.  They struggle to instill corporate values into their employees.


There is a short cut to success.  It is called the Christian Way.  If we treat our staff and our patients according to the Golden rule and according to all the directives of the Bible then we are guaranteed of success. Eternal success.


We must put our christian beliefs into practice. We must make our principles visible. Without abusing the very Core of our faith - God.  We must not use God for our ends - (Success), but rather allow God to use us for His purposes.  Our desires (success) will follow in God's time.

   "But seek first His Kingdom and His righteousness, and all these things will be given to you as well." (Matthew 6:33)

Peters and Waterman put it in different words: "The idea that profit is a natural by-product of doing something well, not an end in itself, is also almost universal."


They also list the specific content of the dominant beliefs of the excellent companies and it is very interesting to measure it against the Christian standard:

1.   A belief in being the best

The Christian way truly offers the believer the best way.  It offers the believer something which nothing else can.  Dentists like to be The Best.  That is fine. We have to.  But it is so much easier and better if we know why.

2.   A belief in the importance of the details of execution, the       nuts and bolts of doing the job well.

Good dentists know how important it is to follow procedures and instructions correctly and meticulously.  If the instructions say "Condition the dentine for 20 seconds" the good dentist will do just that.  Taking a short cut is something the christian dentist will not do.  The christian dentist will not make an inferior temporary crown or accept an inferior impression.  We know that by doing so we will be jeopardising our patient's well being. The christian dentist will establish and follow procedures which will benefit his patients, religiously.  Religiously in the true sense of the word.

3.   A belief in the importance of people as individuals.

This boils down to the second table of the Law, (Excodus 20:12-17) summarised as the Second Great Law in Matthew 22:39.

4.   A belief in superior quality and service.

How can a true christian deliver any other kind of service to his fellow men?

5.   A belief that most members of a organization should be          innovators, and it's corollary, the willingness to support       failure.


6.   A belief in the importance of informality to enhance            communication.

There is an interesting commentary in Matthew 23 verses 8-12: "But you are not to be called 'Rabbi', for you have only one Master and you are all brothers.  And do not call anyone on earth 'father', for you have one Father, and He is in heaven. Nor are you to be called 'teacher', for you have one teacher, the Christ.  The greatest among you will be your servant.  For whoever exalts himself will be humbled, and whoever humbles himself will be exalted."  It is a clear indication that we, the great doctors of dentistry, should get off our high chairs and come down to earth - to talk and especially to listen to our so-called sub-ordinates, our staff and our patients.

7.   Explicit belief in and recognition of the importance of         economic growth and profits.

The excellent companies know that they need money to survive. God knows it too.  Even christian dentists need money.  Capitalism is essentially christian.  Paul himself set the example: "For you yourselves know how you ought to follow our example.  We were not idle when we were with you, nor did we eat anyone's food without paying for it.  On the contrary, we worked night and day, labouring and toiling so that we would not be a burden to any of you.... For even when we were with you, we gave you this rule.  "If a man will not work, he shall not eat."  (2 Thessalonians 3: 7-8)


The Hands-On part of the title of this chapter refers to the role of the leader.  It means the leader actually taking part in the activities, living the values.  It is no good for the leader to talk about the values, he must be the living personification of the system.  Emerson's Charles Knight is quoted, "Set and demand standards of excellence. Anybody who accepts mediocrity - in school, in job, in life - is a guy who compromises.  And when the leader compromises, the whole damn organization compromises."

To which is added Tomas Watson, Jr's comments, "We want to give the  best customer service of any company in the world."


Leadership is something which many have sought to define. In terms of ISOE a few requirements of leaders are described.


Firstly, it would appear that leaders should be masters at the two ends of the spectrum: ideas at the highest level of abstraction and actions at the most mundane level of detail.  On the one hand the leader must create soaring, lofty visions and at the same time he must be a bug for detail.


Secondly, leaders must persist.  It is a case of ten percent inspiration and ninety percent perspiration.  There is simply no substitute for hard work. 


Thirdly, leaders are visible in the field.  The following interesting comment is made: " These leaders believe, like an evangelist, in constantly preaching the "truth", not from their offices but away from it - in the field.  They travel more, and they spend more time, especially with juniors, down the line."

They call this "MBWA", Management by walking around.  In dentistry this would mean being interested in the plumbing of your offices, in the finest detail of your ceramic technician's work, in the magazines and flowers in your reception area.  It means getting your hands dirty - Hands-On.


The chapter is closed with the following paragraph: "Clarifying the value system and breathing life into it are the greatest contributions a leader can make.  Moreover, that's what the top people in the excellent companies seem to worry about most.  Creating and instilling a value system isn't easy.  For one thing, only a few of all possible value systems are really right for a given company.  For another, instilling the system is backbreaking work.  It requires persistence and excessive travel and long hours, but without the hands-on part, not much happens, it seems."


Dentists should establish the central values in the practice on an intellectual basis and they should confirm this by their actions in a very practical sense.


For example a dentist might say "In this practice we do not hurt our patients, because it is not the christian way.  And he should be prepared to take the extra five minutes which it takes to administer effective, painless local anaesthesia.  This is what Hands-On, Value-driven means.


                          Chapter 7


       In Search of Excellence:  Stick to the Knitting


None of the excellent companies studied by Peters and Waterman seemed to do successful business outside their own peculiar sphere of interest.  McDonalds stick to hamburgers, Caterpillar to earthmoving, TI to electronics and IBM to computers.  McDonalds does not actively invest in real estate, 3M does not want to build aeroplanes, Boeing does not want to manufacture medical supplies.


In the excellent companies they just "Stick to the Knitting".  They do what they do best.  They refrain from venturing outside their primary field of interest.  Why?


Well, firstly, to buy and invest in unrelated business flies directly in the face of the Hands-on, Value-driven principle. Management of all the excellent companies are all champions of a cause, fanatical zealots obsessed with the practical details of their products and services.  If they are so dedicated to and knowledgeable about their special cause then how can they all of a sudden get equally worked up about something they know little about.  "Hands-on systems of leadership and instilling values thrive only to the extent that they are totally credible to those down the line.  Credibility is built up almost entirely "because I was there."  Without emotional commitment, without understanding of the product, there will be no suspension of disbelief."


The authors shoot down mergers, aquisitions and diversification in no uncertain terms.


What lessons are in it for for the dentist? Simply this, "Stick to Dentistry." Because dentistry is such hard work, dentists are loathe to accept this. Maybe it is peculiar to South Africa, maybe not.  But it is my observation that dentists are forever on the look-out for other ways of making money.  Only in my own personal circle of friends do I have dentists who have tried their luck at farming, construction, selling insurance, restaurants, dry-cleaning, guest houses and bird breeding, to name but a few.  I don't know of any one dentist who have made a really big financial success outside dentistry.  The exceptions are the guys who invested in fixed property and the stock exchange.


Personally, I have lost a lot of money by investing in a pharmaceutical company.  I stood surety for this company, thereby confirming Proverbs 11:15 "He who puts up security for another will surely suffer, but whoever refuses to strike hands in pledge is safe."


Sooner or later every dentist is tempted by the lure of "easy" money.  There are more than enough clever fraudsters who know that young dentists have a little disposable income and a lot of credit worthiness at the banks.  They know how to manipulate these young (and older) dentists.


The point is to resist these temptations.  Stick to the Dentistry.  Invest whatever spare cash is available in safe havens. Do not invest in high risk schemes. Many have tried and failed.  Only a few individuals have ever made the so-called Big Time by making quick money out of a high risk scheme.


Our paradigm must always be "Service to our patients" not "Money".  By investing in some or other money making scheme you will be negating your own highest values.  How can you be enthusiastic and fanatical about your dentistry when you doubt it so much that you actually commit yourself to something else.  Always remember "For the love of money is a root of all kinds of evil." (1 Timothy 6:10)


"Stick to the Knitting" also implies positively sticking to it.  It does not only prohibit us from venturing outside dentistry, it encourages us to invest in our dentistry.  It encourages us to invest our time and our money in our practices and our profession. It wants us to learn new techniques, it wants us to improve our services and the quality thereof.  It wants us to expand into dentistry and it wants us to be the best dentist we can possibly be.


It also encourages us to become specialised dentists in our own way.  If you are bad at working with children then don't do it!  If you hate dentures, then don't do it!  If you're no good at orthodontics, don't do it!


Chairman Bob Fluor of the excellent company Fluor says "We can't be everything to all people."  This was discussed before.


Doing what we don't like or can't must not be tolerated in dentistry.  It is what kills you.  Stick to the knitting that you know best.


Referral to specialists is a strong practice builder. Patients appreciate honesty more than anything else: honesty breeds trust and a relationship of trust is the only foundation of a successful dental practice.  When in doubt, refer.


If you don't like dentistry, get out of the game completely.  Don't try something else on the side.  It won't work.  Get out and find something else and devote yourself totally to it.  Better still, shift your paradigm, start liking dentistry and stick to it.


                          Chapter 8


      In Search of Excellence:  Simple Form, Lean Staff


The first sentence in this chapter reads, "Along with bigness comes complexity, unfortunately."  The point was already made earlier.  Excellent companies grow big because they are so excellent, and then they spend a lot of energy to act as if they are small.  They try very hard to remain close to their customers, they try very hard to be kind to their staff and to listen to people. They try very hard to keep on doing what made them excellent in the first place, when they were still small.


"Simple Form, Lean Staff" reïterates this. It seems to stress the fact that we are in an excellent position to be excellent.  Dental practices are small, by almost any standards.  Very few practices are overburdened by the presence of too many staff members.


One lesson that we can learn from the excellent companies is that they do not allow a lot of staff to crowd the real issues - sales, customers and marketing.  The excellent companies concentrate their energies in these fields.  They don't seem to be very tolerant of bureaucracies. They value individuals, they think it is important to push authority far down the line.  "The bottom line is fewer administrators, more operators". "At $2 billion Wal-Mart, founder Sam Walton says that he believes in the empty headquarters rule: "The key is to get into the stores and listen.""


Peters and Waterman write "The heart of the entrepeneurial pillar is "small and beautiful."


We as dentists have got no excuse.  We run small businesses.  We control everything, including our own destinies.  We have just got to take control and do it.  And "it" refers to customer service and everything else written about in this book.  We don't need big staff, we don't need formal structures, complicated business plans, strategic plans or any special training.  We only need the will to succeed and to do something about it. 


Running a practice on a cash on delivery basis, like a supermarket, is the simplest "Form" and requires only "Lean" staff.  The minute a dental practice has to collect money from a third party, "Form" becomes more complex - viz the endless accounts, the computer, the queries and enquiries.  One also needs more staff in order to handle all the above.


When a patient pays as he leaves, "Simple Form" is created, cash flow dramatically improves, all queries and mistakes are immediately answered and corrected and one does not need a computer and credit control staff.  A cash practice is "Simple Form - Lean Staff" in action.

                          Chapter 9


  In Search of Excellence:  Simultaneous Loose - Tight                           Properties


It is this chapter really that brings it all together. One becomes almost animated at the reading of it.  The temptation to reprint it verbatim is great, because it speaks so directly to the dentist seeking his own destiny.  The parallels between an excellent dental practice and the excellent companies are stunning.


The excellent companies are run on the lines of this vague description, " Simultaneous Loose-Tight Properties." It refers to the "co-existence of firm central direction and maximum individual autonomy."


Of great significance are the words, "They do this literally through "faith" - through value systems,...They do it also through painstaking attention to detail, to getting the itty-bitty, teeny-tiny things right."  


The role of the leader is two-fold 1.  The creation and maintenance of a value-system     2.  Getting the small things done.  Every one of the excellent companies has a central value system.  At Caterpillar it is fanatical service, at 3M it is innovation, at McDonalds it is Cleanliness, Service, Value and Quality. And everyone at these companies knows about it, believes in it, lives it.  All the great leaders who built these companies did so by believing in what they did.  They lived by their values and they believed.  They believed in their customers, they believed in granting autonomy, they believed in open doors, they believed in quality, and in service. In other words they had a certain well-defined value-system, something in which to believe.  Within this value-system they allowed themselves and their employees freedom and autonomy to experiment and to even make mistakes.  The value system is tight or non-negotiable.  Yet, the individuals are free, that is loose.


The similarities with Christian life are overwhelming.  As Christians we have the best value system known to man and within the boundaries of this system we have freedom.  Christian life does not consist of a lot of rules and regulations, do's and donts, but rather of the one all pervading christian value-LOVE.  The only way to "earn" this freedom is by believing

(Galatians 5:5)  "But by faith we eagerly await through the Spirit the righteousness for which we hope"  And once you believe, and are free, through the power of love you automatically will and must do the right things   " For in Christ Jesus neither circumcision nor uncircumcision has any value.  The only thing that counts is faith expressing itself through love." (Galatians 5:6) The christian is free from the powers of darkness-depression, self-doubt, guilt, greed, lust and all the other vices, and this freedom is definitely not a licence to sin "You, my brothers, were called to be free.  But do not use your freedom to indulge the sinful nature; rather, serve one another in love" (Galatians 5:13) This freedom enjoins us to love and to serve our fellow man with good deeds.


There are no more sound basis upon which to build any dental practice than the basis of christian love.  If you love your patients, if you are dedicated to service, if you are driven by your patient's desires, not your own, you must and you will ultimately succeed.  The christian mindset is the epitome of "Loose-Tight."  Whilst christianity is dogmatically and principally intolerant of other beliefs and religions, the christian is tolerant to the utmost of all other men.  Christianity is by definition an exclusive religion, a religion which leaves no room for any other religion, yet at the same time it teaches that its adherents should not only be tolerant of but actually, actively love its enemies. (Luke 6:27-29)


In this chapter of ISOE, the final chapter, the paradox of the "Loose-Tight" principle is mirrored in several ways. Although freedom and autonomy are prevalent in the excellent companies, so is discipline.  All the legendary champions of the excellent companies were also strict disciplinarians.  They gave their employees plenty of rope.  Violation of the company's value or culture system invariably led to the end of a career.


One of the most beautiful examples is the apparent contradiction between efficiency and effectiveness. "In the same way, the efficiency/effectiveness contradiction dissolves into thin air. Things of quality are produced by craftsmen, generally requiring small-scale enterprise, we are told. Activities that achieve cost efficiencies, on the other hand, are reputedly best done in large facilities, to achieve economies of scale.  Except that that is not the way it works in the excellent companies.  In the excellent companies, small in almost every case is beautiful.  The small facility turns out to be the most efficient; its turned-on, motivated, highly productive worker, in communication (and competition) with his peers, outproduces the worker in the big facilities time and again.  It holds for plants, for project teams, for divisions - for the entire company.  So we find that in this most vital area, there really is no conflict.  Small, quality, excitement, autonomy - and efficiency - are all words that belong on the same side of the coin."  The dentist with a dream needs no clearer, more concise recipe for success, than these words.


Also, it is stated that "autonomy is a product of discipline."  To the casual observer "autonomy" might imply careless, reckless, freedom without responsibility to anyone.  In practice though real autonomy is bred from a seedbed of dedication, discipline and hard work.  The truly successful dental practice will also be bred from the same seedbed. There is no shortcut.


ISOE concludes with a final reflection on a strange contradiction - their so-called "smart-dumb rule."  The authors make the point that many of today's MBA trained managers and their like are a little too smart for their own good. Success is not something one learns from a book or at an university.  All the best business plans or strategic plans or market research of the clever managers are just that, plans.  They hold no secret gaurantee or recipe for success.  The successful men are the "dumber" ones, the ones who simply cannot understand why every product - crown - root canal treatment - denture - injection - consultation - X ray - can't be of the highest quality. "They just don't understand why every customer can't get personalized service, even in the potatoe chip business.  They are personally affronted when a bottle of beer goes sour.  They can't understand why a regular flow of new products isn't possible, or why a worker can't contribute a suggestion every couple of weeks. Simple-minded fellows, really; simplistic even.  Yes, simplistic has a negative connotation.  But the people who lead the excellent companies are a bit simplistic."


"Of course, what one is simplistic about is vitally important.  It's a focus on the external, on service, on quality, on people, on informality, those value content words we noted.  And those may very well be things - the only things - worth being simplistic about. Remember the executive James Brian Quinn interviewed: he said that it was important for his people to want to be "the best" at something.  He doesn't really care very much what. But so many can't see it. There are always practical, justifiable, inevitable, sensible, and sane reasons to compromise on any of these variables.  Only those simplistic people - like Watson, Hewlett, Packard, Kroc, Mars, Olsen, McPherson, Marriott, Procter, Gamble, Johnson - stayed simplistic.  And their companies have remained remarkably successful."


Obviously, it is not possible for all dentists to be "the best." But we can all try.  And herein lies the rub - in the trying.  The excellent companies keep on Searching - for Excellence, and so should we. Even though plagued by failures and mistakes we should keep on pushing and trying.  Every new crown should be better than the previous one, every injection more painless than the last one.  Always remember, the perfect restoration has not been placed yet.  Try and be the first do it, every time you do it. The Search for Excellence is just that, a search or a journey, an endless quest for perfection, never to be fully realised.    

                          Section 2


                         Chapter 10


  Seven Habits of Highly Effective People: An introduction



The book, The Seven Habits of Highly Effective People, written by Stephen R Covey, is a monumental work which needs reading, re-reading and repeated study of its material.  Any attempt to summarize it would be futile, but in order to stimulate the would-be dentist reader the major points will be highlighted.  The author of Seven Habits is the founder and Chairman of the Board of an organization with the following mission statement:

                         Our mission

           is to empower people and organizations

   to significantly increase their performance capability

           in order to achieve worthwhile purposes

              through understanding and living

               principle - centered leadership


The sub-title of the book is "Restoring the Character Ethic." 


Covey's mission statement and the sub-title says it all.  In the introductory two chapters to this book Covey is at great pains to explain the importance of a life lived according to the Character Ethic.  The Character Ethic is in sharp contrast to the Personality Ethic, a set of artificial, learned behaviour taught by countless modern psychologists, books, courses and theories.  The Personality Ethic tries to teach us, in a quick fix way how to relate and communicate and so, even manipulate others - for our own good and to our own advantage.  The Character Ethic is the Ethic taught for centuries by many teachers and embodied and perfected two thousand years ago by Jesus Christ.  His name is mentioned only once, in passing, in Seven Habits but every sentence in the book is heavily laden with christian doctrine.  The first chapter is titled "Inside - out" and deals with personal change which starts with changing  one's own personal way of thinking.  It contains several anecdotes of change of the all-important self - or Ego, just as Jesus had taught us.  Covey begins by showing how important it is for every individual to change him or herself, in other words to seek out his or her own character defects first, before looking for these problems in other people.  Jesus asked, "Why do you look at the speck of sawdust in your brother's eye and pay no attention to the plank in your own eye?  How can you say to your brother, 'Let me take the speck out of your eye,' when all the time there is a plank in your eye?  You hypocrite, first take the plank out of your own eye, and then you will see clearly to remove the speck from your brother's eye." (Matthew 7: 3-5)


Covey gives the very vivid example of his own son and the problems he had.  It was not until Covey and his wife Sandra had changed the way they viewed and percieved their son, that something happened and he, the son, managed to grow to his potential.


The important message is that there is no technique or book or course that can change a dentist or the way he conducts his practice, unless he or she wants to change  and are prepared to do something about it.  Furthermore, it is necessary for this potentially changing dentist to be prepared to look afresh at his or her work and profession, as if he or she is doing it for the first time.  Only when a dentist is prepared to change his or her paradigm about dentistry, can and will effective change be brought about.  There is wonderful examples and descriptions of the word paradigm in these chapters but maybe it is enough  to say that paradigm means something like frame  of reference.


If a dentist's paradigm of dentistry is a relatively comfortable and easy way of earning a living, sooner or later he or she will end up bored and frustrated.  If the paradigm is one of a get-rich-quick-and -at-all-cost - this boredom and frustration will set in faster and at a much more intense level, possibly ending in alcohol or drug abuse, coronary disease, divorce or any of the other problems so well known to us.


On the other hand, if the paradigm is one of service to and love of our patients, dentistry can and will be a noble, fruitful and rewarding profession.   I experienced it myself.  For nine years I tried to be the best dentist, for my own glory.  It was not to be!  I gave up trying and for two years I went to England and toiled and laboured under the NHS and all the time I thought and thought.  I came back to South Africa with a firm conviction - to set up a new practice - to serve my patients and my God - for His glory.  And it worked, because I changed my paradigm.


Covey stresses that we cannot find solutions to our external problems - that is problems with our fellow men unless we ourselves first change.  How true is that in all the divorces happening around us. No amount of counselling or pastoring can save a marriage unless the husband and wife are prepared to shoulder their own responsibilities, to recognise their own faults, and to do something about it, before looking at the spouse's shortcomings.


Covey believes so deeply in this that the first three of his seven habits are grouped together  under the heading Private Victories - that is victories over self.  These private victories lead from Dependence to Independence. The following three habits are the Public Victories leading the newly Independent individual to a state fo Interdependence.  Whilst the modern social structure prizes independence as the ultimate goal in life, Covey says that no man is an island and the ultimate goal should be Interdependence.  We will only be happy and successful if we can relate effectively with other people - that is Interdependence.  It is also one hundred percent in tune with what the Bible tells us.  Dentists, like all other people can never be totally Independent.  For one thing we need patients and for another staff.  We need them and they need us.  If we can relate and communicate with them, effectively, they and we, will be happy.


Another of Covey's interesting concepts is his P/PC Balance, that is the balance between Production and Production Capability. Whilst it is important to Produce , that is fill teeth, it is just as important to preserve, conserve and expand our Capability to Produce.  This includes strategic planning, continuing education, effective recreation, time and motion planning, staff training, scheduling and a myriad of other small but important things.  We spend eight or more hours of every day producing, yet how much time do we devote to our Production Capability?  For the purpose of his book Covey defines a habit as the intersection of knowledge, skill and desire: "Knowledge is the theoretical paradigm, the what to do and the why.  Skill is the how to do.  And desire is the motivation, the want to do.  In order to make something a habit in our lives, we have to have all three." Interestingly, educationalists tell us that we all function and perform on three levels: The Cognitive level, the Psycho-motor level and the Affective level, which can be directly equated to Knowledge, Skill and Desire.  As dentists Knowledge is our theoretical knowledge, Skill is our learned dexterity and practical know how and Desire is our emotional commitment.  We need all three, to be Effective dentists.  We need a sound theoretical background and we need to practise this. Finally we need to love doing it all.  

                         Chapter 11


            Seven Habits: Habit 1: Be Pro-Active


Animals respond instinctively to external stimuli. Humans have the freedom to choose the way in which they respond.  This is the message of Habit no 1, Be Pro-Active.


Whilst we have the freedom to choose, we cannot choose the consequences of our choices.  The consequences are governed by natural law.  Our choices to become dentists have, because of certain natural laws, had certain consequences.  Similarly, our decision to be a certain kind of dentist will have a certain consequence. If we decide to rip-off and defraud a medical scheme/NHS/ insurance company, it will have certain consequences. These consequences may vary, depending on whether we are found out, but inevitably it will always have certain consequences on our character.


Covey highlights the word responsibility and breaks it down to "response - ability" - the ability to choose your response - freedom to choose.


He also makes a clear distinction between Reactive people and Pro-active people.  Reactive people are lived by their circumstances.  They are affected by their environment.  If the weather is good, they feel good.  If it is bad, they feel bad.  They are driven by feelings.


Pro-Active people choose not to be affected by their environment or by other people.  They choose to feel good in spite of bad weather.  Very importantly, pro-active people are driven by values and not by feelings.  Again we meet the word, Values, so emphasised by Peters and Waterman in In Search of Excellence.


Covey draws an interesting distinction between reactionary love and pro-active love.  Reactive people experience love as a feeling.  Pro-active people make love a verb.  Love is something you do: the sacrifices you make, the giving of yourself,....."  The New Testament is full of this Pro-Active, self-sacrificing, love.  Covey also says ".....people who end up with the good jobs are the proactive ones who are solutions to problems, not problems themselves, who seize the initiative to do whatever is necessary, consistent with correct principles, to get the job done."


Note again the words "correct principles." It equates to  values.


Reactive people tend to cop out.  They seek excuses for their failures and mistakes. They blame it on circumstances and on others.  They are also the "have's."

     "If only I had a boss who wasn't a dictator"

     "If only I had a more patient husband"

     "If I had more obedient kids"

     "If I had a degree"


Pro-active people are the "be's".  I can be more patient, be wise, be loving.


Covey states "Anytime we think the problem is "out there", that thought is the problem.  We empower whats out there to control us......  The pro-active approach is to change from the inside-out: to be different, and by being different, to effect possitive change in what's out there - I can be more resourceful, I can be more diligent, I can be more creative, I can be more cooperative."


What does all this practically mean for the dentist? Firstly, we are the masters of our own destinies, not some faceless third party in the form of a medical aid scheme/NHS/insurance company.  We choose to be independent entrepeneurs or we choose to be subjugated to some unfair or unjust system.  We can choose to "work the system" or we can choose to love our patients.  Whatever we choose, we have to suffer the consequences, consequences governed by natural law.  If we choose a dishonest course of action we will suffer guilt, depression and maybe worse. If we choose to do the right and proper thing, we will harvest joy, happiness and also eventually financial rewards.  This is true every time a dentist treats a patient.  Whenever the dentist's motive is his own self interest, read greed, he will suffer a little.  When he puts his patient's interest above his own, he will enjoy many blessings.  If a patient comes in for a check-up and he has a missing lower first molar, his occlusion is stable, he functions well and he is not concerned with the aesthetics of a missing lower molar, no treatment is indicated.  It is in the patient's best interest not to treat, but it unfortunately often happens that patients get talked into expensive treatment because the dentist are concerned with their bank accounts.  It is impossible for a dentist in such a case, to derive job satisfaction from this treatment.  Far better it is to tell the patient: Sir/madam, I see that you have a missing tooth, but at the moment it isn't causing any problems.  However I will review the situation in one year's time and if necessary I will recommend treatment."  This is the way to be pro-active, to love your patients, to build a relationship of trust.


Reactive dentists tend to say: "In my area, patients are so poor, they cannot afford to pay for dentistry.  If only I had rich patients."  "The recession has hit my patients very hard and they cannot afford my services.  I practice in a blue collar, industrial area, they don't want advanced treatment. "If I charged more, all my patients would go to the opposition".  Reactive dentists allow themselves to be governed by influences outside their control.  Pro-active dentists choose to exercise some influence over people and circumstances which are within their circle of influence.  We have no influence over third parties, but we have a lot of influence over patients.


Being pro-active also has a literal meaning. It means acting before hand.  I pre-empted the death of inner Pretoria. It was part of the reason for leaving my well established practice in downtown Pretoria.  I knew I had to move to the suburbs, to where my patients were and I did it, with good effect.  Sometimes we have to plan ahead, to look strategically at our practices and to make decisions and to act them out.  Being pro-active is the first habit of highly effective people.  It is the first Private Victory, a victory over self.  It is not a victory over other people.  Yet, dentists are loathe to allow themselves even this little victory.  They are scared to take even this step, to make a decision to move this one little inch. It is a decision to change only one self.  How to influence other people, how to make those Public Victories over other people is dealt with later.


But first, the dentist has to take this first step on the road to Independence and ultimate Interdependence.  Dentists who make a living out of medical aid schemes, the NHS or insurance companies are totally Dependent on those organizations for their livelihood and it is very understandable that they do not want to leave this form of security.  However, the asphyxiating controls that these organizations hold over our profession leave us with very few options.  Either we work these systems - to the point of defrauding them - or we get out and become Independent.


The future looks very bleak for dentists clinging to the perceived security of these systems.  The crisis in South Africa's, Britian's and the United States' Health Services bodes ill for socialised dentistry.  There is no way that these systems can be sustained.  Medical Scheme/NHS type of dentistry will fall by the wayside, sooner or later.  Dentists have to wake up to the fact that they will have to return to the old doctor-patient relationship, including the direct settlement of fees, without the interference of third parties.


The pro-active dentist will pre-empt the disintegration of organised, socialized dentistry and he will take action to position himself in the changed environment.  The reactive dentist will do nothing, until it is too late.  Then he will complain about what his environment had done to him.

                         Chapter 12


      Seven Habits: Habit 2, Begin with the End in Mind


The first Habit says, "You are the creator of your destiny", the second Habit says "Create!"  this destiny.  It begs you to find out what it is that you want.  So few people know.  This chapter is introduced by Covey's funeral experience.  He asks you to "attend" your own funeral and to listen to the speakers, one from your friends, one from your work, one from the family and one from your church.  You are then asked what it is that you want to hear these people say about you.  It is a startling experiment.  When you mirror your mortal self against your circle of influence you realise the real value of things.


Knowing what you want other people to say at your own funeral about yourself is a sure way of knowing what it is that you want to be. Do you want to be something?  Or do you only want to have some things? Think about it for a minute. 


The second Habit then is about setting goals.  We all know how important it is to set goals, but how many actually do it?  How many people actually sit down and write their own goals down on a piece of paper? At the beginning of 1995 I did just that for the first time in my life.  I formulated my goals, in a very rough and ready fashion and I wrote it down on a piece of paper.  I set goals regarding my turnover, family life, church life, academic life and personal life.


I admit that I didn't fulfill all my objectives, but one thing is for sure: 1995 was the best year of my life so far.  I exceeded my wildest expectations in several fields.  I gave more talks and wrote more papers than I had intended to.  My practice bursted out of it's seams.  We did some major extensions to our house.  I believe that our family grew spiritually.  And I deeply thank the Lord for this.  It all transpired through His loving grace.  Yet I allowed it to happen, I chose it to happen by taking the first step, by defining what it was that I wanted.  I defined it in a very clear cut, concise way, by writing it down.


Covey says that all things are created twice, first when it is conceived and planned and secondly when it is physically created. The first creation is the mental creation, like the architectural planning of the house.  We have to plan our lives in the same way, otherwise circumstances and other people are going to do it for us.  Allowing outside events and persons to impact on our lives is reactive. Creating your own future is pro-active. This is true in all spheres of life. If you do not plan your year, other people are going to ask you to do things at certain times of the year and you will have no valid reason for refusing.  You will be lived by other people and events.  If you do not plan to take lunch breaks, you will not have lunch breaks.  If you do not plan to take an extended overseas holiday, you will not have it.


It is easier when you know what it is that you want, when you know what "The End" is.  Is it money, fame, posessions, freedom, recognition, happiness or what?  It is not always wrong to desire money or possessions but the Lord most definitely does not want us to be slaves to earthly possessions.  The Tenth Commandment actually forbids us to desire. "Thou shalt not desire." (Exodus 20:17) We are told that we should first seek the Kingdom of God and that He then will provide us with all the rest. (Matthew 6:33)


Money and earthly possessions can and will be a trap which can ensnare and enslave us.  We should beware of an overly great desire after material possessions.  But once we know what it is that we want to be to our family, friends, colleagues and community, the relative importance of the things that we also desire will come into focus.  So find out first what it is that you want to be, before you say what it is that you want.


Covey then brings us to the very heart of his message. He says that at the center of every person's being there is something or someone.  This someone or something is the source of that person's Security, Guidance, Wisdom and Power.  He lists several alternative centers: Spouse, Family, Money, Work, Possession, Pleasure, Friends, Enemies, Church and Self.  Every person can choose one or more of these Centers and build their lives around it.  Covey then shows that none of these can succeed as an effective source of Security, Guidance, Wisdom and Power.  It is actually a startling revelation to see that neither your wife, family, money, yourself or even your church can be the Deep Source of your Effectiveness.  Covey shows, quite clearly that the only proper and effective Center is a so called Principle Center.  Covey believes that we should center our lives on correct principles, creating a solid foundation for development of the four life-support factors, Security, Guidance, Wisdom and Power.


He describes principles in eloquent terms: "Priciples are deep, fundamental truths, classic truths, generic common denominators.  They are tightly interwoven threads running with exactness, consistency, beauty, and strength through the fabric of life."  He goes on to describe principles as rock-solid foundations, unchanging guidelines, unalterable sources of wisdom and fountains of truth.


Unfortunately he stops there.  He does not go all the way and tell us what these principles really are.  Where can we read about them?  He does not tell.  I guess it was to be suspected.  One does not produce best sellers by quoting from the Bible.  It is not very fashionable to do so.  After all the Bible is a very old book and what intellectual, lateral thinker still believe all the stories in the Bible?  I do and so do many others.  I believe the Bible is the best possible center for any person's life. 


The Lord is all the SECURITY that you will ever need.


The Bible offers you all the GUIDANCE that you will ever need.


It contains all the WISDOM in the world that is worth considering.


A life in Christ is the most POWERFUL life any person can live.


Covey wants us to live principle centered lives. I believe the best principles are christian principles.  There is no more clear cut, infallible, unchanging, tried and tested set of principles than those contained in the Holy Scriptures and delivered to us by the Holy Spirit.  It has withstood the tests of time, spawned civilizations, salvaged fallen men, built marriages and delivered mankind from eternal hopelessness.


The christian knows exactly what "The End" is.  It is an eternal life with God, but it is also a daily life with Him, lived minute by minute.  It is doing His will, not mine.


Once this is realised, the rest becomes easy.  Once the christian dentist realises that he or she has to live according to the Lord's instructions, he or she will know how to manage every situation.  All of a sudden it becomes crystal clear that it is fundamentally important to serve the patient's best interest, not your own.  It becomes apparent that we have to conduct our practice in an honest way. It becomes obvious that we have to make certain sacrifices so that the Lord's Name can be glorified.


The Lord tells us to love others and to suffer injustices and to sacrifice self, always.  There is no ambiguity about that.  Jesus Himself sacrificed His very life - so that we can have eternal life. These are unchallenged, age-old, unalterable truths, excellent principles to have at the center of our lives.


These principles can and will also work in our dental practices.  Peters and Waterman, in ISOE, concluded that the one most important distinctive characteristic of all the excellent companies is the existence of a value system, known by all employees.  Covey considers a principle centered life thesine qua non of an effective person.  I believe that the Christian law offers us all this and more.  It is such a pity that Christianity has "gone out of vogue."  It is not fashionable to talk about Christian principles and values in today's high-flying business and intellectual circles.  Yet, christianity holds the key to all business and personal problems.


In our lives as dental practitioners we should define our "The End's" in eternal, lifelong and daily terms.  We should know that our little practice also has a place in eternity.  It is our workfield and it is our mission field.  It is the place where we love and serve our fellow men and it can also be the place where we can witness to our fellow men.  We should be doing the kind of dentistry in a way that can bring a little more glory to His Name.  Every action that we carry out, every injection that we give, every root canal that we do, every denture that we make should be done in this way.  Every treatment plan should be devised so as to serve the patient, not ourselves.


We should begin every day with this in mind and we should begin the rest of our lives with this in mind.


As christians we should lead responsible lives. We should also take a look at certain practical aspects of our lives.  We should reflect on what kind of dental practice it is that we want.  Do you want to have the busiest practice in town, with the highest turnover?  Do you want to have one or two or seven surgeries, perhaps with other dentists working for you?  Do you want to do all aspects fo dentistry?  Do you want to specialise in certain fields?  Do you want to have a small solo practice where you see only three or four patients a day?  Do you want to be a slave to third parties? Doctor, do you want to be free?  But most important what is it that you want to hear your patients, staff and colleagues say at your funeral?  "Dr Smith was the man who filled my teeth a few times in my life."  Or rather "Dr Smith was more than a good dentist to me.  He was also a friend.  He was always professional and courteous.  He listened to me and he always helped me."


Once you know what it is that you want, write it down and share it with others.  You can write it down in the form of a mission statement or merely as a set of goals. The important thing is that you crystallise your thoughts into written words.  It is the only way you can properly communicate this to the people you work with - your staff and sometimes also your patients.  It can be a very good idea to let your patients share in your mission statement by printing it in your practice brochure.  But some of your own personal goals might not be that relevant to them.  Of extreme importance is that your staff should know exactly where you are heading. They should know what your goals are, also your financial goals, and they should be in no doubt about what lies in the Center of your being.  If your staff know what it is that drives, guides and inspires you, they don't need to know a lot of more.  They will make it their business to help you achieve your goals.


What it is that you want to be and what your principles (7Habits) or values (ISOE) are should be absolutely crystal clear to everybody working with you.  And they should either identify with all of it or get out.  It is that simple.  If you have people who don't share your basic philosophy you will never be effective and excellent.  But with a team, single-mindedly dedicated to your goals and mission in life, you can and will succeed and flourish beyond your wildest dreams.


                         Chapter 13


          7 Habits, Habit 3: Put First Things First


The final habit which is a Personal Victory is, "Put First Things First."  Or get your priorities right.  How many times have we heard this, said this and how many times does it still need to be repeated?


Yet Covey's approach is fresh and gives new insight into an old problem and when applied to dentistry can be life-changing.


One of the unique characteristics of humans as opposed to other forms of life is the existence of an independent will in individuals.  This is what gives us the freedom to choose.  One of the most important choices we make is the decision of how to spend time.  We only have so much time and no more.  We exercise autonomy over the way we spend this time.


Covey says we spend our time in one of four Quadrants, Quadrants 1 to 4.  Each quadrant is either urgent or not urgent and either important or not important.


              Urgent         Not urgent

     Important      I         II

   Not important        III       IV


Quadrant 1 is Urgent and Important.  This represents crises, deadline-driven projects and pressing problems.  This would represent in a dental practice, the routinely scheduled appointments for restorative work and emergency pain relief.


Quadrant II is Not Urgent but Important.  These are matters such as planning, marketing, relationship building and in dentistry it is items such as educating patients in the importance of oral hygiene, communicating with patients, continuing education, further study, training staff, sending out letters and cards, a recall system and the development of a casebook with before and after photographs to show to patients.


Quadrant III is Urgent but Not Important.  It is time spent with unwanted people, unnecessary telephone calls, some meetings and certain popular activities.  For the dentist this might be time spent on so-called "bad" patients.  These are people with whom a long term relationship is impossible or undesirable. It is also time spent on treatment against the better knowledge and judgement of the dentist for instance doing unnecessary crowns or any treatment which a patient doesn't really need and want.


Quadrant IV is Not Urgent and Not Important.  It represents trivia, some mail and telephone calls, time wasters, television watching, loafing and excessive socialising. 


Dentists universally seem to yearn to spend all their productive time in Quadrant I.  As long as they can drill, fill and bill they think they are happy.  Thirty years ago with rampant caries, a paucity of dentists and a free market this was exactly how dentists spent their time.  Most of them also made a lot of money.  But those days are over now.  Caries are under control and there are many more dentists with even more being produced every year.  Added to this are the strict controls and fee structures of socialised dentistry.  Many dentists thought that the answer was working even faster and doing more procedures on the victims in their chairs.  The result was poor quality, often unnecessary dentistry, a total breakdown in communication and early burnout and a host of other problems among dentists.  Most often these days we have to work hard to attract patients to our practices.  This hard work is Quadrant II activities. Quadrant II is where we should aim to spend more time.  In our personal lives it represents regular physical excercise, talking and playing with our children, effectively communicating with our spouses, regular Bible study and prayer, personal development and planning.  In dentistry this is where we also need to spend some time. Take for instance the simple matter of oral hygiene control.  It is the single most important issue in dentistry, yet arguably also the most neglected.  How much time do you spend communicating the importance and the techniques of oral hygiene with your patients?  It is definitely not purely and simply a matter for the oral hygienists.  Patients want to hear it from the doctor.  I have built up a happy practice, full of very appreciative patients, each one of them highly educated about the value of good oral hygiene.


The answer to a lack of patients to which you can do Quadrant I dentistry does not lie in manipulation and overtreatment.  It also does not lie in trying to be the cheapest dentist or the one who plays the system.  It lies in Quadrant II.


Dentists who spend all their time in Quadrant I can usually not wait to slip into Quadrant IV.  They rush home or to the pub and they indulge in some or other activity, not related to work.  Sooner or later they also get sick and tired and worn out by all the stress.  When a dentist is unhappy, disillusioned or frustrated, the answer to his problems lies in Quadrant II.  It lies in planning, intelligent relaxation, exercise, getting a new vision and proactively and creatively thinking. Personally I experienced such a crisis in the years before I left for England.  I decided to give up my practice in Pretoria, go to England for two years and then to come back and put up a new practice, based on new principles, the christian way.  I spent a lot of time in Quadrant II, planning this new practice.  I was prepared to forsake and forego all Quadrant I dentistry to get it right.  Today I am very happy, but I still spend many hours a week in Quadrant II.  It is the way I attract new patients to my practice, patients who pay a lot of money for my services.


Habit 2, Begin with the End in Mind, is Effective Leadership.  Habit 3, getting your priorities right, Putting First Things First, is Effective Management.  The one follows the other.  Leadership has to have priority over management.  You first have to know where you are heading before you can start working on getting there.


Spending time in Quadrant II exacts its toll. This time has to come from one of the other quadrants, usually III or IV, especially in the beginning. Eventually though it will yield dividends, in the form of more available time.  If you are really very unhappy with what you are doing, even in Quadrant I, like I was, you might have to or want to, even take time off Quadrant I, to spend in Quadrant II. 


Covey begins this chapter by asking his readers to think of one activity they might do, on a regular basis, which would have a tremendous impact on their personal lives,  Personally, I know where I draw my Guidance, Wisdom, Inspiration and Power from and without daily communication with my Lord, Jesus Christ, that is Bible study and prayer, I am not up to much.  It is the most important Quadrant II activity.  Incidentally, all seven of the habits are Quadrant II activities.


When you kneel down and pray, when you attest to your own sinful, useless, powerless, wicked nature, when you realise how weak you are, how utterly worthless, you have made the greatest Personal Victory. You have conquered your Self, your Ego. You can now draw nearer to the Cross, confess your sins and sinful culture, receive forgiveness and live a really powerful life in Christ.

You have also reached the dream of Independence. You are now not dependent on the views of other people or on your circumstances for your happiness.  You find your own self worth not in the views of people but as a true child of God.

                         Chapter 14


           7 Habits: Paradigms of Interdependence


Squeezed in between the first three and the last four Habits, Stephen Covey adds a chapter, called "Paradigms of Interdependence."  It is a powerful and interesting chapter, yet it left me a little sad and disappointed - because I thought Covey did not credit the great Originator of his paradigms - the Lord Jesus Christ of the Bible.


Every word in this chapter is bathed in truth, or rather Truth -the Gospel Truth, yet Covey makes no direct reference to the One who said it all before.


This chapter also contains many direct, practical pieces of advice on which a sound, healthy dental practice can be built. But this advice has been available for centuries - Covey only explains it in a different and new way.  We only need to make it relevant to our practices. The first three Habits represent the so-called Private Victory that is victory over self.  The second three Habits are the Public Victory, that is victory in relationship with others.


The Private Victory is the road to Independence. Independence of what?  The answer is Independence of our sinful nature, Independence of our circumstances and Independence of the opinions of others. It is being able to survive independently of the will and whims of others.  We can only do this by conquering ourselves.  By having a vision or a dream, by establishing personal leadership and by implementing proper, personal management.  Covey says "Self-mastery and self-discipline are the foundation of good relationships with others....Real self-respect comes from dominion over self, from true independence.  And that's the focus of Habits 1, 2 and 3.  Independence is an achievement.  Interdependence is a choice only independent people can make....So the place to begin building any relationship is inside ourselves, inside our Circle of Influence, our own character."


This is vintage and pure christian ethic.  The Bible tells us in a thousand places to renounce ourselves, to repent from our sins.....and to love our neighbour - Interdependence!  Let us hasten to make this relevant to our dental practices.  The point is this - there are many practice management courses, run by highly skilled and professional consultants, which aim to get us to run successful practices.  These one-day, three-day, week long courses are attended by thousands, yet the fruits of these courses are very rarely seen.  Why is it that there are such a lot of unhappy and even unsuccessful dentists? Why does so few of these practice management courses reach the mark?  The answer is quite simply that people percieve these courses to be quick fix, public victories.  Dentists want to go to these courses and learn the techniques which would instantly make them more money -tomorrow.  Dentists want to learn how to sell more dentistry, quickly.  They want to learn the techniques of how to conquer others, make "Public Victories", make patients accept their treatment plans. Yet it does not work this way. You first have to make your own Private Victory, conquer your self, before you can think of developing sound, healthy relationships with others.


That is all we want and need in our dental practices - sound and healthy relationships with our patients.  The rest will follow - treatment plan acceptance, co-operation, payment and loyalty.


                 The Emotional Bank Account


Covey introduces an interesting metaphor - the Emotional Bank Account.  It describes the amount of trust in a relationship.  We deposit through courtesy, kindness, honesty and keeping commitments.  By making many deposits, we build up an account flush with trust and, in Covey's words, "When the trust account is high, communication is easy, instant and effective."  With a high trust account we can even afford to make mistakes and our patients will not turn away from us.  But when the account is low, through many acts of "discourtesy, disrespect, cutting you off, overreacting, ignoring you, becoming arbitrary, betraying your trust, threatening you, or playing little tin god in your life.....The trust level gets very low."  It will show itself in either empty appointment books, many failed appointments, a low level of treatment plan acceptance or poor payments.


Covey stresses that it takes time to build up a high Emotional Bank Account or level of trust.  Quick fix is a mirage, he says. "Building and repairing relationships take time."  They are long-term investments.


The chapter then takes an interesting, but almost curious angle when Covey describes "Six Major Deposits", that is into the Emotional Bank Account.  It appears curious, to me at least, because these are six simple, basic acts of good manners.  It seems to be a bit strange that it needs to be described in this detail in a book of that kind.  Yet, our modern way of searching for the quick fix has maybe blinded our eyes to these simple, wholesome truths.


                   The Six Major Deposits


1.   Understanding the Individual

Covey even quotes the Golden Rule (without reference to the origin in Matthew 7:12) which says "Do unto others as you would like others do unto you."  He also quotes a successful parent about raising children, "Treat them all the same by treating them differently."  We need to understand our patient's individual needs and wants.  We need to understand their individual fears.  But we can only do that if we listen to them, individually.  These issues will be fully explored in following chapters.


2.   Keeping commitments

"Keeping a commitment or a promise is a major deposit; breaking one is a major withdrawal."  Do not tell a patient, "It won't hurt", when you know full well that it is going to hurt.  Do not, never charge more than you had quoted.  Do not be late.  Do the work that you had planned, and agreed with the patient, to do.  Never, never lie to a child.  Never say, "I am not going to pull out your tooth" and then proceed to do it.



3.   Clarifying expectations

This translates to "Inform before you perform" (See Chapter 25).  Covey writes "Clarifying expectations sometimes takes a great deal of courage. It seems easier to act as though differences don't exist and to hope things will work out than it is to face the differences and work together to arrive at a mutually agreeable set of expectations."


Covey might just as well have been describing the haphazard way in which many dentists handle their treatment planning and financial arrangements with their patients.  Many dentists act as if their patients know everything about dentistry and the fee structures or on the other hand as if their patients have no right to know about these affairs.  Afterwards, then they complain bitterly about their patients not paying their accounts.


4.   Attending to the little things

"People are very tender, very sensitive inside." This is very important in dental practice.  The list of what we can do is endless: Birthday cards, remembering names, enquiring about the new baby, about the husband's health, post-operative telephone cards, a thank you note for a referral, are but a few.  All these are our little, or big practice builders.  I have seen the power of these small little gestures a thousand times.  "You know doctor, this was the first time ever a dentist has phoned me to hear how I was doing after treatment."


5.   Showing personal integrity

It is a reflection on our quick-fix society that this needs to be said at all.  Our win-at-all-cost paradigm has shadowed the age old truths to this extent that we actually have to teach people to be honest as if it is some acquired skill. In days of old mothers taught it to their children, from the Bible.  Yet, in dentistry we seem to need these guidelines.  Our peculiar situation, where we know everything about our subject, but our patients know nothing, have put us in an almost god-like position. We are in the position where we have all the power, power which can all too often be abused.  We can, and some dentists do, manipulate treatment plans or fee schedules to their benefit, instead of working to their patients' benefit. We work so hard, that we think we are entitled to great financial rewards and if we cannot make money honestly, well then it is all right to bend the rules a little.


Another problem has been the public image and financial success of the previous generations of dentists.  Rampant caries and a scarcity of dentists worldwide made dentists rich and many young people then entered dentistry with these rich dentists as their role models - and with only one thing in mind - to also make as much money as possible.  In other words, at present we have a great number of dentists who are money-driven and not value-driven.  But the bubble has burst a little and it is not so easy to make money out of dentistry any more.  Now, these money-driven dentists are turning to even dishonest means to achieve their aims.


And it is for all these reasons that we have to teach dentists the importance of personal integrity, the basic rules of life that were taught, in a previous age, at mothers' knees.


Covey says,  " Integrity includes, but goes beyond honesty."  Integrity is one of the fundamental cornerstones of a healing professional, a doctor who took the Hippocratic Oath.  It is the embodiment of decency, servitude, honour, loyalty and love.


Integrity in dentistry means treating all patients to the same set of principles.  It means treating every one as if they were one's most beloved.  It means putting your patient's interest before your own. It means being loyal, not only to your patients, but also to your colleagues and teachers.  It means always, always doing the very best that you can.  It means also referring cases beyond your own capabilities to the appropriate specialists. - a wonderful example of synergy and interdependence - Effectiveness in action.


6.   Apologizing sincerely when making a withdrawal

Examples of withdrawals from the dental Emotional Bank Account is comebacks, being late and unintentionally hurting patients. Only the strong dentist, the independent dentist can apologize sincerely.  Patients love apologies.  And if they trust you, they will always accept your apologies.  And trust comes from making deposits into the Emotional Bank Account.  We all make these withdrawals, almost daily.  We all make mistakes and we all have our comebacks.  A few years in academic life have taught me one thing - even the very best of dentists, even the grand and world renowned ones make mistakes and have comebacks.  It is amazing to see to what lengths some of these high profile dentists will go to hide their failures.  A basic rule of all clinical procedures is that a 100% success rate is always false. All clinical procedures have their problems, yet you do find famous dentists reporting, in front of audiences or in journals their 100% success rate in implants or root canals or whatever. They lie.


So we do not have to hang our heads in shame every time a crown comes off.  It happens. We only need to accept some, not all, responsibility for it, explain to the patient, apologize for the inconvenience and try and help the patient.  When Zacchaeus said to Jesus "....and if I have cheated anybody out of anything, I will pay back four times the amount."  Jesus answered, "Today salvation has come to this house," (Luke 19: 8-9)


The message is reïterated in Matthew 5: 23-24. "Therefore, if you are offering your gift at the altar and there remember that your brother has something against you, leave the gift there in front of the altar.  First go and be reconciled with your brother; then come and offer your gift."  Jesus does not even want us to go to church, even with our offerings if we are not at peace with our patients.


We have to learn how to apologize without accepting legal responsibility.  The professional indemnity companies abhor apologies, but nevertheless we have to do it. We need to learn and cultivate the word skills to be able to apologize sincerely, without admitting legal liability. One should say, "I am truly sorry that you have developed an abscess, so soon after the root canal treatment and I will do everything I can to help you."  You do not have to and must not say "I am so sorry that the quality of my root canal treatment on your tooth was so poor, that you developed an abscess."  Unfortunately life is not that simplistic and unfortunately even the best of us are open to the actions of unscrupulous medico-legal practitioners.


Covey ends this chapter with a few thoughts on "The Laws of Love and the Laws of Life" and he says that basically all deposits in the Emotional Bank Account are acts of love.  He says, "But we love, regardless."  He comes to the conclusion that love is the law of life.  Now, is that not why Jesus came to this earth?  To give us this law?  Was His self-sacrificial death on the cross not the greatest act of love in all of history? I think a reference to this would have been most appropriate in Covey's book.


So, in order to build a successful dental practice, we have to love our patients.  It is really as simple as that.  We just have to fulfill Christ's law, in all it's consequences.  But we cannot do that unless we first achieve our Private Victory - over our Self.  And the easiest way to do that is to see yourself and God in perspective.


You have to realise that you on your own are not capable of any meaningful action.  But when you realise how dependent you are on God, and how much you can trust Him and when you love Him, more than yourself - then you have fulfilled Christ's first law. You are now ready to build meaningful relationships with your patients.  You are ready to make those Public Victories, you can now go from Independence to Interdependence.  You can now work with your patients, synergize, towards a common goal.  You are now ready to begin the final part of the journey to Effectiveness.


Our good deeds to others (Public Victory) flows from the goodness stored inside us (Private Victory).  In the words of Jesus: The good man brings things out of the good stored up in him, and the evil man brings evil things out of the evil stored up in him. (Matthew 12: 35)


                         Chapter 15


              7 Habits, Habit 4: Think Win/Win


There are six philosophies or paradigms of human interaction:

1.   Win/Win

2.   Win/Lose

3.   Lose/Win

4.   Lose/Lose

5.   Win

6.   Win/Win or no Deal


1.   Win/Win

Win/Win constantly seeks mutual benefit to both parties.  It means agreements or transactions are mutually beneficial or mutually satisfying. The patient is satisfied with the treatment, the service and even the fees.  The dentist is satisfied with the co-operation and the fees.  It is the better way, the christian way as we will see.


2.   Win/Lose

From the point of view of the dentist it is the situation where the dentist is satisfied that he has made money, yet the patient is dissatisfied with the service.


On the other hand, from the patient's point of view, it might be, that the patient is very happy with the treatment and everything, but the poor dentist is extremely unhappy with his compensation.  The patient won and the dentist lost.  Honest dentists, in the South African situation often suffer from this when they are intimidated by patients and co-erced into rendering services at the contracted-in/ scale of benefit fees. (These fees equate to the NHS situation in Britain).


3.   Lose/Win

Some dentists are programmed vice versa.  They argue, "Go ahead.  Have your way with me .  I am a loser.  I have always been a loser."  It is a form of capitulation, giving up.


"Lose/win means being a nice guy, even if nice guys finish last."  Covey says the problem is that Lose/Win people bury a lot of feelings alive.  But these unexpressed feelings never die and later on come back in uglier ways.  Psychosomatic illnesses, disproportionate anger and resentment, overreaction to minor provocation and cynicism are manifestations of suppressed emotions. These are often found amongst dentists.


4.   Lose/Lose

When two stubborn people interact and they are not prepared to compromise and communicate effectively, the result is Lose/Lose.  They lose all reason, with their only motive to get back or to get even. "Lose/Lose is the philosophy of war."


5.   Win

Some people want to win badly without necessarily wanting someone else to lose.  They simply don't care.  All they care about are themselves.


6.   Win/Win or no Deal

This is the only way in which to practise dentistry. The No Deal means that you have the freedom to not treat a particular patient.  It is a tremendously liberating feeling to come to the realisation that we cannot be everything to everybody and that we have to sometimes take the No Deal route.


If either party is not happy with the arrangements, then no interaction should take place.  The way that this is implemented in my dental practice will be fully discussed in section 3.


Covey stresses that Win/Win or no Deal is most realistic at the beginning of a relationship.  This is why a proper, lengthy,  detailed first consultation, intensive examination, re-consultation and treatment plan discussion is so extremely important.  We have to Inform before we Perform.  When we do we can negotiate a Win/Win or no Deal situation.


Covey says that Win/Win begins with 1.  a good character, out of which flows  2.  relationships and then 3.  agreements. This dynamic process is supported by 4. supportive systems and 5. processes.


1.   Character

Once again, we cannot negotiate a Win-Win without a good character.  We have to know what win really is and we have to want that win both for ourselves and for our patients.  Do unto others.....  We also need to be mature.  Covey defines maturity as the balance between the courage to speak your own mind and the consideration for other people's feelings.  We need to have the  courage to express in no uncertain terms our financial policies to our patients, without scaring them or putting them into any tight spots.  "Public Victory does not mean victory over other people. It means success in effective interaction that brings mutually beneficial results to everyone involved. Public Victory means working together, communicating together, making things happen together that even the same people couldn't make happen by working independently."


2.   Relationships

Once we have the character, we can start building up the relationship.  In a dental practice this relationship is often started up by "remote control." That is when patients are discussing dentists.  One patient is telling another person about his wonderful dentist and how good he is. This person then phones up to make an appointment.  During the initial meeting the second phase of this relationship building process gets under way.  The dentist meets the patient and a certain rapport starts developing or it does not. The patient, consciously or subconsciously, notes certain things - from the dentist's appearance, rooms and performance and he starts to decide for himself whether he can trust this dentist. Eventually an examination gets done and then a treatment plan is presented.  Depending on the state of the Emotional Bank Account, this treatment plan will be accepted or rejected.  Where the bank accounts are high, a Win/Win situation will develop.


3.   Agreements

When two minds come together in a Win/Win situation a public victory for both parties is the result.  This is what makes people happy and successful.


4.   Systems

Win/Win or no Deal can only exist in a friendly environment.  That is in a dental practice which is patient orientated.  The practice must be geared for communication and the communication must be directed at the solutions of the patient's problems.


5.   Process

The dentist has to, must, be able to produce the goods.  What is the goods?  Good, painless dentistry.


Win/Win or No Deal, Is it christian?

Some people might argue that the christian should always sacrifice himself and so the christian needs to lose/win.  This is totally flawed.  Jesus Himself said, "Love your neighbour as yourself" (Matthew 22: 39) (Emphasis added).


Jesus's death on Calvary was also a Win/Win situation. God won our souls from the devil for Him and we won eternal life.  A christian is always a winner.  Sometimes we lose a little, but if we lose on earth, we win much more in heaven. "What good will it be for a man if he gains the whole world, yet forfeits his soul?" (Matthew 16:26)


Seeking Win/Win is not an easy way out.  It is much harder than seeking Win/Lose or any other way.  Finding Win/Win requires intensive communication, listening, understanding, empathy, thought and reflection, negotiation, honesty and sincerity.  It requires deep, sincere love for our patients. We all have more than enough love for ourselves already.




                         Chapter 16


7 Habits, Habit 5: Seek first to understand, then to be                               understood


This chapter in Stephen Covey's excellent book defies all attempts at summarizing it.  Especially when one tries to make it relevant to a dentist.  Every sentence jumps at you, hitting you between the eyes.


This is really a chapter which should be compulsory reading for every practising dentist.  In fact for every intelligent person striving to achieve excellence in interpersonal relationships.  The subtitle of the chapter is, "Principles of emphatic communication."  What Covey tries to teach us, is how to understand other people.  The keywords are Empathy and Communication.


Empathy is feeling for your patients, understanding their fears and suffering and concerns.


People say things like,

     * I don't like dentists.  Why?

     * I don't like going to the dentist.  Why?

People do things like

     * Not accepting treatment plans.  Why?

     * Changing dentists.   Why?

     * Not going to dentists.  Why?

The answer to these Why's is deeply embedded in this chapter. People say things like they do and they do things like they do because dentists don't understand their patients. Dentists would react almost violently to a statement like this by saying, "But the patients do not understand me.  Do they not appreciate how hard it is for a dentist?  All the years' studies, all the investment, how difficult it is to work in the small, narrow, dark mouth, of a scared patient!"  We have all made statements like these.  And all of it is true.  Dentistry is hard work and it does not come easy.


But the point Covey makes in his Habit 5, is just this, "Seek first to understand and then to be understood." We first have to understand our patients before we can expect them to understand how hard it is for us.


And you can never understand a patient unless you listen to him or her.  And it takes time to listen.  We consider our time so precious, and it is precious, that we think we cannot afford not to have our fingers in their mouths.  Because time is money and unless we have our fingers in their mouths we are not earning money.  And how many times have you not heard the statement, "And he talks with me while his fingers are in my mouth!"


People are crying out, the whole wide world over, to be listened to, to be understood.  They will even pay money for it.  All the psychologists and psychiatrists know it.


Listening is a real art form and Covey mentions several techniques which people can use to practise and implement it.  But he warns that these techniques are superficial and artificial and that it smacks of the Personality Ethic against which he is very strongly.  We can look people in the eye, nod in agreement or shake the head in disagreement, yet if we are not really sincere, they will sense our duplicity.  They will realise that we are using some or other technique to manipulate them.  True listening can only come from a sincere interest in other people.  And that can only come from a person who has already achieved his own personal, Private Victory, over himself, that is a person who has learnt or mastered Habits 1 to 3 and a person who truly wants other people to also Win (Habit 4).


Listening is hearing but it is more than that. Listening with intent to understand involves using all your senses to get into the other person's mind.  It involves also enquiring from your reception staff what the patient said over the phone.  It involves very much, knowing the fact which attracted them to your practice in the first place.  It involves knowing what made them leave other dentists.  It involves very much what it is that they like about your practice. And it involves knowing what it is that they don't like about dentists and dentistry.  The traditional way of practising dentistry has been totally counterproductive in this area.  Patients have always been received at reception, asked to fill out forms and then to wait.  They were then taken directly to the intimidating surgery where they were put into a horrifying chair and asked one or two questions which they had to answer while the chair was in the process of reclining or already so.  Most of the time they were expected to answer while the dentist's fingers were in their mouths.


A dental surgery is no place for verbal communication. There are just too many distracting and even scary features.  In chapter 22 I will show where, how and when we should really listen to our patients. Covey describes the philosophy of the ancient Greeks.  This philosophy is embodied in three words, Ethos, Pathos and Logos meaning personal credibility, feelings and logic.  Many dentists rush in to the logic - "Madam, open wide, yes you need two crowns and it will cost you three thousand rand."  This is totally wrong.  You first have to establish your own credibility and integrity and then you have to develop and show your feelings for the patient.  Both these two processes are greatly facilitated by listening to your patient, by listening with intent to understand.  Your Ethos is also built around what your referring patients say about you to other patients.  It is built by the physical appearance of your practice and by your staff's demeanour. Remember your staff meet your patients before you do.


Behavioural scientists tell us that we have 37 seconds in which to make our first impression on our patients and after that it is over.  This first impression will then stay virtually for ever.  This has many implications and will be discussed elsewhere. But it is important to note that our Ethos should be established within 37 seconds.  We can then concentrate on developing our pathos for our patient by listening empathically, with the intent to understand.  Only when we understand our patient, when we have Pathos, then we can "Then seek to be understood."  Then is the moment when we can use logos - logic -to make ourselves understood.


Covey gives many extremely powerful examples of how business people had clinched deals by understanding their customers. The following is one of them: " I was working with a small company that was in the process of negotiating a contract with a large national banking institution.  This institution flew in their lawyers from San Francisco, their negotiator from Ohio, and presidents of two of their large banks to create an eight-person negotiating team.  The company I worked with had decided to go for Win/Win or No Deal.  They wanted to significantly increase the level of service and the cost, but they had been almost overwhelmed with the demands of this large financial institution.


The president of our company sat across the negotiating table and told them, 'We would like for you to write the contract the way you want it so that we can make sure we understand your needs and concerns.  Then we can talk about pricing.'


The members of the negotiating team were overwhelmed.  They were astounded that they were going to have the opportunity to write the contract. They took three days to come up with the deal.  When they presented it, the president said , Now let's make sure we understand what you want.  And he went down the contract, rephrasing the content, reflecting the feeling, until he was sure and they were sure he understood what was important to them. Yes.  That's right.  No, that's not exactly what we meant here.....yes, you've got it now.'


When he thoroughly understood their perspective, he proceeded to explain some concerns from his perspective....and they listened. They were ready to listen.  They weren't fighting for air.  What had started out as a very formal, low-trust, almost hostile atmosphere had turned into a fertile environment for synergy.


At the conclusion of the discussions, the members of the negotiating team basically said, We want to work with you.  We want to do this deal.  Just let us know what the price is and we'll sign."


He gives another example of a young man who clinched a big deal, right in the middle of a course that he (Covey) had been conducting: "Let me tell you what happened last night, he said.  I was trying to close a big commercial real estate deal while I was here in Chicago. I met with the principals, their attorneys, and another real estate agent who had just been brought in with an alternative proposal.


It looked as if I was going to lose the deal.  I had been working on this deal for over six months and, in a very real sense, all my eggs were in this one basket.  All of them.  I panicked.  I did everything I could - I pulled out all the stops - I used every sales technique I could.  The final stop was to say, 'Could we delay this decision just a little longer?' But the momentum was so strong and they were so disgusted by having this thing go on so long, it was obvious they were going to close.


So I said to myself, 'Well, why not try it? Why not practise what I learned today and seek first to understand, then to be understood? I've got nothing to lose.


I just said to the man, Let me see if I really understand what your position is and what your concerns about my recommendations really are. When you feel I understand them, then we'll see whether my proposal has any relevance or not.'


I really tried to put myself in his shoes.  I tried to verbalize his needs and concerns, and he began to open up.


Finally, in the middle of our conversation, he stood up, walked over to the phone, and dialed his wife.  Putting his hand over the mouthpiece, he said, You've got the deal.


I was totally dumbfounded, he told me.  I still am this morning."


This Habit relates very much to the principle of "Close to the Customer", described in "In Search of Excellence."  Remember the old cliche, "The customer is always right."  Yet, we as dentists always think we know better, after all we are the high and mighty, god-like dentists!  This is wrong!  A treatment can be greatly influenced by the patient's wishes, in fact it should be totally decided by the patient.  There is only one diagnosis but many treatment plans.  The diagnosis is also understanding the patient.  We treat patients, not teeth.  We need to understand the person around the teeth before we can begin to prescribe any treatment to those teeth.  A patient's mouth might be in dire need of periodontal surgery and twenty crowns, but he may be too scared to undergo treatment. He simply does not want to sit in the dental chair for all that time.  The right thing to do is to do what the patient wants.  If this patient only wants one extraction, then so be it, then that is the correct treatment plan.  The patient's fears are part of the diagnosis and the diagnosis dictates the treatment plan.


At the university where I work the post graduate prosthodontic programme teaches the registars to devise an absolutely, idealistic treatment plan for every patient.  This often includes orthognathic surgery, orthodontics, implants, periodontal surgery and crowns.  It is left to the patient to accept or reject this.  This smacks of logos before pathos.  Very, very few patients can be treated in this way.  A treatment plan should be influenced by pathos as much as by logos.


We have already mentioned that listening takes time and time is money.  Dentists know it very well.  Yes, it is true, but as Covey points out it saves a lot of time downstream. "Emphatic listening takes time, but it doesn't take anywhere near as much time, as it takes to back up and correct misunderstandings when you're already miles down the road, to redo, to live with unexpressed and unsolved problems, to deal with the results of not giving people psychological air."


How very true this is in dentistry.  By understanding what it is that our patient's really want, we will save time.  But if we rush in and do the most "obvious" work first, we often paint ourselves into corners from which it is difficult to escape. Remember, people want to be understood before they want to be treated.  Very often patients only want reassurance or an opinion but the dentist wants to drill, because he earns his living that way and he thinks that is what his patient want.  So he gets in there and he tries to solve the problem right away.  And because he is so busy and time is always a problem, he will not have enough time to complete the job properly.  The result is less than perfect dentistry, often associated with pain and a messed-up schedule.  But if we take the little time to communicate emphatically, we might learn that the patient will be willing, even glad to come back at another time to have the work done.


"I am scared to listen, because if I listen, I may understand and I might be changed by what I understand" (Carl Rogers)


The other side of the coin is equally true.  If we take the time to be understood, before we treat, we will also save time.  If our patients know the fees beforehand and if they know the financial policy beforehand, we will spend much less time afterwards collecting our money. Somebody once said, "An account should only confirm what the patient already knows."  Also, if we warn a patient beforehand about complications and post-operative pain and side-effects, we will spend much less time explaining these problems afterwards.  We will also spend less time with the lawyers and in the courts. Emphatic listening does not only take time, it also takes effort.  It does not come naturally, on the contrary, we have to work hard at it.  Why is it so difficult?  Well, again our sinful nature, our self-centredness, our self-interest is to blame.  God says, "Be ever hearing, but never understanding; be ever seeing, but never perceiving.  Make the heart of these people calloused, make their ears dull and make close their eyes. Otherwise they might see with their eyes, hear with their ears, understand with their hearts, and turn and be healed." (Isaiah 6: 9-10)


The Lord asks, "Who is wise and understanding among you? and answers, "Let him show it by his good life, by deeds done in the humility that comes from wisdom" (James 3:13 Emphasis added).  If we treat our patients with a sense of humility, borne of wisdom, we must be successful. If we are aware of our own limitations (that is our own sinful nature) then we can be truly humble and serve our patients.


"My dear brothers, take note of this: Everyone should be quick to listen, slow to speak and slow to become angry, for man's anger does not bring about the righteous life that God desires." (James 1: 19-20)  

                         Chapter 17


                7 Habits, Habit 6: Synergize


The final habit of Interdependence is the habit termed - Synergize.  Covey subtitles it "Principles of Creative cooperation."


One sentence in the paragraph says it all, "Synergy means that 1 + 1 may equal 8, 16 or even 1600."  It really means that the creative cooperation of two people may amount to much more than what the two individuals could have accomplished individually, put together.


Covey begins and ends the chapter by referring to synergism in nature.  Synergy is everywhere and it is natural law.  The modern panacea of so called Independence is a figment of the imagination. No man is an island, no matter how rich he is.  We need each other.  Dentists need patients, patients need dentists, dentists need staff and staff needs employers.  When we can work together creatively, we can achieve much more, in fact the sky is the limit.


It is when we fight synergism, that we become deeply unhappy.  It happens in the workplace, in our social circle and in our family life.  A happy marriage is the closest we can come to heaven on earth and we can only achieve it through synergism.  The opposite is equally true.


But the greatest synergism we can hope to achieve is when we work for our God.  When we live with Him, when we follow His Word, when we love Him.  When we fulfill His Great Laws "Love the Lord your God with all your heart and with all your soul and with all your mind.  This is the first and greatest commandment. And the second is like it: Love your neighbour as yourself" (Matthew 22: 37-39)


Covey asks, "Could synergy not create a new script for the next generation - one that is more geared to service and contribution, and is less protective, less adversarial, less selfish; one that is more open, more trusting, more giving, and is less defensive, protective, and political; one that is more loving, more caring, and is less possessive and judgmental?"


Is Covey not really asking whether the course of the next generation cannot be altered if only people would obey the Lord's Great Laws?  Most certainly it is possible that God can work wonders through and for us.  But we first have to obey Him.  We do this by learning the other five habits.


There is very little evidence of synergy in the average modern dental practice of at least South Africa.  Patients are rushed in and out like cattle.  Communication is ineffective.  Patients are even maltreated, overtreated and abused, because dentists are self centred and money driven.  There is tremendous conflict between dentists and third parties - the medical aid schemes.  They are practically at war.  Dentists try to get as much as possible out of the medical aid schemes and the medical aid schemes are giving them as little as possible.  Dentists spend only so much time on a patient, because they only get so much money.  Patients are unhappy and they change dentists because they are not getting what they want. Nobody understands anybody and nobody would listen to anybody.


Patients are also at fault.  They have over the years been totally brainwashed into the paradigm of free, social, medical-aid sponsored dentistry.  Patients still very often demand contracted-in, that is free dentistry.  I have personally been at the receiving end of these demands, thousands of times and I still experience it, almost on a daily basis.  This has been a tremendous influence in my life, in fact this book and everything that goes with it was inspired by my own lifelong conflict with this unjust system.


It has taught me, the hard way, that my very survival depended on synergism between me and my patients.  I realised that I was dependent on the good will of my patients, that is if I wanted to get payment directly from them.  That, together with my own professional pride, forced me to be a good dentist.  Today, I realise this was the wrong way around.  I should have just been a good, loving, caring dentist, because that was what God and my patients want from me.  The rest, also financial compensation, would have followed almost automatically.


Doing it God's way is so much easier and better. "Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls.  For my yoke is easy and my burden is light." (Matthew 11: 29-30)


Covey stresses that true synergy is characterised by excitement and enjoyment.  The same is very, very true in dentistry.  It works like this: An autocratic old-style god-like dentist will say, "Madam, I am going to do a filling, open wide please.  Did it hurt?  Thank you and goodbye."


A synergistic dentist will do it differently, "Madam, your bottom left hand molar tooth has got a cavity"  He will then wait for a response and listen, with a view to understand.  The patient might say something like, "How bad is it? Am I going to lose it? No, I definitely cannot afford to lose it.  I cannot bear the thought of false teeth, but how I dread the thought of an injection."


The patient had just told the dentist four things:

1.   She is very concerned about keeping her teeth

2.   She is scared that she will end up with false teeth

3.   She is scared of injections

4.   By not referring to it, she has even said, without              expressing it, that money is not her main concern.

If we as dentists would only listen we would hear it very often.


The dentist will now immediately address her real and imagined concerns: "You are definitely not going to have false teeth, in fact we are going to fix up your tooth so that it is better than ever before.  And if you are worried about the injections, we can even avoid them."  The dentist will then wait and listen.  He is listening to understand the patient. Just how scared is she? Does her fear border on the pathological or is it normal?  He is obviously practising Habit 5.


The patient may answer, "Doctor, I am terrified to death, my teeth do not go numb easily and I hate sitting in the chair. I would do anything to avoid this."


"Well, I was going to suggest that we do the work under general anaesthetic...."


The patient has now prescribed her own treatment, said what she wanted.  Up till now, money has not even been mentioned.  "My fees will be two thousand rand and then the anaesthetist will also charge a fee."


"Oh thank you.  I was worried it might be much more.  May I pay by credit card?"


This is synergy in action.  By just talking and listening to each other, a Win/Win deal was struck. 


It is possible to practise like this every day and to treat every patient like this.  In fact, Covey says "Once people have experienced real synergy, they are never quite the same again.  They know the possibility of having other such mind-expanding adventures in the future."  This is very true in my own experience as a dentist.  I have experienced synergy with my patients so often that I can now honestly say that I do not want to do any other kind of dentistry.  I do not want to do dentistry a patient does not want.  I do not want to treat patients  who do not like me - even if I have to sacrifice thousands of rands. I do not want to force myself on my patients.  It is their decision to have treatment, or not to.  But I spend a lot of time communicating emphatically.  I listen a lot and I explain a lot, but I always try to listen more.  And I always go for Win/Win or no Deal.  The patient has to want the treatment and say so, and we both have to be satisfied with the fee, before I commence treatment.  Sometimes it takes a lot of time to synergize effectively. 


Once, a person who speaks a lot in public, with vast financial resources was consulting me about the replacement of his missing lower molars.  When he came to me first, he had implants in mind.  I discussed implants with him and even sent him a two page treatment plan and cost estimate for those implants.  I never heard from him until about seven months later when he returned. We continued discussing implants, until I mentioned the slight risk of nerve damage and a dead lip.  That settled it.  He reacted severely and said that he was not prepared to risk it.  And that led me to suggest a partial denture with precision attachments.  He readily accepted this and said that this was what he wanted.  Treatment was quickly and successfully carried out and payment was promptly made.  It took a long time for synergy to develop and when it did, success was inevitable. Our communication stretched over seven months.  It took me a very long time to understand this patient's very real fears and concerns. It took a long time for us to reach the point where the vital issue was exposed.  The pros and cons of implants are many, but for this one patient, the deciding factor was the very slight risk that a numb lip might have impaired his public speaking.  That outweighed all other factors, all the advantages that the implants might have held.


Once the patient knew what he wanted, the rest was easy. The alternative to this situation could have been very ugly.  Had we proceeded with implants without warning of numbness in the lip and had such numbness developed as a result of surgery, this patient would have been very unhappy.  His quality of life would have been severely compromised and I would have been to blame. Not in practice, because I would not even have done the surgery, but in principle.


I am the dentist and I have the technical knowledge and skills.  My patients have the diseases in their mouths and the cheque books.  Together we have to find solutions to the problems in their mouths.  I have to diagnose and inform of the possible treaments.  But they have to excercise their autonomy in deciding upon what, if any treatment they want.  It is called synergy.


Synergy also means that the patients have to pay us. Dentistry is very expensive and a dentist needs to run a very tight ship in order to survive financially.  What makes dentistry so expensive is all this wonderful modern technology.  It all costs money.  You cannot have high tech dentistry without money.  Yet, in South Africa thousands, maybe even millions of patients are demanding just that - high tech dentistry without paying for it.  Because they belong to a medical aid scheme people feel they are entitled to the best dentistry has to offer.  This is just impossible.  Socialised dentistry has failed spectacularly in the United Kingdom and it is reported to be failing in Scandinavian countries.  In fact, it fails every time a patient is dissatisfied with the service that they receive from a medical aid scheme/NHS/insurance scheme/managed health care dentist.


An amazing thing happens when a patient is responsible for paying his dentist.  Synergy develops!  The dentist knows that he is responsible to the patient and the patient knows that the dentistry is costing him or her money and they want value for their money.  As a result a better service is provided.  If the responsibility for payment is shifted to a third party, the synergy disappears instantly.  The dentists feels almost relieved at not being responsible for his dentistry - "They are getting it for free anyway."  And the patient often couldn't care less, about the quantity and the quality of the service.   They don't care how much dentistry is done, because they don't pay.  The overstressesd system is further burdened with unnecessary overtreatment.


Personally, I just cannot motivate myself to do all the difficult and hard dentistry to the standards of perfection that I do, without being paid for it.  Dentistry is just too hard work and the price we pay in terms of stress and anxiety is just too high.  And I have already in the distant past suffered too much from patients who escaped their part of the bargain by not paying me.


I know this sounds very unchristian-like, very self-centred and selfish.  Why don't I just sacrifice myself on the altar of my patients' unreasonable demands? Well, I would just like to have a say in the people to whom I do my christian charity to.  I do charity dentistry almost every day - to deserving cases.  But I resent very much people taking advantage of me, even though I am a christian. That is because, if enough people manage to do that to me, there is no way that I can survive financially and fulfill my role as a dentist serving God and my patients.  The Great Law says, "Love thy neighbour as thy self."  I do not think we are expected to be self-sacrificial to the point of bankruptcy.  God expects us to work and to work hard and Jesus told many parables of people being rewarded, financially, for the work that they did. So I cannot see how anybody can argue that to be a christian dentist you should be prepared to work without adequate payment.


Synergy is also evidenced by the maintenance of effective oral hygiene.  All dentists know, or should know that successful restorative and periodontal therapy ultimately succeeds or fails due to the standard of oral hygiene.  This is impossible without synergy.  The dentist should spend a lot of time evaluating and diagnosing levels of oral hygiene and prescribing techniques of home care.  I have personally devoted thousands of hours of my time to this critical issue.  I talk to every patient about it.  And I expect co-operation.  I make the importance of oral hygiene very clear to them.  I believe that the simple act of motivating a patient to properly brush and floss his teeth is one of dentistry's most challenging and also most neglected aspects.  I also do not have the answers.  I just know that it is very hard to get them to do it.  When the patient responds positively, doing dentistry becomes fun.  Patients who care for their teeth are wonderful patients and it is an honour treating them. When a patient cares enough to spend time brushing and flossing, it is much easier and more enjoyable to communicate with and relate to them.  I find that the older I get, the more I value this.  I feel, again, that I do not want to treat patients any more, without synergy in this field.  But I keep on trying and I will not give up. 


Co-operation with dental and medical specialities is one of the obvious but beautiful examples of synergism.  Dental specialists are a peculiar breed, but when they are employed correctly, dentistry at its very pinnacle of achievement can be practiced. But the lines of communication should be very clear. 


Scribbled notes, and even detailed reports is not enough. Regular personal contact between the general dentist and his specialists is absolutely necessary.  I have personally lost many patients by referring them to specialists, and as a result I have ceased referring to certain specialists. What I should have done is talk to these specialists, but so often they won't listen!  


Finally, and perhaps most importantly, synergy between dentist and staff should be vibrantly alive.  Staff relationships make or break many dentists.  Good staff is very valuable and should be treated as such. Synergism between dentist and staff leads to an upward spiral of bigger and better production and a happy workplace environment.  Staff should be nurtured and cared for, treated with love and respect.  The dentist should always be prepared to walk the extra mile for them.  The whole issue will be fully discussed in Chapter 27, "Build a Loyal Team."

                         Chapter 18


             7 Habits, Habit 7: Sharpen the Saw


Man exists four dimensionally. The four dimensions are

     *    Physical

     *    Spiritual

     *    Social/Emotional

     *    Mental


We need to develop each of these dimensions daily. We need to hone our skills, "Sharpen the saw" in each of these fields and we need to do it daily and in a balanced way.  One dimension should not be neglected or overdeveloped.  Covey shows that these dimensions exist not only in our personal life, but also in corporate life.  Big corporations exhibit all four dimensions and neglect of one impacts negatively on the whole.  Obviously then, these dimensions also exist in the corporation we call a dental practice.


Physical dimension of a dentist

We abuse the bodies we live in very much by harmful practices such as smoking and overeating, but we also abuse it by just doing honest dentistry.  Dentists are prone to many medical disorders.  We need to work at it daily.  We have to lead healthy lifestyles, exercise and avoid stress.  Stress is worrying about the wrongs we did and the rights we didn't do.  This is what this book is all about.  About doing the right thing.  It is all these Habits put together.  Dentistry is a very stressful occupation and we need all the help we can get.  Covey implores us to do regular physical excercise. It strengthens our physical dimension directly and indirectly, through the impact it has on stress.


Physical dimension of a dental practice

These are our rooms, equipment and furniture. These need to be meticulously maintained, serviced and sometimes replaced.


Mental dimension of a dentist

This is represented by the academic and other knowledge of the dentist and includes financial knowledge.  Dentists often fail to develop this and stagnate into a position where they are unable to deliver good dentistry.  Very often they are or become so ignorant that they don't know what they don't know.  Regular reading of scientific literature and attendance of continuing education courses are vital.  In fact, in several countries, including South Africa there are moves about to make the attendance of a certain number of courses per year obligatory.  Why is this necessary? We as professional people should know that we have to do it, yet, sadly only a very small percentage do.


Reading this book is an excercise of the mental as well as the spiritual dimension.  But don't stop here.  Read "The Seven Habits of Highly Effective People" and in "In Search of Excellence" as well.  And never stop reading.  Covey refers to the bad influence television watching has on our personal and family lives. Make a point of reading instead. He suggests starting out with reading a good book every month.  And to work up to reading a book a week.


Mental dimension of a dental practice

This is the knowledge of the dentist and his staff. It is the dentist's responsibility to see to it that the knowledge of his staff is expanded.  Regular, daily, meetings is the place to begin.  This can be supplemented by ad hoc teaching demonstrations and even lectures.  How can a dental assistant know how to mix a new material if she has not been taught. The best staff will become autonomous and learn themselves but they are few and far between.  The dentist most often have to take the initiative.


Spiritual dimension of a dentist

It is no different than the spiritual dimension of any other person.  We need to believe in something and my Something is Jesus Christ .  We need to work on this dimension and the way to do it is by daily Bible study and prayer, by regular church attendance and by being a Good Samaritan (Luke 10: 25-37)

Covey quotes Arthur Gordon as saying, "In a flash of certainty", he wrote, "I saw that if one's motives are wrong, nothing can be right.  It makes no difference whether you are a mailman, a hairdresser, an insurance salesman, a housewife - whatever.  As long as you feel you are serving others, you do the job well.  When you are concerned only with helping yourself, you do it less well - a law as inexorable as gravity."


Spiritual dimension of a dental practice

This is the set of values, the value system which Peters and Waterman, in "In Search of Excellence" name as the key to success in America's most successful companies.  It is the principles, the character based principles, which Covey extolls as the basis of Effectiveness.  At MacDonalds it is cleanliness, service, quality and value. At Caterpillar it is service.  At 3M it is innovation.  Covey battles somewhat to give body to it, I believe because he is reluctant to publish his religious commitment, but at least he ends his book on a personal note where he writes on page 319:

      "As I conclude this book, I would like to share my own personal conviction concerning what I believe to be the source of correct principles.  I believe that correct priciples are natural laws, and that God, the Creator and Father of us all, is the source of them, and also the source of our conscience.  I believe that to the degree people live by this inspired conscience, they will grow to fulfill their natures; to the degree that they do not, they will not rise above the animal plane."

I believe that there are parts to human nature that cannot be reached by either legislation or education, but require the power of God to deal with.  I believe that as human beings, we cannot perfect ourselves.  To the degree to which we align ourselves with correct principles, divine endowments will be released within our nature in enabling us to fulfill the measure of our creation.  In the words of Teilhard de Chardin, "We are not human beings having a spiritual experience.  We are spritual beings having a human experience."  I personally struggle with much of what I have shared in this book. But the struggle is worthwhile and fulfilling.  It gives meaning to my life and enables me to love, to serve, and to try again.


Again, TS Eliot expresses so beautifully my own personal discovery and conviction: "We must not cease from exploration. And the end of all our exploring will be arrive where we began and to know the place for the first time."


In a dental practice there is no better value system, or principles than the Christian value system, taught so explicitly by Jesus Christ.  It is the dentist's role to make it his own, to live it, to prove it daily in his good deeds and honesty, and to say it, especially to his staff.  The staff must know what is the driving force of the practice.  They must know what it is that makes the practice tick.  And they must be comfortable with it, identify with it, make it their own.  Or they must leave.


Social/emotional dimension of a dentist

This is our relationship with others.  A good dentist needs to be at peace with those closest to him or her.  In the first place it would be his or her spouse and secondly his or her children. But it includes also his personal relationship with each of his staff and patients.  This is life as it is lived by us all, daily.


Social/emotional dimension of a dental practice

It relates very closely to the dentist's personal relationship with his staff members and patients but it transcends onto the formal level where dentist and staff socialise by having coffee together or having a meal together.  It includes also the practice's interest in the patients' welfare, ie sending bithday or Christmas cards.


The physical, spiritual and mental dimensions are reported to be closely related to Habits 1, 2 and 3 (the principles of personal vision, leadership and management), while the social/emotional dimension focusses on habit 4, 5 and 6, the Habits of Interdependence.


The physical, spiritual and mental dimensions require daily exercise.  Covey suggests spending an hour a day doing just that, excercising these three dimensions. That would relate in our situation to something like twenty minutes physical excercise, twenty minutes Bible study and prayer and twenty minutes reading of dental literature.  Obviously sometimes we will exercise a little more, on Sundays we will spend more time in Church and sometimes we will spend a full day or more just attending a continuing education course.


Interestingly these are all Quadrant II activities - important but not urgent - therefore we don't do it as we should.


We don't have to formally excercise the social/emotional dimension at the same level as the other three.  We can do it in our normal interaction and relationship with people.  We can practise to seek Win/Win or no Deal, we can practise to listen and understand and we can practise to synergize in our daily lives when we meet and work with people.


Covey says, "Success in Habits 4, 5 and 6 is not primarily a matter of intellect; it's primarily a matter of emotion. It's highly related to our sense of personal security.......

Where does intrinsic security come from?.....

It comes from within.  It comes from accurate paradigms and correct principles deep in our own mind and heart."


I suggest that the best paradigm and correct principles are Biblical christianity.


George Bernard Shaw is also quoted, "This is the true joy in life - that being used for a purpose recognized by yourself as a mighty one.  That being a force of nature, instead of a feverish, selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy.  I am of the opinion that my life belongs to the whole community and as long as I live it is my priviledge to do for it whatever I can.  I want to be thoroughly used up when I die.  For the harder I work the more I live.  I rejoice in life for its own sake.  Life is no brief candle to me.  It's a sort of splendid torch which I've got to hold up for the moment and I want to make it burn as brightly as possible before handing it on to future generations."


And Eldon Tanner, "Service is the rent we pay for the priviledge of living on this earth."


This is how we should practise dentistry - as instruments of God being used for a purpose, instead of being a feverish, selfish little clod of ailments and grievances complaining that the world will not devote itself to making us happy.  I have heard dentists complaining bitterly about their patients not appreciating them and I have been quilty of it myself many times.  We should believe that our lives belong to our patients and that it is our priviledge to serve them for as long as we can.  It is the rent we pay for the priviledge of living on this earth.


At the end of our lives we should be thoroughly used up. For the harder we work, the more we will live.


The primary driving force which propels us in an ever upward spiral of renewal is our conscience.  Conscience is something only humans have.  Animals don't have it.  Covey quotes Madame de Stoël, "The voice of conscience is so delicate that it is easy to stifle it: but it is also so clear that it is impossible to mistake it."


Dag Hammarskjold is also quoted, "You cannot play with the animal in you without becoming wholly animal, play with falsehood without forfeiting your right to truth, play with cruelty without losing your sensitivity of mind.  He who wants to keep his garden tidy does't reserve a plot for weeds."


In South Africa there are many dentists who for years have been fighting their conscience, trying to stifle it, playing with the animal in them.  They have been doing this by deliberately manipulating the fee schedules of the medical aids.  They have been overtreating, charging for work not done, they have been doing their dentistry poorly, because "we get paid only so much".  The same has happened in Britian's National Health Service.


You cannot stifle your conscience for ever.  You cannot play with the animal without becoming wholly animal.  The symptoms of being an animal is there for all to see.  Broken marriages, disillusionment and unhappiness with dentistry, alcohol and drug abuse, suicides and psychological disorders.


I plead with dentists everywhere.  Let your conscience guide you and lead you to renew your spiritual, mental, physical and social dimensions.  "For God is greater than our hearts and He knows everything.  Dear friends, if our hearts do not condemn us, we have confidence before God and receive from Him anything we ask, because we obey His commands and do what pleases Him" (1 John 3: 20-22)


Every dentist knows in his heart - conscience - whether he has treated his patient right and charged correctly.  You can cheat, stifle your conscience once, twice or even thousands of times, but eventually you will pay the price.


It is never too late to repent and to change. Do it now.

                          Section 3


                         Chapter 19


                The Practice: An Introduction


The first two sections of this book dealt with the theory of excellence and effectiveness in dental practice.  It attempted to explain in terms of "In Search of Excellence" and in terms of "The Seven Habits of Highly Effective People" and in terms of the Bible, the theoretical basis for being a caring dentist, for building sound and healthy relationships with patients and staff and for going beyond Independence.


Section 3 deals with the practical workings of my dental practice.  Section 1 and 2 is the mind and the soul of the successful dental practice whilst Section 2 is the physical body of it.


Section 3 is also the case history of my own dental practice.  It explains the techniques and principles which I personally used to develop and build my own practice.  It tells how I practically did it and how I am still doing it, every day of my life.


I only read "ISOE" and "7 Habits" very recently.  In fact, the "7 Habits" was a gift for my 40th birthday, four months before I started writing this, from my friend, orthodontist Bertus van Niekerk. I bought "ISOE" even later. These books themselves did not bring me my current success, but the principles contained in them, did. Without knowing it, I have been using the two books' ideas and principles for many years, before I was even aware of the existence of the two books.  I have been employing these principles, because these principles have been written down, thousands of years ago already, in the book we call the Bible.


What works for America's best companies and what works for the most effective individual, also worked for me in my dental practice. And it will also work for any dentist willing to build his or her life on these principles. 


I wrote Sections 1 and 2 after I had done what I did as described in Section 3.  I did not have the benefit of the knowledge and wisdom contained in Sections 1 and 2 when I started out in dental practice.  I only had deep in myself the core knowledge of christianity but I thought that that was reserved for Sundays.  I paid the price.


But slowly, the truth seemed to surface in me. It dawned down on me that Jesus Christ is alive and living, every day, not only on Sundays.  He is the Silent Witness in my practice.  He knows all I am doing.  I began to work for Him, not for myself.  And I became successful also.


I then read the two other books, books which do not claim to be christian or religious literature, but books that explain in human terms, the road to success, in corporate life and in personal life.  It seemed to explain also, in retrospect, why I managed to succeed like I did.  So then I wrote this book.  It is an attempt to help other dentists avoid the mistakes I originally made and do the things I eventually did. 


For the sake of logic and simplicity I also name eight principles or ideas, the cornerstones of success.

They are:

     Primum Non Nocere

     Total Dedication to Service

     Listen to the patient

     Provide more quality, less quantity

     Do more to create Win/Win

     Inform before you perform

     Be an Independent Entrepeneur

     Build a Loyal Team


I hasten to add that these are not all my own ideas. They are a result of a lifetime of learning - synergism - and I owe a debt of gratitude to all my teachers. For instance, the phrase "Inform before you perform" was taught to me by Jennifer de St Georges and the principle of informing before performing I learnt from my orthodontist friends, particularly dr Piet Botha.  I made this and the other principles my own and incorporated it into my personal philosophy.


Finally it must be said that all these principles are interdependent.  You can't have one without the other.  Everyone is important and all of them together are important.  Dividing them up into the eight principles diminishes their value somewhat.  But unifying them into one holistic, synergistic, coherent excellent and effective unit is what make a successful dental practice.  Woven through all of them is the thin golden thread of Love, christian Love, Love for patients, other people, dentistry and God.

                         Chapter 20


                      Primum Non Nocere


This is my own personal mission statement and it appears in my logo, which is printed on all my stationery.


Primum Non Nocere is Latin and it translates roughly into First, Do No Harm.  It is the essence and embodiment of the Hippocratic oath.  It says it all.

It says - do not hurt your patients.

It says - do not damage healthy tissues.

It says - be conservative at first, reserve drastic treatment for           later.

It says - do not let the treatment be worse than the disease.

When you fulfill all these criteria you are a good doctor, from the patient's point of view, because you can only do all these things if you love your patients.

1.   Do not hurt your patients

This is the one single most important criteria on which patients choose, leave and judge dentists.  Dentists also know it, but only vaguely, it would seem.  Because dentists still hurt patients, even as we are entering the third millenium, with all the available technology.  Why is this so?  The answer is simple - money.  Dentists do not get paid, or they get paid very little for painless dentistry, or so they think.  Dentists look at the various fee schedules, the medical scheme's, the NHS or even their own private fee scedules and they don't see the item "Painless Dentistry" there.  Yet, it is the one single thing our patients want most.  So when we look at our menu of services, our most popular product does not even appear there.  What does appear there is expensive root canals, dentures, fillings and crowns. So that is what we want to do. That is our paradigm - money generating expensive treatments - instead of a paradigm of painless dentistry.  In many progressive practices, even the top practices in the world it is customary to give detailed cost estimates or quotations and this is followed up by an equally detailed account for services rendered. None of these reflect the concept of simple "Painless Dentistry", yet this is what our patients want most.  We allowed ourselves to be brainwashed by fee schedules imposed on us by authorities. Because we don't see the item "Painless Dentistry" on these fee schedules it does not feature very high on our list of priorities.  We just want to rush in and get to those fee - generating items on the fee schedules. And if the patient suffers a little pain in the process, so be it, we reason.  How utterly and shamefully wrong an attitude like this is.


We should do everything, everything, in our power, and that is a lot, to avoid hurting our patients.  In South Africa, our authorities have recently instituted a fee for local anaesthetic.  It is a fixed fee for the employment of local anaesthetic per visit, regardless of the amount.  This is in a sense even worse, because, the mere giving of an injection is absolutely no guarantee of "Painless Dentistry".  In fact some dentists do it so badly, it only makes the situation worse.  Giving a painless injection is an art.  Giving effective injections is another matter - a scientific skill.  This is not a scientific handbook but this is such an important issue that I will give just a few guidelines.

Guidelines for painless injections

1.   Always use 30 gauge needles, except for mandibular, inferior       alveolar blocks, where a long 27 gauge needle is indicated.

2.   Dry the area of intended needle penetration with air and        keep the area dry.

3.   Apply topical anaesthetic, on a cotton wool pellet, to the       dry area.  (Topical solution cannot be absorbed through a       layer of saliva) Apply for at least 20 seconds.

4.   In the palate, supplement the topical anaesthetic by            freezing the area with a cotton wool pellet sprayed with        ethyl chloride.  Keep this pellet in position throughout the       injection procedure.

5.   The penetrating motion of the needle is a slow push, rather       than a sharp jab.

6.   Inject slowly.  This is the single most critical issue.  It      should take at least 90 seconds to deposit 1,8 ml.  This is      a long time.

7.   Temperature of the solution plays no role.  Dentists, myself       also, for a long time believed that cold solutions hurt         more.  It is a fallacy.


Guidelines for effective anaesthesia

1.   Rather give too much than too little.

2.   Therefore, rather use "safe" solutions, ie those without       dangerous vasoconstrictors.  I use Citanest almost              exclusively.

3.   Mandibular anaesthesia is much more difficult to obtain.        Schedule more time for work in the lower jaw, even if it       means charging more.

4.   Always give at least 3,6 ml, 2 ampoules, of anaesthetic         solution, for inferior alveolar blocks.  Never less.  But       beware of toxic reactions if you are using a solution with      vasoconstrictors.  Many dentists fail to realise or believe       just how many attempts at inferior alveolar blocks actually       fail. One of the causes or explanations for failure is         anxiety of the patient.  It is more difficult to obtain         effective anaesthesia in an anxious patient.  Therefore it       is important to obtain profound anaesthesiabefore starting       to work.  Giving a little, then hurting the patient and then       attempting to give more is much less effective.  In a very       anxious patient with a history of failed anaesthesia I will       often give a third and fourth block before starting to work.       A handy tip is to use a pulp vitality meter to test the         level of anaesthesia before starting to work.

 5.  When necessary, anaesthetise the palate.  This seems like       stating the obvious, but dentists are loathe to do just        that.  We know how much a palatal injection hurts and           therefore we don't like giving them.  But with practice and       dedication it becomes possible to lessen the pain caused by      these injections.

6.   Upper molars are often also innervated by palatal nerves.       This is notable when preparing the palatal surfaces or when       entering the palatal canal.  A simple palatal injection         solves the problem.

7.   Intraligamentary injections are very useful in difficult        cases.

8.   Intra-pulpal injections are ineffective and very painful. 

But "Painless Dentistry" involves more than just painless and effective injections. It also implies the wise and correct use of nitrous oxide and general anaesthesia where indicated and even electronic anaesthesia.  But most importantly it involves the conscious will, effort and time on the part of the dentist to practice "Painless Dentistry". "Painless Dentistry" does require extra time and extra effort and it places, in a sense more stress on the dentist.  In another sense it is one of the greatest stress relievers in dentistry.  It is much more enjoyable to work on a well anaesthetised tooth than one connected to a patient squirming around with pain. But it takes time and effort and time and effort should be rewarded, also financially.


Now, it is not very practical or even legal  to put an item such as "Painless Dentistry" on our accounts.  In fact it would be rather ridiculous.  The only way to do it is to increase our fees for our services.  We have to charge more for our crowns, fillings, root canals and surgery.  It is as simple as that.  But in South Africa that is not that simple at all.  If we charge one rand, or cent for that matter, more than the statutory fee, all payments of the third parties are made directly to the patient.  The dentist has to collect from the patient. This holds major implications for the dentist.


He has no guarantee that he will get the money. For this reason dentists are clinging desperately to these low statutory fees.  At least they are getting a little bit of money.  If they charge more, they might get nothing, they reason.  They don't trust their patients.  And they adapt the quality of dentistry to these ridiculously low fees, instead of adapting the fees to the quality of the dentistry. And so they give their patients reason not to trust them!  And so the whole vicious circle of mutual distrust is perpetuated.  Without trust there can be no Interdependence, no Synergy and the result is Lose-Lose.


One needs to have the honesty and the integrity to be able to tell a patient, "Sir/madam, under these peculiar circumstances, it is inevitable that I am going to cause you a lot of pain by doing this treatment.  I suggest you proceed along another route."  Even if that route involves referral, or,postponement of treatment or no treatment at all.  But we need to be honest about pain at all cost and under all circumstances.  And honesty can only come from a good character, a character developed from Stephen Covey's first 3 Habits in particular. 


2.   Do not damage healthy tissues

This is an age old classical principle of dentistry and it is still a good one.  It is also evidenced by many modern developments such as preventive restorations, Maryland Bridges, bonded restorations, bleaching, and preventative dentistry in general.  These are aspects of dentistry  which I practise in abundance.  And my patients appreciate it.  It contrasts in particular to the ideas of radical, extensive periodontal surgery and full mouth porcelain veneered to metal crowns as practised by many top class specialists in prosthodontics. I have personally seen many patients who consulted me on the basis of a second opinion after being provided with a treatment plan of full mouth periodontal surgical crown lengthening procedures and full mouth porcelain veneered to metal crowns.  I have been able to handle many of these cases by bonded gold restorations and by bonding porcelain or composite.  It is a simple fact that many, not all, crown lengthening procedures can be avoided by the use of the modern adhesive resin cements such as C&B Metabond, Panavia and Opal.  Yet, some of South Africa's top dentists and prosthodontists are still clinging tenaciously to their regimen of these vicious, drastic crown lengthening procedures with all its associated problems such as hypersensitivity, followed by crowns cemented with outdated zinc phosphate cement. 


Stephen Buchanan, world famous Californian endodontist wrote a classical article which was included in Pathways of the Pulp, 1991, in which he described his approach to preparation of root canals.  His approach is based, totally, on the concept of do no harm, and he even uses the term.  His idea is to conserve the structure and integrity of the apical constricture and the apex in general.  The idea can be extended to include the walls of the root canal and the furcation area.  We should aim never to do any iatrogenic damage to these tissues.  The success of endodontic therapy is greatly influenced by this.  Every dentist should ask himself or herself, every time he picks up the turbine, "Am I not going to damage healthy tissue?"  "Is it not possible to treat this case by bonding rather than by preparation?" Or "Is it not possible to bleach these teeth rather than crowning them?" 


The whole idea of implants also comes into question. Implants have become a fad and everybody is climbing onto the bandwagon.  Dentists look at the fees and think that this must be the biggest moneyspinner around.  Treatment plans are specifically structured in order to enable dentists to place implants and other avenues of treatment are neglected. 


At this point in time, it is my and others' views that implants should only be considered as a last resort.  Implants are definitely being overused at this time and the actual failure rates are much higher than the reported failure rates (Botha, SJ, 1995. Reported and the real success of clinical and experimental oral implantology procedures - a Review, Hands-On 7 (2) 12-14.)


Removable dentures, bridges and Maryland bridges are still excellent treatment modalities which can be used with great success. The very nature of the implant process necessitates destruction of sound, healthy tissues such as the bone into which they are placed but there are also very real risks of damage to roots, nerves, sinusses and soft tissues.  These need to be communicated to the patient before treatment and I have a nagging suspicion that surgeons are loathe to discuss these risks and other possible complications before they embark on their implant surgery. 


Another example is third molar surgery.  In South Africa, oral surgeons are still holding on desperately to the tenet of "If it is impacted, remove it."  Why?  They point to the incidence of ameloblastoma and cysts, but they conveniently forget to say that these tumours only occur in about one in a million cases of impacted teeth. They also conveniently forget to mention the incidence of post-operative complications of third molar surgery such as pain, swelling, mandibular fractures, nerve damage, pocket formation distal to the second molars (40% of cases) and damage to other teeth.   The incidence of an impacted tooth associated tumour fades into insignificance when compared to these post-operative complications.


The proper way to manage impacted third molars is to evaluate them six monthly clinically and radiographically and to remove them only when there is a very real indication.


In South Africa, many dentists are still removing sound healthy incisor teeth of members of the Coloured community, because it is a cultural "thing".  This is abhorrent.  Even more dentists are cutting up healthy anterior teeth of black people, just to put in a gold filling.  These dentists claim that if they don't do it, then the next one will.  What a deplorable argument!  It smacks of self-centred greed.


The good dentist will educate these poor uneducated people and he will rather sacrifice his money than his oath.


3.   Be conservative at first, reserve drastic treatment for later

As a rule of thumb it is always better to be conservative at first.  When in doubt, be conservative.  When a patient presents with a pulpitis and it is difficult to judge whether it is reversible or irreversible, consider it reversible at first, treat conservatively, ie a temporary filling instead of root canal treatment, but explain the situation in detail to the patient.  And be prepared to carry out the root canal treatment, even at short notice, even after hours.  The few patients who you spared the root canal treaments will be eternally grateful and the others will understand.  When you are not sure about the small radiolytic area in the interproximal surface of the enamel, defer the restoration for six months, apply fluoride and inform the patient in detail, especially about the use of floss.


When a patient presents with moderate to advanced periodontitis, always begin with oral hygiene instruction, scaling and polishing and maybe deep scaling and curettage under local anaesthetic before embarking on extensive periodontal surgery.  Again keep the patient informed.  It is remarkable how patients can sometimes respond to conservative periodontal treatment.  Those that you do spare the surgery will be eternally grateful and the rest will respond to the surgery better.


4.   Do not let the treatment be worse that the disease

It happens not infrequently that patients develop post-operative complications.  This happens after any kind of treatment but it is especially prevalent after apical surgery, periodontal surgery, third molar surgery and root canal treatments.  These patients bitterly regret undergoing the treatment.  The results of the treatment to them were worse than the symptoms they had previously suffered.  Or the pain and discomfort associated with the treatment were so bad that they would rather have lived with it.


All the treatments mentioned can and should be done in a way that is humane and gentle.  This requires skill and dedication and this can only be achieved through study.  We can not experiment on our patients.


There is a school of thought, originated in America which believes very strongly in extensive crown lengthening procedures. I have personally witnessed the consequences of these cruel operations.  The patients suffer from extreme post-operative pain and severe dentinal sensitivity which might never disappear.  I know of one  patient who ended up in a mental institution as a result of periodontal surgery.  This philosophy is strongly opposed in certain British and Scandinavian schools.  I think it is time for a careful re-think on periodontal surgery.


In essence Primum Non Nocere is putting your patients interest above your own.  The desire to do surgery, to do implants to remove third molars and to do all kinds of damage is very often born of a sick mentality of making money at all costs. It is the antithesis of the Hippocratic Oath and it has no place in the healing profession.     


                         Chapter 21


                 Total Dedication to Service


To try to be an excellent and effective dentist without making a total commitment to service is to begin without the End in Mind, it is being Far from the Customer, it is being Money driven and it is thinking Win - Lose.


In fact without this commitment to service, all efforts will be in vain, because they will be opposing everything contained in this book.  Dentistry is part of the service industry.  It seem so simple, yet many dentists seem unaware of it or so it would seem when their actions and motives are closely scrutinised.  We are supposed to serve our patients, yet sadly, many dentists seem interested only in serving their own purposes and plans.  I know, because I was there myself.


Apart from serving our own selfish needs, and interests through the desire and drive for money, we can be just as self-serving by our desire to do good dentistry.  I know because I was there.


When I started out in dental practice, young and ambitious, way back in 1979, I had only one ambition.  I wanted to be the best dentist in town or even in the country. I thought that meant doing the best dentistry and I worked hard at it.  I plunged myself very deep into debt by buying the best equipment and I worked very hard at doing the best dentistry that I could.  I really did spend a lot of time with my patients and I really did try to do good restorations and to make good dentures and all the rest.  And I think sometimes I did manage to do some good dentistry, but whatever I did, it did not make me either happy or successful. I only sunk deeper into the pits of despair and debt.  And the reason for this was my motives.  I was doing it for myself.  I wanted to be the best dentist for my own glory.  I wanted people to think and know that I was a wonderful denist.


Gradually, over the years I began to realise that my patients' interests were more important than my own glory.  I began to serve them, not myself and things changed around.  I became happy and succesful also.  But it only became possible when I developed a healthy vision, when the End I sought (my patients' interests) became clear.  It happened when I sacrificed my own narrow self interests and began to really serve my patients.  Service to patients includes, but it is much more than mere good dentistry.  It includes all eight principles in this section:

     1.   Primum Non Nocere

     2.   Total dedication to Service

     3.   Listen to the Patient

     4.   Provide more quality, less quantity

     5.   Do more to create Win Win

     6.   Inform before you perform

     7.   Be an Independent Entrepeneur

     8.   Build a Loyal Team


And with the exception of principles 4 and 5 it has less to do with the quality of the fillings or the crowns than it has to do with other things.


In the previous chapter the importance of Painless Dentistry was dealt with in some depth.  There is a direct relationship between the quality of service and the levels of pain experienced by our patients.  The self serving dentist will be in a hurry to get to the money generating part and will in the process hurt his patients, while the dentist, dedicated to service, will take his time and administer proper anaesthesia and give it time to take effect.  We have to do good dentistry, but we have to do more.  That is in part what Principle 5 (Do more to create Win, Win, Chapter 24) is all about.  The quality of our service has also a lot to do with the way our patients perceive our dentistry.  Very often peoples' perceptions differ from reality.  Generally, people judge the service of an orginisation on the behaviour of the lowest employee in that organisation.  An airline may be the safest in the world, but if the stewardess is rude, the passengers will judge it to be a poor and inefficient airline. Or a restaurant may make the best food, but if the waiter is inefficient or unfriendly, the restaurant may fail. The excellent companies know this very well and that is why they focus on being Close to the Customer.  That is why they are Hands-On, Value driven, with the emphasis on Hands-On, and why you find top management so often in the front line - where they meet their customers.


This means that we should realise just how important our other staff members are,  and that our practices are also judged on the personalities and behaviour of our staff. But patients' perceptions of quality of service are created by many other small, seemingly trivial, things. Of the utmost importance, in any relationship is first impressions.  First impressions linger permanently.  We win all our new patients through favourable first impressions being created in their minds by our old patients, talking about us.  This patient then goes through a whole series of first impressions and each one of these is extremely important.  The first, first impression very often is the telephone.  Telephone technique has developed into a minor art form, but the basics are prompt answering, in a clear and friendly voice.

1.   Prompt anwering.  The rule is to answer every call within three rings, at all costs.  People do not mind so much to wait, but they hate being ignored. Staff should be trained to answer every call within three rings, even if they are totally overwhelmed by other calls and other tasks - which they should not be.  When circumstances are very difficult the phone should still be answered and the person should be asked whether they mind to wait a while. And the telephone operator should repeat that question every thirty to forty five seconds.  When a telephone becomes chronically engaged it is time to get extra lines and maybe even extra staff - without compromising the principle of Simple Form, Lean Staff as in "In Search of Excellence".


2.   Clear voice.  Staff who answers the telephone should undergo voice tests, before they are hired. The dentist himself must talk to them on the phone, at the time of the initial interview.  This can be done in the practice.  Even if it is not the deciding factor, when the prospective staff member is hired, it will drive a powerful message home, because it will tell her just how important the dentist considers telephone technique to be.


3.   Friendliness.  The old trick is to teach telephone staff to smile all the time while talking on the telephone, because people can sense friendliness on the phone.  While this can work, it is best just to hire friendly staff.  It is easier to be friendly when it is part of your nature, than part of your job.


The next first impression of the new patient will be at the front desk of the dental office.  It goes without saying that everything should be neat and tidy, but the most important matter of all, again is friendliness, coupled with a business-like, calm, readiness.  Patients, especially new patients should be expected, like guests at a party and should be greeted immediately, "Good morning, are you mr White?  My name is Jill, and we have been expecting you." This, to any person is very re-assuring. And patients attending dentists, and especially a new dentist, need all the re-assuring they can get.  What happens now is not so important, but what is important is that the receptionist/ front office person explains everything in short and simple terms, very clearly.  While people don't like filling out forms and the ideal is to do it for them, they won't mind if the forms are very clear, very short and straight forward to the point of being simple.  The best way however is to ask questions and to fill out the form for the patient because it turns a boring, even difficult task into a listening and understanding experience.  People don't like filling out forms, but they like very much being listened to.  And remember that this is the patient's first impression of this dentist and that this first impression is very inportant.


The patient would normally have to sit and wait a while now.  The waiting environment should be clean, neat, and friendly.  Magazines should be very recent, including the latest newspaper. Fresh flowers is almost obligatory.


Up to this point the patient had already experienced "first impressions" of the dentist and his or her practice -

     *    the conversation with the referring patient

     *    the telephone call to the practice

     *    the first few minutes at the front office desk

It is a simple fact that a negative experience, real or perceived, during any of these, can ruin a dentist-patient relationship before the parties have even met each other and that the patient can and often will ascribe it to poor service.  What our patients say about us to their friends and acquaintances is the result of how we treat them and the only thing we can do about that is to try and be a more effective and more excellent dentist every day of our lives.


But there is a lot of action that we can take about the telephone manners and mannerisms of our staff, about the appearance of our reception areas and about the way in which our patients are received and greeted. The final first impression is when the patient finally, actually meets the dentist, face to face.  A dental surgery with all its intimidating instruments and smells is the very last place that such a first meeting should ever take place.  The dentist must meet a new patient in a non-dental environment.  I meet all my new patients in my private office.  My receptionist will escort them into the office and there she will introduce me.


My private office is a typical study or reading room, with all the degrees, diplomas and books against the walls and with a desk and chairs.  It has two doors, one leading from the reception area, and the other leading directly into the surgery.  Also, in this office is all my audio-visual aids, such as the models of teeth, booklets, pamphlets and a before and after album of some of my cases, illustrating various treatments.


I will be suitably dressed for the occasion.  That means smart shoes, trousers, long sleeve shirt and a tie.  No white coat.  I always dress like this when consulting with patients and I consider it very important. In warm and sunny South Africa, the temptation to dress more casually is almost overwhelming but I resist. Research has shown that patients want their doctors to dress smart.  I would hazard a guess that the smart image inspires confidence, something which patients need badly.  I believe that patients take me more seriously when I look smart.  Apart from the learned look, smart dress also reflects and conveys a sense of respect towards the patient and conscientiousness to the profession.  I definitely did not dress like this in my early life as a dentist, but I learned to do it from the English.  To me this is now a non-negotiable issue.  I know it works to dress like this and I will not change to more informal dress.  I am very much aware of the importance of first impressions.  I want to look different and better than other dentists and I want to get the patient's attention right from the start.


In this office I talk to the patient, or rather I listen to the patient.  Listening to the patient is such an important issue that the next chapter is devoted to it. For the purpose of this chapter it is only necessary to point out that this initial consultation is carried out in this non-dental office with my patient sitting across the desk from me. My intention is to listen to the patient's main complaint, medical and dental history.


The patient gets the message immediately, this dentist is different.  He wants to listen to me.  The seed of perceived superior service is watered and nurtured in these surroundings.


I really concentrate very hard to find out just what it is that this patient wants from me.  I do this through listening (see next chapter) and I will do everything to deliver that service.  If the patient only wants an amalgam filling I will give it to him.  If he only wants an opinion I will give it to him.  The purpose of this consultation is just to find out what it was that brought this patient to me.  If it is "Painless Dentistry" everything that I do or say will be geared towards it.  I will eventually devise a treatment plan which will enable me to do "Painless Dentistry", even if it takes whatever.  If this patient wants an examination I will go all out to do just that. But I first have to listen.  Eventually then, after this conversation I will know what it is. I will then inform the patient very directly, friendly and honestly what it is that I want from them - immediate payment at completion of all treatments.  I can only recall two occasions where patients had then boldly told me that they do not want to do this and that they preferred to seek treatment elsewhere at more convenient terms.  I go out of my way to inform the patient  of all possible methods of payment, ie cash, cheque or credit card and I hasten to re-assure him or her of the fact that a specified account and receipt will be made available immediately and that they will be able to claim some of the fees back from the medical aid scheme. 


If there is any history of cardiovascular trouble, I will then take the blood pressure.  This is suggested as routine for all dental patients and I have discovered a number of cases of hypertension and referred them to their medical doctors. I admit that it might look like a little bit like practice-building or marketing or even showmanship, but my patients appreciate it.  They are often surprised to be tested for blood pressure at the dentist, but I see it as part of my commitment to service.


After this little talk we leave my office and enter the surgery where I don my white overcoat, and put on the mask.  At this point, if the patient had previously told me that he only wants a filling or whatever I will then proceed to do just that. I will only do a cursory examination to see if it is practical to fulfill this request and then I will proceed to do it as quickly and painlessly as possible.  If the patient had indicated that he or she wanted an opinion or an examination or some form of advanced dentistry I will then proceed to do an examination.  But this is intentionally, the best examination that this patient had ever had.  


Before I put on the gloves, I will examine the extra-oral structures, such as the TM joints and the lymph nodes.  Normally, a dentist just wants to get a mirror and a probe into the patients' mouth to find out how many fillings he is going to do. I purposefully leave that for last. Only after the extra-oral examination do I put on gloves and ask the patient to open the mouth.  I then first examine the soft tissues, such as the tongue, lips, floor of the mouth, palate and cheeks.  Next is the occlusion which I examine in some detail, including testing for non-working interferences with the cellophane strips.  All of the time I will be communicating my findings to my chairside assistant who will be filling in the form and chart.  After the occlusion, I will examine the periodontal tissues in detail recording every pocket deeper than 3.5 mm.  I aim to do at least a Basic Periodontal Examination, previously called the Community Periodontal Index of Treatment Needs (CPITN) and I call out the code numbers to my chairside assistant.


Finally I will check the individual teeth, carefully checking and recording the condition of each tooth.  I purposefully aim to record as much detail as possible - because it is good dentistry and also because patients appreciate it.  It is a very educational experience for a patient to hear all these words and phrases and numbers being called out.  Also, once again I am reïnforcing the patient's perception of superior service.  "If this is the way he does just an examination, then he must be good...." Only at this stage will I decide whether to take any radiographs and I always try to take as few as possible.  I look at the details of the examination on the chart and I then decide which radiographs to take and I try to explain very briefly the need for each.  I know I have been successful when the patient exclaims at the end of the examination, "Wow, I have never had such a good examination!"  I know then that I have won this patient and that we are going to develop a sound relationship. 

This would normally conclude my examination and I would then remove the coat, mask and gloves and take the patient back to my private office, where I try to give the patient an idea of my diagnosis and treatment plan and of the possible costs involved.  Once again we will both be sitting comfortably in this non-threatening, non-dental, relaxed environment.  We talk and discuss the problem and we try to find a mutually satisfactory, Win-Win solution. Once again I will listen a lot to the patient's ideas and fears and by just listening most of the fears often disappear.  The patient is then told that this will be followed by a written quotation to be mailed soon and I use the phrase "For your peace of mind......" and then eventually the patient is dismissed.  Such an examination and consultation might take up to 90 minutes but I consider it a very wise use of my time, because it is the patient's first impression of me.  It forms in the patient's mind a very clear picture of superior and excellent service. I also think it is a wise use of time which I use to sell some very expensive dentistry.  But mainly, it is wise, because this is what patients want. Patients don't want fillings, crowns, root canals or extractions, they need them.  But they want quality examinations.  They want to be cared for, they want to be important, they want time spend on them, they want to be noticed.  They will even pay for all of this, because they want it.  If I get the impression early on that they only want a certain filling I go out of my way to do only that, equally well, without the detailed examination, but I tell them that they need such an examination later on. 


I am totally committed to give them what they want. That is called Service. 


One of the most important issues to which I personally devote a lot of time is oral hygiene.  I talk to my patients about it, I explain the rationale and demonstrate the techniques.   This is often repeated at some stage by my oral hygienist, but I generally aim to introduce the patient to the problem myself.  I like to talk about it right at the outset, sometime during the first consultation.  Once again, all dentists know that this is good dentistry - they just don't practise it. But it also tells the patient this dentist is really interested in his or her teeth, not only in how many fillings he can do.  Even patients who are not really interested in oral hygiene and who , in all probability will never change their harmful ways, are impressed by the genuine concern. Even though they are not going to do "all that flossing and brushing" they will keep on coming to this dentist "because he cares".  Talking about the importance of oral hygiene is not only good dentistry, it is also good service. 


Good service is exemplified by listening, neatness, promptness, giving them what they want, courtesy and friendliness.  It is important to be on time.  It is important to be able to treat emergencies almost immediately.  This would mean scheduling daily time for emergencies and it can be very difficult to do this but it does not change the fact that it is important.  When a dentist is totally comitted to service, he will find a way to handle those emergencies.  There is no better example of excellent and effective Service than Jesus Christ.  His whole life was dedicated and committed to serving mankind.  And He is the glorified King of the universe!  How much more should we be prepared to serve.


Jesus said, " But you are not to be like that. Instead the greatest among you, should be like the youngest, and the one who rules like the one who serves." (Luke 22:26)  But He did not only talk about it, He also lived it.  He went as far as to wash His disciples feet, a very menial task, usually reserved for slaves (John 13:1-17)  Not only did He live it, but Jesus also died for mankind in the greatest act of service ever recorded in history.  He died so that we could live, eternally.


We should serve our neighbour, our fellow man, our patients, because it is a direct command from God, God who loves us.  This does not mean that we should serve God and our fellow man because of the rewards that we may reap from it.  That is not the idea.  We cannot manipulate God.  We serve because we love.  We love God and we love our patients, regardless of anything.  Even if we don't get any reward or worse, even if we are on the losing side, we still serve.  "Though the fig tree does not bud and there are no grapes on the vines, though the olive crop fails and the fields produce no food, though there are no sheep in the pen and no cattle in the stalls, yet I will rejoice in the LORD, I will be joyful in God my Saviour.  The Sovereign LORD is my strength; he makes my feet like the feet of a deer, he enables me to go on the heights" (Habakkuk 3:17-19).  This is Total Commitment to Service.  It means doing things without expecting immediate compensation.  America's excellent companies know and use this principle very well.  IBM, Caterpillar, Disney, Delta airlines and all the others know that it is vitally important to serve their customers, even if it costs them money to do so.  Examples of these companies putting it into practice abound in "In Search of Excellence" just as it does in the Bible.


                         Chapter 22



                    Listen to the patient


There is an old saying in the medical world, "Listen to the patient, he will tell you the diagnosis."  The art of taking an history developed from these words. A good doctor knows how to do this and he knows how important it is.


Sadly our high tech world has changed this, for the worse.  Very often, patients have to undergo blood tests and X rays before they are even seen by the doctor.  Some doctors are only met, minutes or seconds before an operation. Some doctors, like the pathologists and radiologists, never meet their patients.  How odd?  These doctors would argue vehemently about how busy they are and how specialised their services are and that it is far more practical to have the results of the tests available at the time of the examination, rather than having to do the examination, then refer for tests and then to see the patient again.  This argument has a little merit but it is also costing billions of dollars/ rands/ pounds for tests done unnecessarily.  I hesitantly would like to suggest that many doctors are losing the skills of a clinical examination and diagnosis, because they are so dependent on special tests.  A good doctor will always first take a history, then examine and only then refer for tests.  Yet many top specialists work the other way around.  Because, they say, they do not have the time to wait for results of tests. I say, hesitantly, it is because they consider themselves too important to listen to their patients first. Their time is more important than their patients' feelings.


A good doctor knows how to listen and he knows how to use the information obtained by the listening process.  A good, wise doctor often can diagnose before or without special tests and he carries out the special tests only to confirm his diagnosis.  It is these special tests which are making medicine so utterly expensive these days. By just first listening to a patient, a good doctor will rule out many unnecessary testing and by doing a good examination and making an intelligent diagnosis many more will be ruled out.


It is true that the absolute nature of the tests can rule out human error but it can also lead to serious clinical problems.  Both my parents would have lived longer, without the angioplasty and bypass procedures performed on them.  The doctors acknowledged it, but hastened to add, "He or she would have died a few weeks or months later, anyway." There  is very little comfort in a statement like this.  I do not blame the doctors, they were trying their best.  But I am pointing out that high tech medicine and surgery can and will also fail.  And that there is a very definite place for listening to our patients.  Because they must tell us the diagnosis.


While all this many sound a little negative about the medical profession, I took a few leaves, directly out of their book and built my practice onto them.  A good doctor meets you in his office and asks you to sit at his desk.  He sits at the other side of the desk and he asks you a lot of questions.  And he listens to you.


He then asks you to go into his examination room, where you have to take off your clothes and lie on the examination couch. He then proceeds to examine you clinically, after which he asks you to get dressed again and then you go and sit at his desk in his office, again.  At this point he will then prescribe treatment or discuss the possibility of further tests.


This is the classical, traditional correct way in which the old, good, doctors listen to their patients, examine them, make diagnoses and prescribe treatment.  And with this in mind I designed my rooms and I follow this style with all my patients. I do it because it is the best way to listen to them.  A dental surgery or operatory is no place for communication.  There are far too many distractions in the form of intimidating instruments.  The worst scenario is with the patient fully reclined in the dental chair, with the dentist having his hands in the patient's mouth.  It is a universal complaint about dentists.  "He talks to me while his hands are in my mouth." A dentist cannot talk to a patient, more importantly a patient cannot talk to the dentist, if the latter has his fingers in the former's mouth.  Our patients know it, why can the dentists not understand it?   In my practice, I first meet my patient in my private office - as descibed in Chapter 21.  I then talk and listen to them in this non-dental, friendly environment.  We then only go into the surgery, where I put on the coat, gloves and mask and I do my examination or treatment and then we go back to my friendly office where we discuss my findings and the possible solutions and fees.  While we are in the surgery, only small matters are discussed.  I fall victim to talking to them with "my fingers in their mouths" every day but I try hard not to. 


My office is the place where we communicate - not the surgery.  It is amazing and most gratifying to see how patients react to this.  They relax immediately.  They were expecting to enter a typical dental surgery and now they are sitting in a normal office.  They were expecting to be told to get into the chair and to open wide and now they are being listened to.  What a change from their usual experience at the dentist!  Everything I do or say in this situation is directed at telling the patient, "I am listening to you."  I look them in the eyes and my eyes do not dart to my watch.  My desk is absolutely clear.  There must be not a single shred of paper on this desk, except this one patient's file.  Even a small piece of paper with a telephone number scribbled onto it might convey the message that my thoughts and attention are elsewhere.  Or a book or a journal might indicate that I would rather be reading.


I also do not accept any telephone calls, from nobody, during this time.  I am just too busy listening to my patient.  Now and then I will be recording notes on the patient's file, but I sometimes find that even this is too distracting.  For what do I listen?  Mainly I listen to find out what it is that the patient wants.  I listen carefully to learn the patients preferences, likes and dislikes of dentists and dentistry.  I listen for give-aways such as, "...And my teeth are crooked and ugly." or "...The other dentist wanted to cap my teeth and I don't think there is anything wrong with them" or "Mrs X said that you won't hurt me."  I try to understand why they came to me.  Is it for Painless Dentistry?  Is it for Quality Dentistry?  Is it for the Service Experience at my practice?  Is it for cosmetic treatment?  Is it for root canal treatment?  Is it because they think I am  a good dentist?  Is it because I did such a good examination/crown/root canal treatment for her friend who referred him or her to me.  The list is endless.


Very often, but not always, patients end up at my doorstep after a long series of visits to other dentists who failed to solve these patients' problems.  By just listening to them, these anxious patients become almost totally relaxed and relieved.  Sometimes it is a patient who perceives his mouth to be in a bad state, yet the previous dentist failed to detect anything wrong.  By just listening to them they rid themselves of their grievances and unhappiness.  Whatever I do or say after this, they will accept.  I fully realise the magnitude of this unconditional trust this patient now places in me and I know that I just cannot afford to disappoint them.  I perceive it to be a great responsibility to be trusted like this.  The listening experience changes the patient, but it also changes me.  Very often, patients come to see me for a second opinion. Now, this is the time to the listen. They don't really come to seek my opinion.  They actually come to tell me their opinion of the previous treatment plan.  When they say they want a second opinion, they are really saying, "I don't like what the previous dentist proposed." I will then listen very carefully for their reasons and I won't say much until I have completed my examination. At the end of the examination I will rather impassionately describe all treatment options, with the advantages and disadvantages of each.  I then leave it to the patient to decide.  Invariably they will choose one of the treatments not proposed by the previous dentist and they will choose me to do it. 


When they come to seek a second opinion, they do so because they did not trust the previous dentist and they did not have confidence in his or her capabilities. All that is really necessary is to listen to them.  By listening you convey respect for their feelings and this in turn breeds respect for you, and inevitably their trust and confidence. 


Listening also holds some very important and very real, practical, implications in the clinical situation.  If the patient says that a tooth hurts when drinking cold drinks and it hurts when biting, I will immediately suspect a cracked tooth syndrome or at least I will include it in my differential diagnosis.


When a patient presents with a main complaint of toothache, the diagnosis can often be made and the treatment predicted in my office, before I have even looked in the patient's mouth.  If the toothache is characterised by sensitivity to external stimuli, ie cold, heat or sweet foods, it is most probably an acute, reversible pulpitis which will react favourably to a temporary dressing or temporary crown. I just have to ask the patient and listen to him or her to get the information I need.  It breeds a lot of confidence and it puts the patient's mind at rest if I can actually tell them what is going to happen before we have to go into the surgery. 


On the other hand, pain of a spontaneous nature without external stimuli, especially a pain which worsens at night is indicative of an irreversible pulpitis, which will only respond to a root canal treatment. Again I can get all the information I need by just listening and my clinical examination and special investigations will most often only confirm what I already know.


And then there are one of our most difficult challenges - our TM-joints/bruxing-grinding-craniomandibular dysfunction patients.  These patients present with vague symptoms, notably headaches, joint pains, TM-joint pains, earache, muscular pains and sometimes toothache.


These people are highly stressed, anxious individuals, who clench or grind their teeth.  Very often they are not even aware of this harmful habit.


I have seen countless numbers of these patients who have suffered even more stress and anxiety because of unnecessary eye tests, Cat-scans, neurological investigations, allergy tests and a whole host of other tests, all because of their symptoms.  The doctors' and dentists' failure to diagnose the condition for what it is, causes even more stress, because the patients invariably suspect cancer or such like.  All the tests are negative and nobody understands.  If only they would listen to these patients.  If only they would give them time to describe their feelings and concerns - their pathos - then they will feel better immediately.  The following from an unknown author, freely translated from the original Afrikaans, explains it very well:



When I ask you to listen to me and you start giving me advice, you didn't do what I asked.


When I ask you to listen to me, and you start telling me that I shouldn't feel like that, you trample and negate my feelings.


When I ask you to listen and you feel that you have to do something to solve my problem, you have failed to help me, how strange it may seem.


Listen!  All that I am asking is listen - do not do or say anything, just hear me.


Advice is cheap: For a few cent you can find information in the Readers Digest on how to handle stress and how to diet.  I can still think for myself, I am not without a brain.


When you do something for me, which I can and ought to do for myself, then you increase my anxiety and weakness. 


But, when you accept it as a simple fact, that I feel the way I do, regardless how irrational, then I can stop convincing you and I can begin to understand what it is that lies behind the irrational feeling.


When it is clear, the answers are obvious and I don't need advice.  Irrational feelings make sense when we understand what is behind them.


Maybe this is why prayer works for some people, because God is quiet and He doesn't give advice or try to fix things.  He just listens and allows us to work it out for ourselves.


So, please listen and hear what I am saying.  If you want to speak, just wait a few moments for your turn, and then I will listen to you."


This applies to all people, to all our patients but it applies especially to our patients suffering stress and anxiety. Fundamentally, stress and anxiety are irrational.  It performs no beneficial function, in fact it is very harmful.  Yet in spite of this we succumb to it.  Peters and Waterman write a lot about irrational man in ISOE. Man is irrational, therefore it does not help to be logical in the first place.  Remember the Greek philosophy - Ethos, Pathos, Logos = Personal character, Feelings, Logic.


We first have to understand our patients' Pathos, their feelings, before they will be able to understand our Logos, our logic. But all of it is impossible if the dentist does not have Ethos, personal character and integrity.  The very word ethics is devised from Ethos.


We are given some very sound advice in the books of Proverbs and James in the Bible, regarding the art of listening.  We are warned, "He who answers before listening - that is his folly and his shame." (Proverbs 18:13)


Also, "The heart of the discerning acquires knowledge; the ears of the wise seek it out." (Proverbs 18:15)


And finally, "A fool finds no pleasure in understanding, but delights in airing his own opinions." (Proverbs 18:2)


Listening to our patients is an expression of Christian love, as commanded by God in his Great Laws "Love thy neighbour as thy self."  That explains why it is so successful.  Our God is a God of love.  He loves us and He wants us to love Him and our patients - because He knows it is good for us and for them if we do so.  It is all so simple, but people want to make it so complicated.  Because it is so simple, people do not want to believe it.  Yet, God wants us, above all, to believe.  He wants us to believe in Him and in His Word. And His Word is good.  If we keep His laws, if we obey His commands, in His Word, we will be Happy and also Successful, Effective and Excellent.  Listening to our patients is caring for them.  People want dentists who care for them, more than they want dentistry.


"Patients want to know how much you care, more than they care how much you know." (George White)             

                         Chapter 23


             Provide more Quality, Less Quantity


In a previous era, dentists made money by doing thousands and thousands of amalgam fillings, extractions and dentures and a few tooth coloured fillings.  Periodontal treatment, root canal treatments and crowns were almost unheard of.


Then with the development of proper impression materials came the era of the crowns.  Dentists had to replace all those failing amalgams with crowns.  This, of necessity, was accompanied by a growth in periodontal surgery, endodontics and oral hygiene procedures.  Instead of thousands of amalgams, dentists were now doing thousands of crowns.  Both these procedures cost the patients and the third parties a lot of money, but the crowns obviously more so.  And the third parties naturally tried to apply some brakes to the runaway costs. They did this by regulating the fees and keeping the fees down.  The dentists responded by doing even more expensive treatments and the third parties reacted by more controls and regulations and limitations.


But something has got to give.  Some dentists give in.  They just cannot take the pressure of all the patients and their demands and the financial strain imposed on them by an unfair fee structure.  They give in by giving up private practice or they succumb to drugs or alcohol or they react with extra-marital affairs. The ones that persist, the fighters, the ones that manage to push on, live with repressed fears and anger which only manifest years later with coronary and other diseases.  They keep on doing the one amalgam after the other, the one crown after the other.  They battle and struggle on valiantly, and in vain.


The constraints of the fixed, low, fees allow them to do only so much and no more.  The crown or root canal treatment- or whatever has to be completed within 30 minutes, because they only get paid so much and not more.  As a result, quality falls.  That is the real quality of the dentistry, but also the perceived quality of the service.  There is no time for Quadrant II activities and as a result the practice suffers from a lack of planning, marketing, maintenance, development and vision.  The dentist is so busy with his Quadrant I dentistry, filling holes, that he totally loses sight of what it is he is doing - LIVING.  He is too busy making that living.  Slowly but surely a Lose-Lose situation develops.  The dentist hates his work and he hates it even more because the harder he works, the less money he makes.  And the patient is unhappy because he perceives the dentist not to care. He is just rushing around, hurting his patients, not talking to them, or only doing so with his fingers in their months, and to crown it all (no pun intended) his fillings and crowns do not seem to work that well.


I see the result of all this every day in patients' mouths.  Incomplete root canal treaments seem to be the rule, not the exception.  Crowns leak, amalgams have overhanging margins, composite restorations leak and become discoloured.  Oral hygiene is ineffective.  Periodontal disease is not recognised.  Bridges fail. Implants fail.  Dentures fail.  I venture to say that all these problems are caused by dentists spending too little time. They would respond, as they always do in private discussions, that they don't have time because their fees are so low.


It is part of human nature to always blame someone or something else.  Adam did it when God asked him why he ate the forbidden fruit.  He blamed Eve.  And Eve blamed the serpent.  We live in a society which cries "Victim!" when someone is blamed. When someone abuses his children or his wife, he is a victim of his environment.


Dentists blame the system.  In South Africa it is the contracted-in or medical aid scheme system. In Britian it is the NHS system.  Dentists blame their poor quality of dentistry on "the system", just like Adam and Eve.


For decades, dentists have depended heavily on these systems to support their lifestyles.  They  have used and abused and manipulated these systems to the limit and they cry "Foul!" when the systems oppose their actions.  They go on to blame their professional associations, the BDA in Britian and DASA, in South Africa.


They even blame their colleagues for abusing the system, but never, never are they prepared to accept some of the blame themselves.  Such is our human, sinful nature.  The Bible tells us in no uncertain terms that we are all sinners, all of us.  "The fool says in his heart, "There is no God."  They are corrupt, and their ways are vile; there is no one who does good.  God looks down from heaven on the sons of men to see if there are any who understand, any who seek God.  Everyone has turned away, they have together become corrupt; there is no one who does good, not even one." (Psalm 53: 1-3)  "If we claim to be without sin, we deceive ourselves and the truth is not in us." (1 John 1:8).  Dentists blame their precarious position on others and they react to threats of controls, rules and regulations by the third parties, by doing even more dentistry.  The lower the fees, the more dentistry they do.  In the end something has got to give.  Many dentists give in.  A young dentist, who studied under me and qualified eighteen months ago, lasted only one year.  He now works as a plumber for the government.  If the dentists don't give in, the systems will.  Socialism has failed miserably the world over and it has failed because it carries the very poison of its own demise in it's bosom. It is simple arithmetic.  One cannot expect to contribute a thousand dollars per year to an insurance scheme and then claim ten thousand dollars every year. It can work for a certain time but eventually something has got to give.  And this is what happened to socialism.  Wealth can not be redistributed, it has got to be created and the people who do it are the independent entrepeneurs, not the government or some or other bureaucracy.


For some years now dentists have responded to their perceived threats by turning out more quantity.  This is a fatally flawed principle.  The answer to the challenges facing dental practitioners today lies in giving our patients more quality.  That includes quality dentistry but it goes beyond that to include also painless dentistry, quality service, friendliness, after sales service, cleanliness, all the little things, effective communication and the personal integrity of the dentist.  By just doing more dentistry we only make the problem worse.  We are attacking the third parties head on and they are responding accordingly.  We are also alienating our patients in the process.  The more dentistry we do, the poorer the quality of that dentistry.


Jennifer de St Georges, that venerable grand dame of practice management, says that the ideal number of patients that a dentist should treat per day is one.  Whilst this is a little bit idealistic, it also has a lot of merit.  One of America's greatest dentists, dr Harold Shavell of Chicago, does just that.  He treats one patient per day - and he charges accordingly.  Dr Shavell spends up to four hours or more just making six temporary crowns.  But his temporary crowns put to shame some of the best efforts of some of the world's best ceramists.  He spends an hour doing an occlusal amalgam and he charges $150 for such an amalgam. Dr Shavell's fees reflect the quality of his dentistry.  He does not adapt the quality of his dentistry to some fixed fee imposed on him by some or other bureaucracy.  In my practice I do the same, but I hasten to add that in South Africa we just cannot charge the same fees as in Chicago.   But my fees are definitely at least 120 per cent higher than the average contracted in fees.  That should be seen in perspective.  When patients go to a so-called contracted-in dentist they pay quite literally nothing for their dentistry, and ninety five per cent of South Africa's dentists provide this free service.  But if these patients come to me they have to pay all of these fees, directly to me, out of their own pockets.  It really takes a lot to get a patient to sacrifice so to speak, his right to go to a contracted in dentist and to come to me and pay a great deal of money for the privilege.  I do it, through the grace of God, by providing more quality and less quantity. The dictum "Primum Non Nocere", Do no Harm, is the basis of this.  I go out of my way not to do dentistry to people.  I do everything I can to save them from the discomfort, the pain, the agony and yes also, the financial costs of dental treatment.  I am always putting myself in their position. How would I feel?  What would I want?  My reasoning is, "If it can be avoided, avoid it."  I try to do as little dentistry as possible.  Someone said, the best dental treatment is the least treatment which satisfies the patient.  It may sound like I am sitting around doing no dentistry and just talking to my patients.  That is most certainly not the case.  Very often I will spend 10 hours a day, doing root canal treatments, amalgams, crowns and whatever comes my way.  But I am never unfaithful to my principle of "Less quantity and more quality."


My limited experience with American consultants has created the impression in my mind that the American dentist goes all out to sell as much dentistry as possible and they use any and all means to do that. They use sales techniques, intra-oral cameras and advertisements, i.e. the hard sell approach.  At least the third parties in America are not as strong as in South Africa and Britain and therefore the self-regulatory nature of the free market prohibit the abuse and manipulation of a system.  However, it is my impression, that certain individuals in America, using the hard sell approach, are overtreating their patients in the same way as their colleagues in Britain and South Africa.  At least the American patients have the option of choosing, of saying yes or no to the hard selling dentist.  The moral question is really, are these American patients given all the information?  Are they being told of all the complications and disadvantages of treatment also?  Or do their dentists only tell them about the advantages?


I do not do a crown, if I can get away with an amalgam. I do not do a bridge if the patient does not need it or want it.  I do not take unnecessary radiographs - and I know that a case can be made, quite "scientifically" - for taking routine panoramic radiographs.  I can only answer that we can then also make a case for routine radiographs of every other part of the body.  And what about routine blood tests and routine electrocardiograms?  The need for a radiograph is an individual matter.  There are very few absolute rules.  I look at every case and decide whether it is really necessary to take a radiograph.  Implants provide us with a spectacular example of maximum treatment, not necessarily with maximum effect.  The risks and failures are much greater than what the practitioners of the art are generally prepared to acknowledge.  And the costs are so unbelievably great that it overshadows many of the so called advantages.  I have seen many single tooth implants placed in between two heavily restored teeth. This is outrageous.  A good three unit bridge is much less expensive, less invasive and more predictable than a single tooth implant.  When the two teeth adjacent to the missing tooth are heavily restored it makes absolutely no sense to do an implant.  And when they are not restored, there is also the option of an acid-etch (Maryland) bridge - the ultimate in non-invasive fixed therapy. A quality Maryland bridge will last for years, it involves no surgery, very little damage to sound healthy tissues and can be done almost without any form of anaethesia.  Compare that with the two stages of surgery of implants, the risks of nerve damage, the risks of failure, the number of appointments, the post-operative pain and the inevitable costs.  The advantages of a single tooth implant pale into insignificance.  But, there is one very important proviso -the Maryland bridge has to be a QUALITY Maryland bridge.  It has got to be designed according to the most modern concepts and guidelines.  The preparation and impression need to be perfect, the technician must use only the best materials and techniques and finally, the bonding procedure must be carried out without any shortcuts and using only the very best materials.  When I bond a Maryland bridge, I isolate the teeth with a rubber dam, I sandblast the enamel surfaces to remove plaque and pellicle, I tin-plate the fitting surfaces of the bridge and I use C&B Metabond, the best and the most expensive cement.  I follow the manufacturers' (of C&B Metabond) instructions to the letter.  All this results in a quality Maryland bridge, which involves much less Quantity dentistry, than an implant.  The argument can be extended to the use of a removable partial denture, which involves even less treatment, but the patients' wishes and desires most often rule this out. But I have one eighteen year old patient with congenital missing lower second premolars.  She has worn quite successfully and happily a removable partial chrome-based denture for six years now.  She does not want anything else and therefore to do nothing is the best form of treatment - for her - and also for me.


When I was still a student, my father consulted one of South Africa's top specialists about his teeth.  The specialist advised full mouth crowns.  When I innocently asked the specialist why he intended to crown three anterior teeth, which only had small buccal fillings, he replied that he wanted to create a "nice whole".  I think that should have read - hole - that is in my father's pocket.


The issue of periodontal surgery is a contentious one. Many South African periodontal surgeons are proponents of drastic and radical surgery and I have seen many, many patients suffer severe sensitivity and who exhibit long, ugly teeth after this surgery.  Also, I have heard many gruesome tales of severe, extreme post-operative pain.  No periodontal surgeon has ever been able to give me a satisfactory solution to this problem. 


As a student I was taught the importance of oral hygiene in the treatment of periodontal disease.  We were also taught to do proper scaling and deep scaling procedures before doing surgery and not to do any surgery unless a patient is able and willing to maintain a plaque index of less than 10 per cent.  Now, in my experience it is impossible to teach a patient in a matter of even one hour exactly how to use a tooth brush and dental floss properly.  It takes firstly a willing patient and secondly repeated visits to me and my oral hygienist before they begin to grasp the idea.  They have to be shown again and again before they understand.  And the rule says, and it is a good rule - do not do periodontal surgery unless the patient is willing and able to maintain a plaque index of less than 10 per cent.  If the patient will not or can not keep his mouth plaque free, then it is pointless, even positively harmful to do periodontal surgery.  The treatment will fail and the disease will progress even faster. Yet, I see it happening everywhere in South Africa. I see patients undergoing periodontal surgery after one or even no visit with an oral hygienist.  They see the surgeon once, he refers them to the hygienist and a week or two later, he operates on them.  The result is often the disaster described above.  If a patient does not or cannot comply with the demands of oral hygiene, then it is totally unjustified and contra-indicated to do periodontal surgery. A patient has to master and understand all the appropriate techniques before any periodontal surgery is planned. Also, all periodontal surgery should only be done after, at least one attempt of deep scaling and curettage and a three month healing period and then a re-evaluation.  And then only the teeth with persisting pockets should be surgically treated.  I know of several very well-known specialists who routinely refer all their patients for full mouth crown lengthening surgery - in order to get retention for their crowns. Patients are subjected, in their hundreds to extensive, invasive, painful, expensive, periodontal surgery, just so the crowns won't come off.  And these same specialists refuse to consider the modern adhesive resin cements such as C&B Metabond.  They won't even listen to anybody talking about it, because they have this implicit trust in their zinc phosphate cement.  C&B Metabond, and some of the other adhesive resin cements, have the potential to save some of our patients from unnecessary, painful periodontal surgery.  I do everything in my power to save my patients unnecessary dental treatment. Yet, I have to, and I do refer patients on an almost daily basis to a periodontal surgeon who shares some of my philosophies.


The maxillofacial surgeons have long been the prophets of removing all impacted wisdom teeth.  I dealt with this elsewhere in this book but it is necessary to point out that this is another treatment which is often, in my opinion being carried out unnecessarily, because this is the way the dentist responds to financial pressure - by seeking to do more treatments.  In South Africa we have the very rigid system of general dental surgeons and the specialists.  The fees of the specialists have over many years been regulated, first by the government and lately by the medical aid schemes, to be 50 per cent higher than the fee for the same services rendered by a general dentist. To be quite truthful, this was originally conceived and formulated by the profession's own organisation, The Dental Association of South Africa.  The government and the medical aid schemes only followed DASA's guidelines.  The first thing that a dentist, who experiences a shortage of money or work, does is to consider doing some form of specialised dentistry, such as orthodontics, or removal of wisdom teeth.  In other words he or she responds by doing more dentistry, instead of "Sticking to the Knitting" and doing his "Knitting" - that is the bit he knows best - better.  I take very great pride in the quality of my examinations, my radiographs and my scalings and my amalgam fillings and I continuously strive to improve this quality.  And therefore my patients don't mind paying a little and even a lot more.


Business people tell us that it is good business sense to respond to a lack of business by expanding our product and service range. That translates exactly into doing more kinds of dentistry, yet I am not sure whether this works well in dentistry. Certainly, if you have several excellent specialists in your area and they are ready, willing and able to help your patients, you have no moral right to intrude in their fields of specialization and render an inferior service - just because you need the money and the work. You are under an obligation to offer your patients the best possible quality of service and if there is someone who can do it better, then you have to refer that patient to that person. But then that person is under an even greater obligation to fulfill his part of the bargain - to render that quality of service.  And as I have shown there are a few very real problems in this area.  I have often been disappointed by specialists, not only by the quality of the dentistry, but also by the quantity of the service. Unfortunately the specialists, because apparently there are too many of them, suffer from the same ailments as the general dentists.  They increase production by concentrating on the quantity instead of the quality. Because they are also ruled by third parties, instead of by their conscience.  In South Africa, they have had the advantage of that cushion of the extra 50 per cent in fees which have shielded them somewhat from the financial pressures, but it is becoming more and more apparent that the specialists are also suffering from the same ills, and responding in the same way as the general dentists.  

                         Chapter 24


                  Do More to Create Win-Win


Providing more Quality is the one side of the coin of the Win/Win relationship.  Giving the patient more than he or she bargained for is allowing him or her to Win. 


Being friendly, caring, loving, doing a better filling, a better crown, a better denture, having fresh flowers and new magazines in your waiting room is allowing your patient to Win.  There are quite literally thousands of little things which one can do to get your patients to Win. 


One of the little things which I stress a lot in my practice is post-operative calls.  I phone or ask my receptionist to call all my patients the day after root canal treatments or other major treatment to enquire about their welfare.  I know this is a tremendous practice builder. Patients appreciate this as a sincere form of caring and validation. 


Something else which I do, which is a tremendous Win for my patients is the emphasis on communication.  It begins with the pre-examination consultation and history taking in my office, continues with the after examination consultation and it culminates in my personal letter to them detailing the diagnosis, treatment plan and cost estimate.  This will be fully discussed in Chapter 25.  In fact, everything in my practice is geared towards letting my patients Win. This is what Jennifer de St Georges calls a "Patient Centred Practice." 


The other side of the coin is getting the dentist to Win as well.  A dentist need to Win very badly.  Dentistry is hard work and the professional lifespan of a dentist is relatively short. Becoming a dentist is an expensive business and practising as one is even more expensive.  The sad fact is that, most certainly in South Africa, I think also in Britain  and maybe in other countries dentists are losing all the time.  For the first nine years of my career as a privately practising dentist I was on the losing side almost every day of my life.  I was doing wonderful dentistry, most of the time, but I was not getting any just reward for my efforts.  It drove me to the verge of bankruptcy and despair.  It was shown in the previous chapter that dentists often respond to this Lose situation by increasing the quantity of their services, by doing even more dentistry.  They sense that their income is slowly diminishing and they decide to work a little harder, maybe one extra afternoon or evening or a Saturday.  And the situation only gets worse.  Their turnover might increase, but so does their overhead costs, tax, stress and anxiety.  The increase in profit, if any is negligible.  So the Lose/Win (that is lose for the dentist and win for the patient) situation continues, until the burnt-out, fed-up dentist begins to resent himself or herself, his or her work and his or her patients.  The quality of his or her work, which has slowly but surely deteriorated because of the harder and faster working, plummets to the point where his patients are also losing.  The patients are suffering more and more painful episodes in the chair, fillings leak, root canal treatments and crowns fail and patients are generally unhappy and they start to leave the practice.  A full blown Lose/Lose situation has developed.


The proper response to the financial and other pressures facing dentists is to Provide more Quality and Less Quantity.  This equates to a Win/Win relationship.  But in my personal experience this only became possible when I added the No Deal proviso.  My relationship with my patients are firmly founded on the principle of Win/Win or No Deal.  I provide the quality, they provide the funding, or else I cannot help them.  My whole practice is geared towards this.  I want my patients to Win, to get the best possible service, only the highest quality.  But this is only possible if they continue paying for all of it.  I am totally dependent on them for my funding and they are totally dependent on me for their dental services.  We are interdependent.  They know it and I know it.


The difficult part was the first step. Making that very first move and taking that decision was the most difficult part.  But I was able to do it, because I trusted God implicitly, with my future.  When I started my second life as a dentist in South Africa in 1992, I took this difficult step and I have never looked back since.  I decided then it was going to be Win/Win or No Deal.  I was going to make this new practice work the way it should or else I would pack up and return to cold and wet England and spend the rest of my life there.  I would accept it as God's will that I should go there and I would not complain.  I came back to South Africa at one of the worst moments in this turbulent country's history.  I came back when many of my compatriots were fleeing.  The economy was almost dead, the political future seemed very bleak, crime was rife and increasing.  And at the time that I came back, I was just beginning to live very comfortably in England.  We had made some very good friends, who to this day are very dear to our hearts.  I was earning a lot of money, more than I would ever earn in South Africa.  I left all this to return to my beloved, troubled fatherland.  And I did it because I trusted God.  He would see me through all this, I was sure.


I was going to put up my cash, private, Win/Win practice, against all the odds and I was going to make it work at all costs or else there would be No Deal.  In the worst scenario the No Deal would have meant returning to a safe and secure England. With this mind I opened my doors to the public.  I did not have one patient.  God sent me the first one and the next and He continues to do so to this day.  Today, four years later, I can look back at the most fruitful years of my life.  My practice has grown out of all proportion.  My patients come from far afield and they all come because they want to Win.  They want Quality service, more than they want it cheap.


And it all started because I had the courage to think No Deal.  It started with the first patient.  I told him, "Sir, I would appreciate it very much if you could settle your account as soon as you leave."  What I meant, but didn't say was, And if you don't want to, then I am not prepared to treat you.  Thank you and goodbye."  I waited for his answer outwardly casually, but with abated breath.  This was the first time in my thirteen years as a dentist that I had actually said this to a patient.  He said, "Sure, no problem."  That settled it.  I could not believe it.  I was fully expecting him to get up and leave and here he accepted my terms and conditions just like that.  I have to shamefully admit that I was astounded.  Today, I can only ask myself, "But you trusted God, didn't you?". And I know now that God is to be trusted in spite of ourselves.  That first patient accepted my No Deal condition and so did hundreds after him. It is true that a few did not. They left my practice to seek treatment elsewhere because they are so deeply brainwashed by the socialist system of free dentistry that it is impossible to create a Win/Win relationship. So it has to be No Deal. 


Dentists in South Africa are desperately scared of their patients rejecting them, leaving their practices and going to the dentist next door, if they, the dentists, just dare to suggest cash payment. I have been told this in countless private conversations.  "But my patients will leave, if I contract out (go private)". "The area in which I practice is a blue collar/ industrial area and the patients are not educated.  They will not pay me."  "The patients are so used to not paying, they will not understand."  "There are so many other dentists in my area, the patients will just go to them if I charge them."  A favourite argument is, "I have such high overhead costs, and I have so many financial commitments to serve (read debt) that I cannot afford to loose patients."  These are the guys who are sailing very close to the wind.  They have huge practices, big houses, many cars, holiday homes, boats, they take many expensive holidays and they generally are big spenders. They are the very ones who need the message of this book most, yet they won't listen.  They work very hard to produce those big turnovers.  They have to because they are not prepared to sacrifice the farm, or the fourth or fifth car or the holiday home or whatever. They know that they are earning a reasonable living by this mass-production - Quantity instead of Quality and they think that their patients will leave them if they changed to a cash system.  And they probably wiil leave, but some won't.  Their whole security is based on these big practices with the thousands of patients and with the massive turnovers squeezed from the medical aid societies or the NHS.  Their livelihoods depend on the continued existence and benevolence of these third parties, or so they think.  Their frames of reference is the amount of money they must generate every month, every week, every day of their lives.  They are truly cost-driven, not value-driven. 


The Bible warns us in very explicit terms against putting our trust in money, that is being cost-driven.  "No servant can serve two masters.  Either he will hate the one and love the other, or he will be devoted to the one and despise the other.   You cannot serve both God and money." (Luke 16:13)  At some point, somewhere, we have to exercise our freedom to choose, our unique human attribute.  Either we are going to trust God or we are going to place our trust in corrupt, manmade systems.  We have the freedom to choose, one of the characteristics which distinguishes us from animals.  But we also have to live with our conscience, that other uniquely human attribute.  We are warned about putting out trust in money, "And He told them this parable: "The ground of a certain rich man produced a good crop.  He thought to himself.  'What shall I do? I have no place to store my crops.'  "Then  he said, 'This is what I'll do.  I will tear down my barns and build bigger ones, and there I will store all my grain and my goods.  And I'll say to myself, "You have plenty of good things laid up for many years. Take life easy; eat, drink and be merry."  "But God said to him, 'You fool! This very night your life will be demanded from you. Then who will get what you have prepared for yourself?'  "This is how it will be with anyone  who stores up things for himself but is not rich towards God." (Luke 12:16-21)


If we would only open our eyes we would see it happening daily around us.  People are losing their lives, their spiritual lives, because they serve money. We are promised, "And do not set your heart on what you will eat or drink; do not worry about it. For the pagan world runs after all such things, and your Father knows that you need them. But seek his kingdom, and these things will be given to you as well." (Luke 12:29-31)  Of course it is a great step to become Independent of the third parties and Interdependent with our patients.  If it was easy, everybody would have done it, and there would be no point in this book.  No, it is a difficult choice to make.  It is a choice only somebody with Security can make.  Some people find their Security in Money, which we have already seen is the wrong way.  But for argument's sake let's consider for a moment a dentist with millions in cash to back him up.  He would have no problem in dictating terms and conditions to his patients.  In fact, if the patients would not come to him, it would not matter at all, he would only be to pleased to do nothing.  So he would be in command, he would even be in a position where he would Win all the time and the patients would Lose all the time. Only he would have no patients eventually.  But this same dentist would also be in a very good position to develop Win/Win with every patient, if he chose to.  So it is easy when you have the money, they say.  True, but we can all have much more than mere money.  God is available, ready and waiting for each one of us.  He is there to guide us.  He is there to provide, only we have to trust in Him. We have got to trust Him to the end. And if this means that we really end up losing every single patient, we still have to trust Him.  This is not a get rich quick scheme or a quick fix recipe for success.  God does not work that way.  Choosing to go the right way, might in the short term, mean giving up the holiday home, the second car, the overseas holidays.  It might necessitate the wife having to work or it might involve some or other sacrifice.  Yes, it might even involve losing everything.  But in the end it will all be worthwhile.  God can and will, in His time, bring deliverance.


For me it involved giving up my practice in South Africa and living and working in England for two years.  It also cost me my share in a holiday farm, which I could no longer afford.  But today I can only rejoice in the Lord.  I have more work than I can comfortably handle and all my patients accept my terms and conditions of payment - cash on delivery.


I found the strength to implement the No Deal option only by trusting God.  I was prepared to risk losing everything.  I was prepared to have all the patients reject me, because I had accepted the Lord as my Saviour and I know that some way or another, He would provide.  And He did, in a great way.  I will end by three anecdotes illustrating the principle of Win/Win and how it had come alive over a period of several years.


Case report 1: The family W

This family was my patients for several years in my old practice.  In the beginning I charged them so-called private fees, without properly informing them of the fact, I might add.  One day mr W rang up and complained quite severely about the fees.  I immediately backed off and relented and said that I would now only charge them the contracted-in fees, which amounted to about a 50 per cent discount.  The relationship continued until I packed up and left for England.  One day, when I had been back in South Africa again, for some time, they phoned up again.  They had heard that I was back and they wanted to see me again.  They came in for treatment, I explained my new financial policy and they quite calmly accepted it and paid me quite happily.  From this point onwards our relationship prospered. I was able to do some wonderful dentistry for them and they never, never complained about my fees again.  I found out much later why not.  One day, Mrs W told Marlena, my receptionist the story of how, since my departure to England they had struggled to get a "good" dentist.  They had been to five or six dentists, each of them apparently suffering from the usual shortcomings.  When they heard I was back they were so glad.  They only realised what I had meant to them when I was gone.  Now they understand why I did and why I charged the way I do.  We have moved through the whole range of relationships during the course of several years.  First it was Win/Lose from their viewpoint.  Then, when I charged less, it became Lose/Win in my view and Win/Win in their view.  Then it changed to Lose/Lose when I was not available and they suffered "poor" dentistry.  Finally it had a happy ending with a true Win/Win situation, from both viewpoints.


Case report 2: Mr G

Mr G was another regular patient of mine in my old practice.  He also seeked me out after my return to South Africa and said how glad he was that "his good dentist was back".  One day he brought his two teenage children to me for routine examinations.  I did the work and he was quite happy to settle his account immediately.  The total amount was in the region of R400. ($120 or £80).  He also told me that the whole family was leaving within a week for an extended overseas holiday.  I knew that mr G was a rich man.  Two months later I received a scribbled note from him, on the back of a payment advice from his medical aid scheme.  They had only paid him R200, about half, for my account.  He wrote in his note that he would no longer come to me, because my fees were too high.  I was a little sad and also a little angry but I accepted it and tried not to think of it anymore.  Two years later, he phoned me again.  He wanted to come and see me again.  I smiled inwardly and said that he was most welcome.  He came in and told me his woeful tale.  Since leaving my practice he had tried out two dentists.  But neither of them could treat him painlessly. One dentist had tried twice, unsuccessfully to anaesthetise his lower teeth.  He lost all confidence in him and he asked very humbly whether I would re-accept him as a patient.  I did and immediately provided him with the treatment he wanted and needed - without pain, but only after giving him a very accurate estimate of the costs involved. I quoted him the very highest fees I could possibly do.  He never blinked an eye.  In fact, he said he considered it a bargain.


Case report 3: Mrs S

Mrs S, a young very likeable, friendly lady, known to my family, came to see me with an accute toothache one day.  I did an emergency root canal treatment and gave her a written quotation for a root canal treatment and crown.  I then dismissed her.  A few days later she phoned up to say that her toothache was gone and that she was very happy with the way we treated her, but sadly, she could not afford to come to me for the rest of the treatment.  Because she was well known to the family, and especially friendly with my children, and she was such a likeable person, I felt very sad that I had lost her.  I asked myself whether I did the right thing by quoting her such high fees.


Then, two months later, a remarkable thing happened. She referred a patient to me.  I was very interested to find out what was behind this.  The patient was a three year old boy.  I listened to the parents. The father said that he and his wife were friends of mrs S and that she had said that I was such a good dentist, even though I was so expensive, but he did not mind the money.  He only wanted the best possible dentistry for his three year old son.  He volunteered all this information without me even having to ask  one question.  He practically told me that I could charge whatever I wanted, he didn't mind. Imagine now for a moment the bliss of such a situation.  Of having a practice consisting of patients who feel this way.  This patient came my way, because I lost mrs S on the No Deal basis. The parents were seeking the best dentist and I think they would have been even a little disappointed if it came to them cheaply.  I think they wanted to pay a lot of money.  People are like that.  They think if it is expensive, it must be good.  We all know it is true.  People pay exorbitant prices for clothes, food, perfume, cars and all kinds of goods and they believe it is top quality, just because of the price tag.  This principle also works in dentistry.  People think I am good, because I am expensive. It is a notion that I am not going to actively discourage, but I realise that it is also a temptation to abuse this explicit trust placed in my capabilities.  When somebody gives you a virtual blank cheque by making statements like those made by this patient's father, it is a real and true test of character.  In a case like this, a dentist has a free rein to do and charge whatever he wants. The patient is expressing his trust in a most profound way.  There is no greater example of a win situation for a dentist.  The way this trust is honoured or abused is a matter for the conscience of the dentist.


Personally, I experience situations like these as very humbling.  I know full well all my limitations and I know and understand how much these people need and want somebody whom they can trust.  And I know the magnitude of the responsibility that this places on me.  I react to this in the only way I know - By DOING MORE.  I know I have the power to react by charging whatever I want, by actually abusing the trust. And I have worked very hard over many years to be in this position.  But I know to Whom I owe it all and I can never disappoint Him.  So I react to a situation like this by doing even more than I have ever done.  I really try and give this patient the best possible service that is humanly possible and by DOING MORE, WIN/WIN is once again created. 


The story of mrs S has a beautiful ending.  I sent her a box of chocolates and a little card thanking her for the referral. She phoned me to thank me, for the chocolates and she was almost in tears.  She had never been appreciated in this way, she said.  Subsequent to this, she has referred many more patients to me. 


                         Chapter 25


                  Inform before you perform


I have borrowed this phrase from the famous consultant Jennifer de St Georges.  She stresses it in all her lectures, "Inform before you perform, no surprises."  Patients do not like surprises, especially when it comes to matters such as fees. Somebody else said, "An account should only be a confirmation of that what the patient already knows." Doctors and dentists have always been loathe to discuss fees.  In earlier times it was considered positively rude to ask a professional man, especially a doctor or dentist about his fees.  It was just not done.  The professional man was seen as some sort of super human, almost a deity and the whole community stood in awe of this man with his very special skills.  This worked well in older times - for a few reasons. Firstly, in a previous era, professional people behaved as they should, like professional people.  Doctors did house calls, dentists provided only a very basic service but they did so effectively.  Obviously this wasn't true for everybody but as a general rule it can be said that doctors and dentists had more time to spend on their patients. Secondly, the public was less well-informed in years gone by and they were overawed by the professionals.  So in one sense maybe the professionals earned some of the public's respect and in another sense they obtained this respect by the fact that the public was less knowledgeable than they themselves.


Because of all this respect for the professionals, trust was implicit in any doctor patient relationship.  "Trust me, I'm a doctor" is perhaps a joke today but many years ago people did actually trust doctors, just because of the title.  And because of all that trust, it was inconceivable to question a doctor's account. Whatever he charged, you paid.


And it was also a little easier in the old days. Dentists and doctors did not have all of today's high tech.  Dentistry and medicine were relatively simple and inexpensive.  There were no expensive gadgetry and gimmicks.


All this has changed in our wonderful, modern, materialistic world.  People don't trust doctors just because they are doctors, anymore.  Patients are a lot better informed and we must thank the media for it.  News travels ever faster.  Horror stories about unscrupulous or errant doctors spread like wildfire.  And a few visits to the dentist can actually bankrupt an unsuspecting patient.  Dentistry and medicine, with all its high tech wizardry, have become almost unbearably expensive.  It is very, very expensive just to run a small, basic dental practice.  So, while we have inherited a reluctance to discuss our fees, we are in a position where we have no choice but to do so. Patients want to know.  Patients are scared of dentists for two reasons - pain and money.  But they are more scared of not being in the know, of not knowing how much, than they are scared of actually paying.  Like all purchases, they soon become used to the price and they just accept it.  But they just want to know.  And we have to tell them.


Incidentally, informing before performing is the logos part of the  Greek philosophy - Ethos, Pathos and Logos.  (See Chapter 16)  Ethos means character, implying that no meaningful relationship is possible without a sound character - on both sides.  Pathos is the feelings, the empathy shown to our patients.  We first have to master this before we can proceed. We do this by being "Close to the Customer" and very importantly by "Listening".


Once we have proven our Pathos, then only is it in order to proceed to the Logos.  Now the patient will listen to our logic.  Once we have shown that we care (Pathos) the patient will accept our Logos.


There is no reference either in ISOE or 7 Habits to anything which is even remotely connected to the idea of "Inform before you perform", yet I consider it to be a major cornerstone of any successful dental practice.  It seems almost odd and it is odd.  Yet, the explanation is simple.  All businesses, non-dental and non-medical businesses, operate on this principle anyway. All business is conducted on the basis of both parties being fully informed about the nature and the costs of the transactions.  The whole advertising industry is geared towards informing any potential customers. All sales techniques revolve around informing the customer about the benefits of his or her purchase.  Yet many dentists and doctors are still very reluctant to do it.  They just want to treat diseases, they don't want to talk about it and most definitely they do not want to talk about the fees involved.  That does not befit their status.  How wrong they are!


It is becoming increasingly important to obtain "informed, legal consent" before treating patients.  It is fast becoming a legal requirement to inform a patient of all the advantages, disadvantages, risks, complications, costs and alternatives before treating any condition.  In other words, a dentist may have to discuss with a patient gold, amalgam, composite and porcelain before doing any single restoration.  Dentists view this as a threat.  I see this as a wonderful opportunity.  I love to talk to my patients about the benefits, the disadvantages, the complications and the costs.  I use this opportunity to show them once again that I care, not only about their teeth, but also about their feelings.  I show them that I value their opinion, that I respect their fears and concerns and that most of all I only want to treat them the way they want to be treated.  This need not take a long time.  It can be done in a few sentences, "Gold will last longest but it is also expensive - around R1 500 and obviously not tooth coloured.  Silver amalgam is cheaper, around R150, and it will last for a very long time, but it is positively ugly.  Resin is tooth coloured, costs around R250 but it will last only a few years, but porcelain, also tooth coloured, will last much longer, and it costs the same as gold.  With all these materials it is possible that we might have some sensitivity afterwards and in a very small percentage of cases this sensitivity might necessitate even drastic treatment."


In these few sentences is conveyed a whole mass of information.  It takes a few seconds to say it and it is very easy to write it down and to even give it to a patient.  They appreciate it very much.


The above is a very simple example but the idea can be extended to some of our most complicated treatment procedures such as implants versus conventional bridges versus acid etch bridges versus precision attachment, removable partial dentures.  The advantages, disadvantages, costs, risks and complications of each should be discussed, in simple layman's terms.  The law now requires this of us.  The law now forces us to do what should have come naturally to us.  All laws do that.  Laws have the intention to make people comply with what society sees as fair and just.  Is it not fair and just for the patient to have his wishes and desires respected? Is it not fair and just to want to be informed?  In dentistry, especially of the costs?  Of course it is fair and just to do all these things.  By informing a patient of all the above, a dentist also affirms his own character (ethos) and feelings (pathos) towards his patients.  A beneficial cycle of ethos, pathos and logos develops.  The more the dentist shows how much he cares for his patient's total well-being, the higher the emotional bank account and the more trust develops.


The dentist should also, honestly, care for his patient's financial well-being.  Therefore, the patient should be given the choice to select also the least expensive treatment plan, with the same, if not more vigour, enthusiasm and skill than he would have tackled an expensive treatment plan.


In the American capitalist society it is considered normal practice to go all out for selling the most expensive dentistry. The hard sell approach is accepted. Personally, I frown somewhat on this behaviour.  The most expensive is not necessarily the best for the patient.  Generally speaking, the most expensive dental treatments are those consisting of periodontal surgery and multiple crowns and bridges, with or without implant support.


This is difficult, (for operator and patient alike) expensive, aggressive, traumatic, invasive and irreversible treatment.  The maintenance of these cases is also very difficult and a very high degree of patient co-operation is needed.  Normally the patients stop this co-operation after a few years and then these cases start to fall apart.  The dentists then can only shrug their shoulders and say, "Such is life, people won't listen."


The issue here is, are these patients being fully informed of all the above  pitfalls? The cost, the pain, the risks and especially the irreversible nature of the treatment.  I would hazard a guess that they are deliberately not fully informed. 


There is very often, but not always, a compromise treatment possible.  When a compromise is what the patient, our customer, really wants, is that not the true, real, ideal, treatment plan?  Just because a treatment is more expensive, does not imply that it is the best.


It is impossible to know what a patient wants if we do not listen to him or her.  And a patient cannot make an intelligent, informed decision, without being informed.


So how then must we inform our patients?  How is it done exactly?  Firstly, the information game is an education game, an endless game.


I am often amazed at my own shortcomings when I see how miserably I personally sometimes still fail to communicate dentistry to my patients.  One of the reasons that we all fail to get our messages across is the fact that the patients do not listen to us.  They are often as much to blame as ourselves.  But that does not help to conveniently accept it as such.  We have only one option.  We have got to make them listen.  How then do we do it?


     Firstly by creating a listening environment 

     Secondly by using more pictures than words

     Thirdly by repitition, including the written word.

But all of this is still impossible without ethos, without genuine concern for the patient's well-being.


1.   Creating a listening environment


A dental surgery or operatory room or treatment room is not conducive to effective communication.  It is in fact everything, a good listening environment should not be. Yet, this is the very place that dentists use to talk to their patients.  It is a small wonder that any form of communication does take place in this environment.  A dental surgery is a clinical room, it is relatively small, there are many intimidating instruments, sounds and smells present and the whole place is just altogether consumer unfriendly.  It is also the place where a dentist just cannot resist getting his hands into the patient's mouth, and then talk to them.  How the patients hate this, yet we all continue doing it.


This room is definitely not the place to talk to a patient, to inform him or her of any proposed treatment.  It was mentioned elsewhere that I designed my practice with the whole idea of communication uppermost in my mind.  I just had to create the perfect environment for communication, that is for listening to and for informing my patients.


This place is my private office.  It is the place where I communicate with my patients. This office is a totally non-dental environment.  There are no sharp lights, dental instruments or dental materials lying around.  This is where I first meet my patient and this is where I present the findings of my examination to the patient and where I set out my treatment plan to the patient.  I have already described how I listen to the patient in this office (see chapter 22) Sometimes, if I sense severe apprehension about fees, I will inform the patient before we enter the surgery, of the cost of the examination and radiographs, and I tell them that after I had done this, I will be better able to inform them of the further cost of treatment.


This private office is decorated very ordinarily. Furniture consists of a desk and three chairs, one behind the desk where I sit at the initial meeting and consultation. On the one wall are three shelves full of dental books and on the other wall hang all my certificates.  Both these walls are deliberately intended to send out a message.  It is my little bit of internal marketing and my subtle way of telling the patients just how good I am!  On the one side I also have a table with all my educational toys, booklets and flip charts, which will be described below under the heading "Use more pictures, less words."


My office looks like a doctor or a lawyer's office. It definitely does not look like the place patients expect to meet a dentist.  I believe at least 50 per cent of my success lies in patients being totally surprised at what they see when they first meet me.  Everything is different.  My practice is located outside town, on what may be called a small farm.  I do not wear the traditional white clothes of a dentist, but a neat shirt and tie. And I meet my patients in this friendly office.  It is a very strict rule in my practice that I shall never be disturbed while consulting with a patient in this office.  I never take phone calls and I never leave the company of a patient, for no reason whatsoever.


I have also mentioned that I try to keep this office as neat as possible, which with all my writing activity is difficult, yet at the very least the surface of my desk will be absolutely clear.  Even the presence of a small piece of paper with a name or telephone number scribbled onto it might convey a message to the patient that I have something else but their interests on my  mind.


I always first meet my patients in this office, talk and listen to them, then go into the surgery, put on my white coat, mask and gloves, do my examination and radiographs, remove the coat, mask and gloves and then return to the office where we sit down again in this relaxed non-threatening, non-intimidating environment and now I can start informing the patient. Sometimes at this stage I will sit not behind the desk, but I will sit with the patient on the same side of the desk, giving the silent message of working together on a solution to a problem.  Now is the time to discuss the diagnosis and treatment plan with both parties seated comfortably, on equal footing so to speak, looking each other in the eyes without the interferences of instruments, sights, sounds and smells peculiar to a dentist, not to mention the strange and uncomfortable reclined position of the patient with the dentist towering from above.  The rest is easy.  I just tell the patient in plain and simple terms what is wrong and what can be done to rectify the situation.  And what it will cost.


I hasten to admit that I do also talk to my patients inside the surgery.   I make use of an ordinary mirror to show them what is wrong in their mouths but I make quite sure that the critical issues - money in most instances - are discussed in the office -not in the surgery.  Informing patients of financial arrangements is one of the functions which all dentists would love to delegate, yet it is a practice which should not be encouraged.  If the patients hear it from the dentist, they believe it and adhere to it.  Many patients bluff their way around front office staff and they make the lives of these staff members miserable by manipulating them.  Patients respect a dentist who shows that he or she has principles or values.  People stand in awe of rules and policies and for fear of embarassment will go out of their way, just to comply.  But they must be informed of the rules.  And the best person to do it is the dentist.  I believe that it is better to concentrate on the solutions rather than the problems.  People do not like to hear that they are ill, they prefer to be told that they are going to be healed.  So it is better to say, "We are going to do five fillings" rather than "You have five cavities."


It is important to work sparingly with words. Most people have very short attention spans.  And most people prefer talking to listening.  So it is better to listen than to talk.  But we have to inform and so we have to talk.  But we should always aim not to bore our patients with all our talking.  We have very little room for manoeuvering and we have to be direct and to the point, yet remaining extremely courteous, kind and friendly all the time. 


When we talk to patients we must use non-dental terminology.  We must use words such as fillings and caps instead of restorations and crowns.  We must be very careful not to confuse and bore our patients with our techical terms.


Our dilemma is that we have to live with this two-edged sword.  On the one hand we must inform, but if we do this well, we run the risk of boring our patients and losing their attention.  On the other hand we must listen to them, because that is what they want more than anything else, but listening is not informing and vice versa.


There is no secret short cut recipe for success. Conversation skills can not be learnt from a book.  It takes dedicated practice.  But there is one little bit of advice which is invaluable.  Communication becomes instantly easier and simpler when there is genuine ethos - concern, love and empathy - for the other party - in our case the patient.  If a dentist really cares for a patient's best interests he will automatically listen to hear what it is that the patient wants.  And when he, the dentist talks, his words will be a genuine expression of this concern and love.  Stephen Covey makes the point very early in 7 Habits that the artificial Personality Ethic of the last fifty years, is flawed in that it tried to teach people how to manipulate their own and other people's behaviours by tricks and gimmicks.  This stands in stark contrast to the Character Ethic, the age old value system of ethos, whereby people are what they really are, not what they pretend to be.


Therefore it is futile to try and teach people how to have a normal conversation.  It is something which should come naturally.  And it does this - for people of character.  Patients do not care for fancy words or slick sentences, especially not in dentistry.  The very nature of dental treatment is such that patients sooner or later find out that they have been conned.  It is easy for dentists to con patients initially, but the truth has a way of catching up.


Someone once said, if you always speak the truth, you don't need a good memory.  This is also true for dentistry.  You can fool a patient in the beginning but you had better remember every word you said, because if you had lied or manipulated your patient, the truth will come back to haunt you.


If a dentist is really and truely honest in his intentions, the patients will sense it and they will act and behave accordingly. If a dentist proves to a patient that his concern is for their interests, they will accept everything he says and they will follow his advice.  There is no need for glamouristic word skills and catch phrases. Just be honest and tell the truth.


2.   Use more pictures and less words


When I started out in my first practice, many years ago, on the road to educating my patients and marketing my services, I began by writing my own informational booklets on subjects such as overlay dentures, periodontal disease and orthodontics.  Writing is my game and so I wrote long dissertations, explaining to my patients the whole, boring story.  Fortunately I also illustrated these booklets with photographs and sketches. Slowly, over the years I have learnt that people are not interested in reading this material.  I have also learnt that they find it hard to listen to me reciting it all to them.  But they really enjoy the pictures.


As a lecturer I know it is true also for professional people like dentists.  Give them a good picture, almost any picture, and they will be interested.  But don't bore them with a long story.


So, I gradually developed my own photo album of before and after photographs.  It does not need to be the best kind of dentistry,  but it must have visual impact.  My album shows not only crowns, but also very simple things like a class 1 amalgam changed to a class 1 composite restoration.  It also shows a little bit of cosmetic contouring and closing diastemas with composite.  I believe this to be my most powerful educational instrument.  It does not matter that the patient looking at it needs some other or different procedure to that illustrated.  It matters more that the patient wants the same kind of dentistry, meaning the same level of quality.


Obviously it is better if the patient wants and needs exactly the same dental procedure which is illustrated but it is not a major obstacle if the treatment is different.  What is important to illustrate to the patient is the dentist's technical abilities, prowess and expertise.  It is not even so important that the work shown be the dentist's own. What is important is to show the patient what dentistry can do for them.  Therefore it is all right to use other dentists' photographs, with their permission.


It is extremely important to realise that patients generally do not want to see the treatment in process.  They definitely do not want to see blood, decay, surgery or teeth being prepared.  Patients only want to see the before and after photographs, not the in between ones. This is very true for implant surgery, root canals and periodontal surgery.  These are equated with pain and fear.  Our first aim in everything we do is to minimise pain and fear, and we know that the expectation of pain and fear does in fact cause perceived or even real pain and fear.  Therefore it is very undesirable to actually show something to a patient that might induce these emotions.  Exceptions to the rule might be treatment like bleaching or acid etch bridges, which involve no pain anyway.  In my practice I also collected and made all kinds of models of teeth, crowns and restorations and I use them occasionally, but I know that they have only limited educational value.  The best instrument is the before and after album.  All that is needed is before and after photographs of amalgam, composite, porcelain and gold restorations, several crown types, a bridge, a few veneers and some periodontal treatment cases.


Very recently I have expanded the idea of the before and after album to a slide projector with the appropriate slides.  I find that slides, displayed on a screen, gets and holds the attention of the onlooker even better.


There is one particular instance in which I do actually communicate a lot inside the dental surgery.  This is where I will be changing a patient's smile by means of crowns or veneers.  I first listen to the patient, in my office.  And I listen with the very sincere intent of actually hearing what they want.  Do they want the teeth longer or shorter, more or less protruding, whiter or less so, wider or narrower, straighter or less so, bulkier or smaller or whatever. And then I try and give them what they want, in a reversible way.  When there are gaps or slightly chipped or fractured edges present and the patient is concerned with this, I will build these defects up with composite without any etching or preparation.  I will just mould the teeth to the desired shape with the aid of a little bit of composite material and a flat, plastic instrument.  I then show the patient the result in a wall mirror and ask them about their opinion.  When this technique is employed successfully it is very gratifying, both to the patient and the dentist and normally the patient cannot wait to start with the real treatment.  These bits and pieces of composite are very easily removed and the patient is then left with very clear before and after mental pictures of their smiles.


Sometimes this communication process has to be carried out in the form of temporary crowns.  It might even involve multiple visits but the golden rule is to never start fabrication of the final crowns before the patient is fully satisfied with the temporary crowns.  I will continually change the temporary crowns until the patient expresses full satisfaction at least at the size, shape and arrangement of the temporary crowns.


One of the most rewarding exercises is to change the shape and size of overly large porcelain crowns.  Many dentists fall into the trap of making crowns with labially protruding incisal edges, instead of the incisal edges curving back lingually. Patients sense this with their sensitive lips and they perceive the crowns as being too long or too bulky. They have difficulty in clearly expressing what it is that bothers them.  They just know that something is not right.  It is very easy to take a diamond bur and slice the incisal edges back to size and shape.  It is then wonderful when they react by saying, "That's much better."


So, it is impossible to carry out all communication in the private office and some of it has to be carried out inside the surgery.


3.   Communication by repetition, including the written word

In spite of the very best efforts, communication with patients regularly fails.  The critical issues in dentistry are just so technically complicated that it is extremely difficult to get the message across.  It is only with a really decent sense of humour that one can battle on and continue the struggle.  I have personally experienced it many times that patients ask me things which I know that I have told them several times.  The mass of information which we try to convey is perhaps too much.  Or perhaps the issue of fear is so great and all pervading that it clouds all rational thinking.  Be that as it may, we just have to live with it that patients are sometimes very slow to really understand what is going to happen next.  Therefore we have to repeat ourselves, "Good morning, as we discussed last time, today I will treat the infection at the root of the lower tooth.  The first step will be to really numb the tooth, and I promise that we will not start before everything is really numb."  At the end of the treatment repeat the message again, "Right, that took care of the treatment of the infection in the root.  Next time we can do the impression for the crown." 


One of the best ways to show Excellence and Effectiveness is to confirm everything in writing.  Every patient of mine receives a personalised, written quotation which takes on the form of a friendly letter.  A few examples are shown in Appendix A.  Perhaps my original intent with these letters was an overreactive attempt at compensating for my earlier failures in communicating with my patients. Perhaps it is not really necessary, but I am too scared to stop writing them.  I know that something that I am doing is working and therefore I will continue doing it all, including the tedious task of writing these letters.


I begin all my letters with the phrase, "Thank you very much for the trust you have placed in me.  I consider it an honour but also a great responsibility to be your dentist."  These are two very powerful sentences conveying some very important messages. The first sentence states the fact that the patient had placed trust in me.  And I thank him or her for it.  People like to be thanked.  They also believe what they read.  With the first sentence I confirm and affirm one very important point, their trust in me. That is what it is all about. Trust.  If a patient trusts a doctor he will go to him and if not, he won't. It is that simple.  By putting it down in writing, I am making a bold and positive statement.  They came to me because they had some trust in me.  I am merely stating the obvious and in doing so I am watering the seed of trust.   The second sentence immediately gives the patient two very good reasons for putting that trust in me.  Firstly I am saying that it is an honour to have him or her as a patient.  It is an expression of appreciation.  People like to be appreciated and they should be appreciated.  After all, they are the ones who finance our very existence.  Secondly, by stating that it is also a great responsibility to be their dentist I am telling them that I care for them and that I am deadly serious about their teeth in particular and my work in general.


What follows in these letters are usually the diagnosis and suggested treatment plan.  I begin this with another standard sentence, "I confirm that I carried out a comprehensive examination of your mouth and that I found the following:"  With this sentence I once again affirm the thoroughness and completeness of my examination.  I need to do this, because I need to subtly remind the patient of this detailed examination, whilst he or she is reading this letter, in the comfort of their homes. The letter contains all the "bad news", so to speak, so I have to do everything in my power to put it in a better light.  I need to sell my services, so I need to remind the patient of the quality of these services.  After this sentence I give the diagnosis in layman's terms. (See the examples at the end of this chapter) And then I give the proposed treatment plan with the estimated costs in brackets.  I do not like to give complete itemised breakdowns of the costs.  For instance I do not wish to give quotations for infection control, local anaesthetic, root canal treatment, post and crown separately. I will give one fee to include all the treatment.  I prefer this because I do not wish to enter into a debate or argument with a patient about relatively trivial matters.


I know very well that there are many eyes that read these letters of mine.  I know that these letters get shown to husbands, wives, other dentists and friends. I know that patients even use these letters to shop around and to compare prices.  I do not want to make it too easy to compare my fees with others. But from time to time I do give detailed quotations (See example of letter to mr Smith).  I take great pride in these letters.  I do not mind who reads them.  In fact, I like it very much when other people, especially dentists, read them. I know what they think, "Gee, this guy is expensive! And he has the audacity to even demand cash payment.  I wonder how he does it."


A dentist might try and undercut my fees and they actually do this often.  But I know that it places a tremendous burden on these dentists to provide, at a cheaper price, the same quality service.  Very often they fail to do this, the patient becomes dissatisfied and he is compelled to return to me.  Normally the second time around they don't argue the fees.  Experience is a wonderful teacher.


Obviously these letters carry with them a lot of legal weight, cutting both ways.  I place myself at risk, because I make certain written promises.  But I also indemnify myself from certain complications, because I have forewarned or informed the patient beforehand.  Once again I do not mind the risks I impose on myself.  These letters become part of my conscience and they raise even further my sense of responsibility towards my patients.  If I had written it, then so be it.  If I had promised it, I have to keep the promise.  It forces me and reminds me to consider very carefully every single word that I wrote.  Therefore I do better examinations, take better radiographs, study them better, consider everything better before I write it down.  I spend a lot of time diagnosing and planning, therefore I make fewer mistakes.  Equally, I spend more time actually performing the treatment and as a result I make even fewer mistakes.


By accepting and understanding the full extent of my responsibility towards my patients I have improved the quality of my dentistry tremendously.  And when I still err, I step in quickly to rectify the matter - for my own account. 


Writing these letters have maybe done more for me than for my patients.  Merely writing and mailing these letters do not constitute in itself effective communication.  Some patients do not even bother to read them or they quickly read it and then forget it. Therefore I test the patient's knowledge of the contents by asking innocent little questions or by making a small statement.  I would ask, "You know that we first have to do the root canal treatment?" or "You are aware of the cost of the crown?"  If, by closely watching the patient's reaction, I surmise that he or she does not really fully understand and know everything I will take time again to explain matters. 


Finally, effective communication can not be achieved by a certain dogma, rules or a secret recipe.  Essentially, communication is a meeting of two minds. It is a magical process. What works for the one will not necessarily have the same effect  on the other.  There is no step by step guide.  Communication to be effective needs to be customized to the individual.  There is only one common thread which can guide us - Love, good old fashioned christian love for the other party.  And the Bible teaches us all about it.

                     Examples of letters


Dear mr Smith                               21 February 1996


Thank you very much for the trust you have placed in me. I consider it an honour, but also a great responsibility to treat you.


I confirm that I have carried out a comprehensive examination of your mouth on 15 February 1996 and that I diagnosed the following conditions in your mouth:

1.   You are suffering from moderate periodontitis, that is gum      disease.  This can be directly ascribed to the presence of       plaque on the teeth around the edges of the gum. Your gums       are so sensitive that I cannot even do a proper examination      of the gums.

2.   There are 8 fillings in your mouth, on the necks of the         teeth, which are very, very rough and discoloured. These       fillings contribute very much to the plaque and gum problem.

3.   There are five other lesions on your teeth which can be         termed as cavities.

4.   Your lower wisdom tooth has grown out of its socket;            it is totally inaccessible and permanently covered in          plaque.


You need the following treatment:

1.   Your teeth need to be properly cleaned.  This will involve       a so called deep scaling procedure.  It is not physically       possible to even probe the gums, let alone clean underneath       them, without effective anaesthesia.

2.   You need thirteen fillings

3.   We need to remove your wisdom tooth


It is apparent that it is very difficult to work in your mouth.  Your jaw muscles tire easily and it is hard to get access to all the back teeth.  I suggest that we do all the work during one appointment, under general anaesthesia.  This will be done in hospital.


But, very importantly, once we have got everything (teeth and gums) back into shape, we must see you every three or four months for a quick (20 minutes) cleaning of your teeth.  By doing this we will prevent massive build-up of plaque - plaque which needs long appointments to remove and which also causes cavities and gum disease which is difficult to treat.


So the best course of action is to clear your mouth of all disease and then to institute a regular programme of maintenance. These short cleaning visits to my oral hygienist will be at least tolerable if not pleasant.


Find enclosed a cost estimate for the proposed treatment plan.




dr Koos Marais

              Cost Estimate for mr Derek Smith



13 Fillings:                  8343                R 154

                              8353                R 164

                              8352                R 128

                         3x   8351                R 282

                         6x   8367                R 708

                              8341                R  84

Extraction:                   8201                R  77

Deep cleaning:          4x    8182                R1284

Miscellaneous:          4x   8304                R 248

                              8139                R 127       


                      Financial policy


We request all our patients very courteously to settle all fees upon completion of treatment.  Payment can be made in cash, by cheque or credit card.  A specified account and receipt is issued and this should be submitted to your medical aid without delay, so that you can be reimbursed promptly.







Dear George and Sonia                        31 January 1996


Thank you very much for the trust you have placed in me. I have always considered it an honour but also a great responsibility to be your dentist.  It was very pleasant, even a little emotionally so, to see you again after all these years.


I am very happy with Nicolette's teeth.  Pity about the one cavity though.


As far as Sonia's teeth are concerned I found five crowns to be leaking and four teeth needing fillings.  Of this I have already informed you.  And then, alas, the x rays which I took showed two areas of infection at the roots.  This means that these teeth need root canal treatments.  One of these is not yet crowned and will then also need to be crowned - because of the root canal treatment.


I suggest the following treatment plan:



Three crowns, two root canal treatments, four fillings, and cleaning of the teeth.  The total cost will be ±R6 900.


Re-examination, cleaning of the teeth and five crowns. At the time we will provide you with a quotation.


Fortunately, the 1996 treatment is mostly on the lower teeth and the 1997 treatment is exclusively on the upper teeth.  This will help us to minimize the number of appointments as well as the number of injections.  The one root canal treatment which I have to do is in the upper jaw and this will unfortunately have to be done this year and it might involve an extra visit.


                      Financial policy

We request all our patients very courteously to settle all fees upon completion of treatment.  Payment can be made in cash, by cheque or credit card.  A specified account and receipt is issued and this should be submitted to your medical aid without delay, so that you can be reimbursed promptly!


I hope you understand everything but if you require more information please do not hesitate to contact me. 


Once again thank you for your co-operation and support.


Yours sincerely










Dear dr K                                       17.01.96


Thank you very much for the trust you have placed in me. I consider it an honour but also a great responsibility to be your dentist.


I wish to confirm that I carried out an examination of your mouth on the 8th of January 1996 and that this was supplemented by a full mouth set of x-rays on the 15th of January.


I found the following:

1.  There is widespread gum disease in your mouth.  On the x-ray there is already definite evidence of loss of bone.  If this is allowed to continue then you will eventually lose your teeth.


2.  On X ray I found a big cavity on your second upper left molar tooth.  Apparently you have been suffering from toothache in this region.


3.  Your upper right second molar tooth's filling is leaking badly.


4.  There are thirteen teeth of which the necks are either badly abraded by overenthusiastic brushing or the necks have already been restored, but the fillings are very rough - leading to further gum disease.


For the sake of carrying out the treatment in as few as possible visits and without having to inject the same area three or four times, I suggest that I treat your mouth quadrant by quadrant.  By quadrant I mean that we treat on one day, for instance the the upper right hand side, on the other day the upper left hand side and so on.


You need the following treatment.


1.  Root canal treatment and crown - upper left second molar.

    (±R 2500,00).


2.  Crown upper right second molar.( ± R 1400,00).


3.  Thirteen fillings (± R 120,00 each).


4.  Deep scaling and curettage of the teeth and gums(± R 1200,00).


We have already carried out an initial scaling and polishing.  The importance of proper brushing and flossing is of the utmost importance. Without it there is no sense in doing any kind of treatment.


                      Financial policy


We request all our patients very courteously to settle all fees upon completion of treatment.  Payment can be made in cash, by cheque or credit card.  A specified account and receipt is issued and this should be submitted to your medical aid without delay, so that you can be reimbursed promptly.


I hope everything is clear, but if you have any questions, please do not hesitate to ask.


Once again thank you for your kind co-operation.


Yours sincerely.








dr Koos Marais.


                         Chapter 26



                Be an Independent Entrepeneur


A highly Effective and Excellent dentist can only exist and thrive when he or she is independent and free to practise the art of dentistry without outside interference.


Dentistry is an extremely stressful and difficult profession, yet to the outsider it seems to be exactly the opposite.  The public image of a dentist is that of a smiling, relaxed, cheerful and even rich individual, without a care in the world. All dentists know how important it is to project just such an image, without the rich part, to our patients. We have to appear cool, calm and collected, all the time, every practising day of our lives.  The surest way to terminate an appointment is to tell a patient that you are not feeling too well or a little tired.  I find it quite interesting when patients enquire very seriously about my well being before an appointment.  I know then just how scared they are.  People project their fears and anxieties on those close to them, so we have to act calm all the time, even if we are feeling downright poor.  At the very same time we are having our scared patient's fears being projected on us. And we still have to stay friendly, calm, collected and also do some very difficult high tech dentistry in a dark, wet and hostile environment.


Yes, dentistry has more than enough stress as it is. We don't need more, we need less. Third parties create stress.  They also create dishonesty, overservicing and underservicing, all practices which create even more stress.


I do not believe it is possible to be Effective and Excellent when practising under the sword of the third parties, the medical aid schemes in South Africa, the National Health Service in Brittain or the Insurers in the USA.  These systems stifle creativity, they dehumanise patients and they make money driven machines out of people who are supposed to be professionals dedicated to the service of mankind.  This argument can be expanded to include the regulation of fees by whatever means. Dentists often ask me what list or schedule of fees I use - strictly the one or strictly the other.  I find it difficult to answer this question because my mind does not work that way: I do not adjust the quality of my work to a certain fee, I adjust the fee according to the quality of my work.  So, because mostly I do very high quality work, I tend to quote and charge accordingly, that is in South Africa according to the National Schedule of Fees as published by the Dental Association of South Africa.  But I might even charge higher, or lower.  I do a lot of charity work also, at much lower fees, when I think the case warrants it.  Because I have more than enough patients.  I do not need to attract patients by means of low fees.  I admit that it is a very comfortable position to be in but I must point out that it did not come easily.  It still does not.


Many young and also older dentists argue that in their area it is too difficult.  They cannot work outside the third parties, they say.  Their monthly overhead costs are just too high, they have to reach that target.  They fail to understand that people are prepared to pay for anything, provided it is worth the price.  These dentists have been so brainwashed by the system that they think opting out of the system, immediately forces them into another system.  They reason that they have to change from the bad system into a new system overnight.  This need not be so.  In my case, I started my practice with a new set of values and principles, fresh from nothing.  I had just returned from two years in Britain and I opened up a brand new practice. From the beginning I worked on a cash basis, as an Independent Entrepeneur, with no exceptions.  It worked well for me and it still does.


But I also accept that it is not so easy to transform an existing practice overnight into a practice such as mine.  All patients do not accept such a change easily and many will leave a practice when told that ".....from Monday, 1 st March, all treatments will have to be paid for upon completion of treatment."


Such a bold move needs a lot of security.  A small financial fortune is a comfortable base from which to take such a step, but I found my security in the Lord, Jesus Christ.  "His divine power has given us everything we need for life and godliness through our knowledge of Him who called us by his own glory and goodness. Through these he has given us his very great and precious promises, so that through them you participate in the divine nature and escape the corruption in the world caused by evil desires." (2 Peter 1: 3-4)


I battled with my conscience for years about the issue until I finally realised and accepted it as a fact that I cannot practise dentistry the way I think I should, or rather the way I believe the Lord wants me, within the system.  So I took the steps required of me boldly and without looking back.


But I know that many dentists will be afraid to make such a bold move.  I therefore suggest that it be done in several well-planned steps.  Start out by demanding that all laboratory fees be paid in cash before the work is completed.  Laboratory fees run into tens of thousands of rands in many practices and when these fees are not collected, it hurts very much.  Most patients will understand such a request.  Some won't and will leave the practice, but that is the price one has to pay.  It is better to lose the potential turnover of say R10 000 and in the process save the non payment of a R500 laboratory account.  With the very low profit margin of a dental practice the worst thing that can happen is when a laboratory account does not get paid.  It takes a lot of work before such a loss is made up. In fact, it can never be made up, but it takes a lot of time and effort before the dentist is back to the financial position in which he was before he had done the work for which he was not paid. 


The second stage might be to decide to insist upon cash payment for all crown- and bridgework, not only for the laboratory fees, but for the professional, clinical fees as well.


Later on this can be extended to include root canal treatments and still later on all fillings.


It is a good idea to keep all fees for consultations, radiographs and oral hygiene procedures on a third party basis until the final stages of the practice's conversion.  These items are the most cost effective procedures and at the same time the ones which patients resent most paying for.   This conversion process should be well planned and staggered over a period.  The period should be decided upon beforehand.


Example of schedule of practice conversion

January - cash payment for all laboratory fees.

April - cash payment for all crown- and bridgework.

October - cash payment for all restorations.

June (following year) - cash payment for all services.


The dentist must preplan the process and then he or she must stick to the plan.  The patients must not be informed of the total plan.  They must be gradually educated and they must perceive it as a series of occurrences, a few changes in policy.  When it happens like this it gives the dentist the opportunity to learn what it is like asking a patient for money.  The dentist learns how to communicate this issue properly. It is easier to start by asking or rather demanding payment for laboratory work, because the blame can be shifted.  Once the dentist has mastered the technique of asking for cash payment for laboratory work, it is easier to just go ahead and ask for the full fee to be paid.  The majority of patients will understand that the dentist has to pay the technician and so they will not mind paying the dentist so much, if only he would ask them.  Patients know that dentistry is expensive.  In South Africa at least they know that medical aid schemes are slow payers and they also know very well that interest rates are high.  Due to these facts I think many patients are silently amazed when dentists in this day and age does not demand cash payment.      


What shouldnever happen in any dental practice is that any patient is allowed to leave the practice without an account for any services rendered.  Before any patient leaves the premises he or she should be issued with an account. Most decent people will automatically reach for their cheque books or credit cards.  This is something all dentists can institute immediately and it will instantly improve their cash flow.  Even in practices which are totally dependent on third parties. Patients are much more appreciative of the good dentistry they have just received than of the good dentistry they got three weeks ago.  With time the experience becomes less memorable and what seemed a bargain at first, now suddenly seems to be quite a lot of money.  Most patients are very relieved to leave a dental surgery and they actually say, " It wasn't so bad."  But if they only receive the account three weeks later, the memory of the treatment, smiling faces and the friendly good dentist has already fazed a little.  All that they experience now is a demand for a lot of money.  Patients are at their most grateful immediately post-operatively. This is the time to get the money from them. 


Stephen Covey describes Interdependence as the pinnacle of human achievement.  He regards it as more important than independence.  But he also says Interdependence is a choice only Independent people can make.  Being an Independent Entrepeneur does not contradict Covey's ideal of Interdependence, it actually confirms it very positively.  Dentists who work for some or other system are totally Dependent - the lowest form of existence.  When they break free from these systems, they become Independent.  But in dentistry it is only possible when you realise how dependent you are on your patients.  When patients are dependent on a dentist for good dentistry and the dentist is dependent upon the patients for paying his fees, true Interdependence results.  This happens when an Independent dentist who had moved through Habits 1 to 3 ("Be Pro-Active", "Begin with the End in Mind" and "Put first things first") starts to "Seek First to Understand... Then to be Understood", to "Think Win/Win" and "Synergize."


Peters and Waterman lists "Autonomy and Entrepeneurship" as one of the cornerstones of success of America's best companies.  They mention the existence of the "Fellows" at IBM who are given a free rein to do what they like and they give numerous other examples of people succeeding because they are allowed to do their own thing.  All that is needed is motivation and commitment. "Its amazing, in fact, what one highly charged, crazy man can do."  (p222)

"Whenever anything is being accomplished, it is being a monomaniac with a mision." (p225)

There is nothing to motivate a dentist to walk the extra mile, to do a better root canal treatment, to make an excellent crown, if he or she knows that some or other faceless or authority had decided long ago that the dentist should be paid so much and not a penny more for his services. There is no incentive to listen to the patient, to provide more quality.  The dentist perceives that he is in a lose-win situation, with him or her losing all the time and the patient winning, because the latter is getting his dentistry for free anyway.  So the dentist decides that it is wrong and he goes all out to win and he does so by doing more dentistry, with the concomitant drop in quality and the situation turns first to win/lose and finally to lose/lose.


Undoubtably, when a dentist is not adequately compensated there is a very bad lose/win situation, with dentist losing and patient winning.  Because of the stress situation.  As explained in the introductory paragraphs of this chapter, dentistry is a very stressful occupation.  Dentists must be compensated for stress.  The higher the stress, the higher the fee.


But only an Independent Entrepeneur can do this. Only he or she has the freedom to choose, the liberty to decide how much he or she wants to be paid.


No slave can ever hope to be Efficient and Effective. No slave can be a success, happy, healthy and live comfortably.  Third parties make dentists their slaves.  They put them in chains.  They tell them how to practise dentistry and they prescribe how much dentistry they are allowed to do.  Dentists respond by trying to first work the system and then to beat the system.  They work the system by seeing all patients as potential quotas of dentistry allowed by the system.  They try to beat the system by manipulation of codes and tariffs. One thing an individual can not do easily is to break a system.  He or she can break themselves against the system but it is not so easy to break the system.


What is possible is to break free from the system.  This is possible.  It is not easy but it can be done.  All it takes is one "highly charged, crazy man", "a monomaniac with a mission."



                         Chapter 27


                     Build a loyal team


Dentistry is a high tech business today.  It is really very exciting to attend all the congresses and courses and to hear about and view all the latest innovations, machinery, instrumentation and materials.  And it is really amazing to see what dentists are prepared to spend on all these gadgets.


Dentists are forever looking for ways and means to make their lives easier and to make more money.  And the technology gets more and more expensive.  But still the dentists buy.  Yet still they are loathe to spend money on good staff.  Dentists, in South Africa at least, pay some of the poorest salaries in the country.  They rationalise it very easily by a frame of mind which is controlled by the iniquitous third party system.  Because of the low fees they earn, there is a limit to what they can afford to pay their staff, they say.  There is nothing, no technology or gimmick or material which can have such a great influence on a dentist's stress levels, feelings, emotions, well-being and earning capacity as good staff.  Yet, they are not prepared to spend real money on good staff.


Good staff are more valuable than an intra-oral camera, or a cad-cam porcelain milling machine or a fancy computer.  And like all valuable items, staff should be cared for. They should be nurtured and handled with care.  They should be listened to and they should be attended to.  But most important of all they should be appreciated.  People will do almost anything for an employer who appreciate their efforts and shows it.


Appreciation can be shown in many ways.  It can be in the form of a mere thank you, a personal thank you card for a job well done, a bouquet of flowers, a gift or money.  But it is something which has to be done - regularly.  According to Maslow the highest form of motivation is self-fulfillment. Self-fulfillment for dental staff also means pleasing the dentist and the patients.  Like justice, appreciation has to be seen to be done, almost daily. Stephen Covey talks about Interdependence and Synergize.  Peters and Waterman enthuse about Productivity through People.  The message in both instances rings loud and clear; Respect, honour, love and appreciate the individual.  It is also undeniably the message of the gospels, therefore it must be true.


Many progressive dentists faithfully attend continuing education events.  They want to broaden their minds and improve their knowledge and skills.  But they fail to do the same for their staff.  If staff is so important, should they not also be developed?  Dentists should have their staff attend regular courses, at least once a year. But the dentist himself should personally be involved in training and development on a daily basis.  Staff should know what is expected of them and they cannot know if they have not been told.


It is unprofessional to talk to a staff member about anything which is not concerned with the patient present. And patients are ever present.  So there is precious little time for talking and education and training of staff.  Yet it remains extremely important.  So time has to be created.  A very good venue for this training is the early morning conference. This should be scheduled for first thing in the morning.  I suggest 8:00 am or 9:00 am or whatever suits the individual practice.  By scheduling it in "my" time, time I pay for, I send out the message of how important this meeting is.  In my practice I start seeing patients at 8:15 am. Eight o' clock is conference time. It is an informal time of chats and jokes but it is also time to reflect on yesterday's mishaps and successes and to plan today and tomorrow.  We drink coffee and we try and cheer each other up.  When we are trying out a new material we can discuss it at this meeting.


We really need these relaxed times to lower the stress levels and just to be normal human beings for a change.  All America's excellent companies share an obsession with the welfare of the people working for them.  They seem to genuinely care for their people.  It is usually evidenced by many small and big things.  These include structural devices, systems, styles and values, all intended to allow people to control their destinies, to succeed and to stick out.  In other words the companies allow their employees to follow Stephen Covey's first three habits, Be Pro-Active, Begin with the End in Mind and Put First Things First.  They allow their people to become Independent or Autonomous Entrepeneurs.  One may ask how can that be done in such a big company or even a small company?  Where do you go without all the rules and regulations?  You cannot just allow the dental nurse or assistant and the receptionist or practice manager to do what they like.


The answer is simple.  It is called Values or Principles.  All the excellent companies share also the one all important characteristic, they are value-driven.  In Covey's terms, they lead principle centred lives.  Within the broad framework of a well communicated value system or principles, people can and will be effective if they are allowed freedom, independence and autonomy.  If a dental nurse knows that the practice's values are patient centred and that the patient's interests are all- important, there is no need to stipulate and monitor working hours, or even sterilization regimens and protocols.  She will know that it is important to be on time, to handle materials properly, to make life easier for the dentist.  If she does not have the knowledge of how to do these things, then the dentist must provide the training; but that is only a small matter. What is much more important is for the dentist to communicate the value-system, to instill the values and principles in his staff members.  If they have the framework and they also have the technical skill and knowledge, provided by training, then there is no need for rules and regulations.  It is much better to refer to the values and principles. Even a practical matter such as dress and neatness can be covered and handled in this way.  Give people freedom to wear what they like as long as it portrays and effects the practice's value system.  People respect principles.  Rules and regulations are viewed as things to be bent and manipulated.


Once again, the christian value system, delivered to us by Jesus Christ, provides us with the best value system ever devised. The christian attitude of love, unselfish love that is, can and must guide us in all and any relationships we enter into.  If our staff members know we are christians and if they see it in our attitudes and relationships, they too will respond accordingly.  If they do not, it will become clear, sooner or later, that a long term relationship is not possible and then they will have to leave the practice, unfortunately.


Where does one get good staff?  There is no easy answer to this question.  But one thing is certain.  No staff is almost better than bad staff.  A rude receptionist can break a practice or at least do a lot of harm and is something which should not be tolerated.  The customer is always right and a receptionist/practice manager must accept that and live with it.


Jennifer de St Georges says that we should look for and find our receptionist/practice managers outside dentistry, in the fields of banking, travel and car hire.  Apparently these industries are very much service orientated in the USA and therefore one finds good, friendly communicators working for these people. Unfortunately, South Africa is a country not very well known for the quality of its service.  Generally speaking South Africans are subject to some of the poorest service in the world.  The culture of customer service is not well developed.  The answer is to persevere with what is available and to develop and train them.  Fortunately, many courses and lectures focusing on these issues are currently being presented and staff should be encouraged and helped to attend as many as necessary.


It would seem that the production of dentists outstrips the production of dental chairside assistants in South Africa. And dental chairside assistants leave the profession very quickly.  A senior lecturer training dental chairside assistants, mrs Elise Prinsloo says that the scarcity of available chairside assistants can be directly ascribed to the poor salaries they earn.  There is no other explanation for it.


Personally I cannot work without the aid of a highly competent assistant.  I know of dentists working like this but I cannot.  The simple act of giving a painless injection is a routine where I depend heavily on the synergism between me and my assistant.  I owe it to my patients to only work with an Effective and Excellent dental chairside assistant.  And therefore I pay quite substantially more than the average in the market place.  One of the most successful measures which I have instituted in my practice is the bonus system.  If my earnings exceed a certain amount of money I pay a percentage bonus, every month that it happens.  This is a tremendous motivating factor.  The excellent companies all have bonus schemes and so should we.  I have had particularly good months where the bonuses were greater than the salaries and I paid them gladly and smilingly.  Is it unchristian to be motivated by money? No, but it is definitely unchristian if money is your primary value in life.  It is not wrong to work for a financial incentive, as long as the desire for money is always subject to your earnest desire for the well being of others. It is not wrong to work harder and smarter to earn more money, as long as it is done in a Win/Win relationship. If the patient really wins, then it is all right if the dentist and his staff also wins.  But a patient can only really win if he or she can also afford the treatment.  Good teeth are no good if you don't have money for food.  Therefore it is wrong to sell expensive dentistry to people who cannot afford it.  That is unchristian.  Money should also not be the only reward staff receive.  All the excellent companies have social functions, newsletters, christmas parties, sports events and much more.  I mentioned above that these companies all seem to genuinely care. A dentist should do the same. Have a relaxed evening at the opera, cabaret or whatever once or twice a year.  Remember birthdays, also the childrens' birthdays.  It is the little things which count and are remembered. 


Someone once said, "Life has been made more bearable by two things, the love which I have received, and the love which I have given."  This is a sound basis upon which to base staff relationships, a dental practice and an entire life.



Back Back to top