Dr. Kroeger

Discussion in 'Dental' started by Mr. So-So, Jul 26, 2001.

  1. Mr. So-So

    Mr. So-So Senior Member
    7+ Year Member

    Jul 25, 2001
    Likes Received:
    i found this page helpful, so i thought i'd post(his advice):

    I would like to share some ideas that I have gathered over a 25+ year career in dentistry. Take whatever seems to work. I'll share some successes and failures that I've made. I hope that you can use some of this information in planning for your future. I will add to this section as my time and energy allow. If you are interested in visiting my office for a day of observation, that can be arranged. Just give us a call. In general, the best time to visit is from November to March. FOR THOSE OF YOU WHO ARE NOT DENTAL STUDENTS, READ THIS AT YOUR OWN RISK OF BECOMING INCURABLY INFECTED WITH THE BURNING DESIRE TO BECOME AN EXCELLENT DENTIST.

    1. Study hard. Hit those books. Learn as much as you can and concentrate on being meticulous in your techniques. Don't be shy about asking questions. Understand the rationale.

    2. Challenge everything your teachers tell you. Does it make sense? I took courses from Dr. Pete Dawson in the early '80s. In my opinion, he was and is one of the top ten dentists in the U.S. It was he who told us to challenge everything we heard from speakers. What are the long-term studies? What are the side effects? How does the restoration affect biologic width? If you are not familiar with that term, you're missing an important concept.

    3. Remember that dental school teachers are not in private practice. You've heard the phrase: those that can, do; those that can't, teach; and those that can't teach, teach at Ohio State. Just kidding. I graduated from OSU and had a number of great teachers ... and some not so great. If you can find a part-time teacher who has a private practice, listen to him or her and ask if you can observe in that office. Keep your mouth shut and ears open and watch what goes on. If your school doesn't have such teachers, call dentists at random for a half or full day of observation. Ask questions. You'll be surprised what you'll learn. Remember this: the most dramatic change in our field in the past 20 years is direct dentinal bonding (are they etching the dentin yet at your school?). Despite millions and millions of dollars spent on American dental research, it was a not an U.S. dental school researcher who discovered it. Rather, two oriental researchers (Korean and Japanese) gave us this wonderful method of bonding.

    4. Why are you entering dentistry? Status? Money? Lifestyle? To help people? These are very important questions. A wise professor at USC once said: those who go into dentistry primarily to help people and secondarily to make a living will end up accomplishing both goals. Others whose primary purpose is to make a lot of money and whose secondary goal is to help people will usually fail to reach either goal.

    5. What is your personality? Buy the book, Please Understand Me by David Keirsey (a second edition is now available). Learn about your personality. How important is this? Very!! If you are an introvert, you will need to surround yourself with extroverts in your staff to help liven up the office. If you are an extrovert, you need to learn to listen. Patients love to tell their stories and they love for the dentist to listen. I am an INTJ, but didn't find that out until I did stress management research in the early 1980s. Fortunately, I have a strongly extroverted staff who compensate for my quietness. A classmate of mine is an endodontist in a small town. He is as busy as he wants to be since he is the only endodontist for miles and miles. A virtual monopoly. And he hates dentistry. His personality is very introverted and he does not like dealing with the interpersonal issues that cross his path daily: staff problems, patient communications, hiring and firing. He told me dentistry was too stressful for him and wondered how any 20 year old could know what being a dentist would really be like. When I asked him what he would rather do, he said he would rather be a cop. He thought that it would be less stressful. However, a policeman's occupation ranks much higher on the stress scale than dentistry. But, what would have happened if my friend had known about this when he was 20. For him, a career in a research laboratory would probably have been much more enjoyable.

    6. I happen to like being a dentist. I had an associate dentist years ago and tons of staff ... and the stress to go along with it. No thanks. Don't want a heart attack at age 60. I've had friends that have been there. I am good at what I do and paid well. I have many patients whom I've know for over 20 years. It will be very hard for me to leave my profession and to leave my friends. That is why being a dentist in private practice is great. You call the shots. You can practice six days a week when you're young and energetic (as I did) and yet, when you get older, you can slow down to what is comfortable. When many are forced to retire or lose their jobs due to industry reorganization, the dentist can cut back to two or three or even just one day a week. And he or she can still keep seeing those grand friends who've been coming in for so many years.

    7. Do you think that dentists have a high rate of suicide? Unfortunately, most of you will nod your heads affirmatively. The answer is NO!! In the early 1970s, two studies were done on suicide rates in California and in Oregon. Dentists in these two states did have a higher than average rate of suicide. The media jumped on this news like flies on you-know-what. They publicized it heavily, even though it was a small study. A few years later, Dr. Mumma, a researcher at the University of Pennsylvania, examined death certificates from dentists across the entire country and discovered that dentists had no greater risk of suicide than anyone else. Did this study get much press? Hell, no. Most of the media want to sell their products (T.V, radio ratings and newspaper and magazine circulation) by controversy. So they portray dentists as sadists and stress-laden creeps who kill themselves at an alarming rate. Dr. Mumma found out that dentists generally die of heart attacks. So there. Start jogging and stop eating fatty foods and you'll live forever.

    8. In dental school, try to graduate debt-free. I know dental students who lived better than I did after I was a dentist. Many students have a large debt load and suffer for it. Being in debt is stressful and being deeply in debt is worse. While in dental school (which I paid for), I had every part-time job you could imagine. I cut expenses to the bone. Really to the bone. Then I went into the Navy and saved a little money. The Navy was great because I got a chance to see some of the world: Washington, D.C., Spain, and most of Europe. A great (working) vacation between dental school and private practice.

    9. When you start private practice, it is much easier if you are debt-free. Banks don't look kindly on young dentists with a negative net worth. Consider a rural area. Right now, many areas around the country need dentists. You may have to drive an hour to a shopping mall but that's life. Some small towns are willing to help you set up your office. And many rural areas have little dental insurance regulations. Most cities and suburban areas are heavily into managed care, a subtle form of socialized dentistry. Many dentists + much HMO insurance = stress city. It's important for you to be happy and enjoy your work. My office is not in the most affluent part of town. We are in a blue-collar suburban area but have a nice mix of white-collar and blue-collar patients. Most of my patients are lovely and I enjoy taking care of them.

    10. When you graduate, you'll be pestered by every insurance company to come aboard their PPO/HMO ship. In Cincinnati, dentists have formed their own insurance company (an IPA) to try to fight the influx of these programs. Direct reimbursement is the best way. Many companies are beginning to find this out. If you sign up for these PPO programs, watch your overhead. You can't charge $450 for a crown, pay a $200 lab bill, pay your staff, and make a profit. You'll have to find a lab that charges $50 or less, and you'll have to cut other expenses. Yes, there are labs that charge this for a crown; many are located along the Mexican-U.S. border and overseas. Ask, yourself one question: would you want this crown in your own mouth? Or in your spouse's? I know a dentist whose practice is primarily insurance contracts. He uses such a lab and claims the crowns are as good as any regular lab can make. I hope he knows the difference. Is this what we learned to do in dental school?

    11. The biggest story that the ADA hides is what is happening in the United Kingdom (England, Scotland, and Wales). I have had the opportunity to travel there many times; talk with dentists and patients; and observe the phenomenal exodus of dentists from the socialized system. I have offered to write about this for the ADA or to supply a writer with the information, but they are reluctant. Why, because, in my humble opinion, the ADA has struck a deal with our government to substitute insurance company-controlled dentistry for governmentally controlled dentistry. Well, it's socialized either way. And I know that socialized dentistry does not work. I have seen nearly 100% rampant periodontal disease in the U.K. Why? It's because the NHS does not reimburse adequately for periodontal treatment. That is the main reason why 50% of adults in Britain have complete dentures. In Great Britain, dentists are leaving the National Health Service (NHS - the government agency that controls dental fees) in droves. That's right, in droves. Dentists are risking their futures by not accepting government payments. It is because they are tired of being beaten down by controlled, archaic fee structures that regulate what they can do. And, the exciting thing is: they are surviving!! Their patients are returning and paying their fees. (Under NHS, patients paid 75% of the fee anyway: the dentist then collected the remaining 25% from the government ... and usually waited three to six months to get it.) Our patients are very intelligent: they know what insurance companies are all about. You don't hear about insurance companies going bankrupt, but the sad thing is ... you do hear about young dentists failing. American patriots fought and shed their blood for our freedoms in 1776. Don't sell your soul!! Look at our colleagues in England and Scotland. Remember Braveheart's last words before execution: FREEEEDOM!!

    12. And that brings up the next point: excellence in dentistry. It's your choice. Learn about it. Take good seminars. Try to find lecturers who practice what they preach: dentists like Peter Dawson, Frank Spear, and John Kanca. They all ascribe to excellence and can teach it. They will all tell you to work under magnification. I know what you're thinking. Your eyesight is great. I am sure it is. But you still can't see as good as I can with magnification. And the bottom line is: dentists who work under magnification do higher quality work than those who don't. No debate. Try using loupes just once. You can get them from a variety of places. Most supply catalogs carry them. Then, after you get established, try a set by Designs for Vision (1-800-345-4009).

    13. In the early years, work hard. If you aren't busy enough, pound the proverbial pavement. Hand out business cards to anyone you meet. Go to area companies. Have your spouse do the same. Talk yourself up. You're worth it! Hell, anybody who can survive four years of undergraduate college, four years of dental school, and pass the boards can't be all bad!!

    14. Watch your income and watch your expenses. Buy a practice if you can. Visit other nearby dentists and tell them you'll cover for them if they're out of town. Join groups and ask your spouse to do the same. Most importantly, keep your living expenses within your income. AVOID DEBT!! Pay off all credit cards monthly. No exceptions. Yes, this might mean eating a hamburger instead of a New York strip. It might mean renting a movie instead of going to the hottest concert at $50 a ticket. Let your colleagues live like this. Instead, put at least 20% of your practice revenue into a savings program. Every year. As you know, when you turn 62, social security will only be a memory. And I can't tell you how many dentists and physicians cannot retire. And many others are in the same boat (even those who have made a decent income but have never had the discipline to save). The best and only book you need to buy on this subject is The Millionaire Next Door. Get it, read it, and follow its advice. I am giving a copy to each of my five children when they graduate from high school.

    15. Listen to motivational tapes. In your spare time: driving, jogging, etc. I have a collection of about 30-40 tape series. Each series has six tapes. They will help you tremendously. A great source is Nightingale-Conant, 1-800-323-5552. They have a fire sale every January. Take advantage of it. Listening to these tapes has helped me to grow not just as a dentist, but as a person, a father, and a husband. Some of my favorites are: The Psychology of Achievement (Brian Tracy), The Psychology of Winning (Denis Waitely), See You at the Top (Zig Ziglar), How to Build Self-Esteem (Jack Canfield), and The Greatest Management Principle in the World (Michael LeBoeuf).

    16. Some dentists wear ties and white jackets, and some wear scrubs. I have worn both in my career and now wear a tie. It's the age of sterilization: have your clinical staff wear scrubs and provide them with scrubs of matching colors. It will help enhance your office's sense of teamwork. Decide which will work best for you: a tie or scrubs.

    17. Fees. Begin by charging an average fee. Check around with dentists to see what that is. Then take post-grad courses and, as your skills increase, you can raise your fees. If you are an excellent dentist, you can charge for it. If you are a mediocre dentist, charge at that level. And don't be afraid to donate your services to a patient in need. In Ohio, there is a program called Donated Dental Services, which screens patients to determine if they are truly in need. They also find labs (often the one you use) to also donate their services. Some folks need help but do not qualify for welfare.

    18. Identify your best referring patients and those patients who always keep their appointments, are never late, and always pay their bills on time. Put a star on these patients' charts and give them Cadillac service. Never keep them waiting. Tell them how much their referrals mean to you. They are the lifeblood of your practice. Give them a referral bonus and extra service. 20% of your patients refer 80% of your new patients.

    19. As a young dentist, try to join your local dental society. I know it will be expensive, but do it. One mistake I made was not becoming active in my local society. I opted to have five children, write books, and give lectures. I thought I would become active when the kids grew up. Well, they are still in grade school and high school and, with all their activities, I don't have the time to become involved in our local society. Flimsy excuse, huh? So, my advice would be for you to volunteer (when you're young) to serve on committees and work your way up to positions of authority in your society. Join a dental study club. It will be good for you and your professional growth.

    20. Try to develop a 'niche' in your practice. My niche is treating dental phobia. You can read my C.V. to see what I've done. It has helped many people, not only in my practice but also across the country. By becoming extremely proficient in one special section of dentistry, you can make a contribution to your profession. By sharing your research and your ideas with others, including other dental professionals, you will improve the image of dentistry. Learn to be a giver, and not just a taker. In your own little way, you are making the world a better place to live. And who knows, maybe I'll come to one of your lectures someday.

    21. Learn to give a gentle injection. And learn to stop if the patient is in pain. I would not treat patients without a periodontal ligament injection syringe. I have found it to be the most predictable way to assure no pain during treatment - if the conventional injection does not produce enough numbness. Unfortunately, PPO and HMO insurance emphasizes speed and efficiency. It's tough to stop if a dental phobic requires extra time to get numb. But, you can charge for it if you aren't constrained by an insurance contract. We have two main goals in our office: to provide excellent dental care and to provide it gently. We talk the talk, and we walk the walk.

    22. Every great dentist trims his or her own dies. Under magnification. Pete Dawson taught me that. Seeing your preps under high power will teach you how to improve. You will critique your own work. The lab will regard you as a fine dentist, as well. They like distinct margins. To get a feeling for what the average dentist does, go to a commercial lab (a large one, if possible) and ask if you can randomly look at the bridge or crown impressions and untrimmed models. Also, take a paper bag. You will see so many quadrant impressions and blurry margins that you may vomit. You will learn that you don't want to do this kind of dentistry. Do the patients know the difference? No, they just know that their monthly insurance premium is lower. And you wonder why the ADA sets the lifespan of a crown for ten years.

    23. Always do a thorough initial screening with each new patient, even if it's an emergency. Personally review the dental and medical history. Learn from an experienced dentist how to do this. THIS IS VERY IMPORTANT. In your first exam, always do an oral cancer screening, periodontal charting, occlusal analysis, and TMJ evaluation. In my career, I have found four cases of oral cancer. Two of the cases were detected early enough to save patients' lives.

    24. For posterior teeth, try to use metal occlusals. There is an emphasis on esthetic dentistry today. But, conservative dentistry is still the best. Metal will not wear the opposing dentition. And, no matter what the 'metal-free' experts claim, a gold crown is still the finest full-coverage restoration a dentist can provide. We have used Targis, a metal-free white material for posterior onlays but we are watching these closely. I enjoy doing gold onlays. If done well, they will last 40-60 years. This knowledge gives a dentist a great sense of accomplishment.

    25. Be wary of lecturers in post-grad esthetic courses. Many do not have any long-term research to back up the materials or techniques that they are using. Many use the data provided to them by the manufacturers whose products they promote. Ethical? You be the judge. I like John Kanca because he conducts independent research and is not swayed by manufacturers. Gordon Christensen also has a good reputation, although sometimes he recommends products before they have stood the test of time. Challenge everything you hear. But be willing to change, if products have been in use for at least three or four years without complications.

    26. Also be wary of dental salesmen. Recently my rep wanted to give me a free sample of a condensable posterior composite resin. I asked him for studies. He said they have done a nice one-year follow-up. That is not good enough for me. I don't want to use my patients as guinea pigs. He understood, and did not take offense.

    27. Forget using pins. They will crack teeth, sooner or later. The bonding of today's resins is so powerful, you don't need pins. And amalgams, unfortunately, are going the way of the dinosaur for the same reason. They crack teeth. Even small ones. To check this out for yourself, use an intraoral camera to magnify the areas around the amalgam. The mercury is not a problem, but the cracking is. Decay gets down the cracks and, if the crack continues, it eventually reaches the pulp or, even worse, the root, requiring extraction. In my early years, I didn't think too much about cracks. Amalgams were fine. I placed a lot of posterior composites in the early 1980s when the mercury scare first surfaced. It is hard to believe but many of these (primitive in technology, compared to today) have survived and, most interestingly, have not caused teeth to crack like amalgams. In 1992, I first began to bond amalgams, etching the dentin. That worked but I still noticed teeth cracking. Finally I reviewed the literature from the ADA library and decided to stop doing amalgams. Bonded amalgams are certainly better than unbonded ones but they take more time. Does PPO insurance pay for this extra time? You're catching on.

    28. When you begin to set aside a little money for your retirement (like, in your first few years of practice), set up an IRA or a Keogh, or some such plan. Get a good CPA at a reasonable cost. Look around. They're out there. Then you're faced with two dilemmas: investments and taxes.

    29. Let me make this simple: pay your taxes and don't worry about it. Period. Deduct everything you can, but avoid exotic tax shelters. Someone I know very well had a great practice when I came to Cincinnati in 1977. He was on top of the world. But he agonized over having to give the government a large share of his hard-earned dollars. And so, he investigated ways to avoid paying taxes. In those days, the tax laws allowed more shelters. And there were 'sharks' on every corner. They must have inspired Jimmy Buffet to write "Jaws". What exactly is a 'shark', you might wonder? A 'shark' is someone who preys upon young health-care professionals. They view you as a tasty meal and, if you let them, they will consume you. Back to the story. This professional discovered some interesting ways to avoid paying taxes. After a few years of doing this, he paid no income tax. Wow, was I impressed. However, down deep, I thought he would be caught. Nothing happened. He talked like an expert and finally I, too, followed his advice and got involved in some of these tax shelters. I will discuss my story later. After several years, the IRS began to 'harass' him but he always convinced us that his shelters would weather the storm. Then he bought an expensive piece of machinery to drill for oil and gas. In those days, there was a lot of money in that. He claimed in a few years he would be on easy street. He convinced several relatives to invest with him (but not me) and assured them that they, too, would soon have it made. Then a nasty, unexpected market correction killed oil prices. It became unprofitable to use the machine, but the bank loan payments were due monthly. The IRS was closing in. They wanted their money. Feeling pressured for cash (his practice provided only so much), he resorted to committing a crime for which he spent time in a federal prison. It's a true story: very sad, but true. He lost his practice, his DEA license, his wife, and his self-esteem. He owed tons of back taxes, interest, and penalties. Slowly he has regrouped but he's not the same man. And his story is repeated in each city in the USA with different names and different games. The sharks are there: watch out.

    30. Lesson on shark detection. Sharks are people who will give you information on a product. It will be something that sounds too good to be true. They will let you research the product. They will get you to trust them. This may be a friend of yours: a high school buddy, a sorority sister, or even, sadly, a relative. And this is how you say 'no' gracefully: you give the information on this wonderful investment or tax shelter to your accountant and tell the shark that the accountant will review it. The shark will try to tell you that this information may be too complex for the accountant and that his or her advice will probably not be significant. Stick to your guns and stick with your accountant. A good conservative CPA is a great asset, especially when you're surrounded by sharks in the water.

    31. What is my investment story? Well I screwed up, as did many of my friends. I fell into some rinky-dink tax shelters that the IRS eventually discredited. They left my professional corporation and my pension plan alone: that was the only good out of all that mess. In that time period, a shark sold me an apartment complex - 27 two-bedroom units located in hell. One of the apartment managers embezzled money. Another had a garage sale, selling supplies he purchased with apartment funds. One nightmare after another. A few years later, an attorney friend helped me sell it, with a loss, not a gain, despite the hefty tax savings early on. Don't invest in something you aren't familiar with. Overall, I have been lucky, though. Since 1982, I have invested in mutual funds that have grown nicely over the years. Janus, Vanguard, Price, Scudder, and American Century are my favorites. It's slow growth, but it's worth the wait.

    32. When you can afford it, get a digital X-ray unit. We have had ours since 1998 and it is wonderful. It reduces radiation to patients by 90% and the image is displayed immediately on a computer screen. An intraoral camera is integrated with the unit, for better diagnosis and better patient education. I waited six years for this technology to be improved and come down in price. The good news: the units will improve and come further down in price in years to come. They are the future of all medical X-rays.

    33. Consultants. Dental consultants will teach you the business part of dentistry. They can be very helpful but are generally expensive. Gary Henschen (phone - 1-800-447-3265 or [email protected]) is a good one and reasonably priced for those of you in the Midwest region. Again, challenge everything they say. For those who want you to have a daily dollar goal, be wary. For those who want you to use every waking minute for profit, be concerned. But, if you've been in practice for 5-10 years and you're having a lot of problems, it would be good for you to have a practice evaluation. Most consultants will schedule a no-charge initial visit to give you an idea of their program.

    34. One final thought: learn stress management. In helping dental phobics, I figured that being a stress management expert would make it easier for me to be successful in treating these difficult patients. I was right. And there was a wonderful bonus: this knowledge helped my staff and me manage our own lives more effectively. Read books, take seminars, listen to audio and videotapes. Read the book, Don't Sweat the Small Stuff. Then read it again. And again. Make others smile. Tell a joke. To a stranger. While you're in the grocery line. Stay in aerobic shape. Be kind to your heart. Exercise it. Eliminate fat, salt, and sugars from your diet. You always feel better when you're in shape. Mentally, as well as physically.

    35. Well, that's it for now. I will add to this section when I can. I hope it has helped you and I hope you have a great career in dentistry. Remember: we are in the top three trusted occupations, according to Gallup polls. We got there for a reason: we follow the scientific method. Strive for excellence in all you do. Be happy and smile. Do something nice for dental students when you are in my position. Maybe we'll meet someday. Best of luck to your and yours.
  2. Dr. Pedo

    Dr. Pedo Senior Member
    10+ Year Member

    Jan 14, 2001
    Likes Received:
    Wow! Incredibly helpful, thanx for posting it.
    R.R.B :)
  3. osamah

    osamah Member
    10+ Year Member

    Dec 14, 2000
    Likes Received:
    dear dr.,

    i read all of your post very extensively and it gives me insights to the areas of dentistry, which were new to me untill now. your experienced comments and suggestions are the beacon light for the new comers and fresh dentists coming in this profession.

    i appreciate your time and effort you strived to write such a detailed note of your past experiences happenings.

    i think, we all at the forum will learn a lot eventually from you.

    please keep it up and note it, we all here are reading your posts with great interest and zeal.

    Dr.Osamah Qureshi
    [email protected]
  4. MedCruiser1

    MedCruiser1 Junior Member
    7+ Year Member

    Jul 16, 2001
    Likes Received:
    I agree with Osamah,

    Great post even though I am not a pre-dent or dental student!
  5. drmouse

    drmouse Member
    7+ Year Member

    Jul 16, 2001
    Likes Received:
    Hi! thanks for sharing so many experiences with all of us.I am sure all the students will appreciate it as much as I do.I am looking forward to learning from your experiences and hope you keep on updating this post.

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