The Marketing of Orthodontics

Painless Parker Rides Again

Throughout history, yesterday's criminals have frequently turned out to be tomorrow's heroes. Mahatma Gandhi, Jomo Kenyatta and Fidel Castro are internationally known examples in this century. In dentistry 50 years ago, it was Dr. Painless Parker, a flamboyant advertising dentist. While not predicting a place of honor in the Dental Hall of Fame for Dr. Parker, it is ironic that the social stigma attached to the term "Advertising Dentist" has been lifted by the same law courts which once certified his infamy. (One cannot help but wonder if future court decisions will administer a similar coup de grace to prejudices against arrangements such as closed panels and capitation programs currently viewed with disfavor by the dental establishment.)

Prior to the 1977 Supreme Court decision upholding the right of professionals to advertise, it was easy to see why those professionals providing what might be termed "critical" services neither needed nor wanted advertising. For physicians, lawyers (even undertakers) demand for services was automatic. As long as the supply was controlled, all could prosper. In their case, failure to control supply (not in toto, but in distributive terms) led to demands for the right to promote the individual practice.

In the case of dentistry, the establishment prejudice against promotion is harder to understand. Dental services can rarely be classed as "critical" even from a patient's point of view. Many lose their teeth, learn to live with dental pain, and eke out their existence on a semi-liquid diet. Possibly the social parity with physicians, so eagerly desired by the dental profession, was purchased at too high a price. Since dentistry for the most part is a deferrable expense, perhaps a slightly more aggressive attitude on the part of dentists in general would have served to stimulate popular awareness of potential problems in the oral cavity and increased the nation's understanding and acceptance of the many benefits of oral hygiene. The American public has never been unwilling or unable to spend money on products or services they believe in. Perhaps if dentistry had used automobiles or electronic gadgets as its role model, the American mouth would have been a prouder monument to scientific achievement than it is today. More tangibly, the American dentist would undoubtedly have been economically better off than he is today.

The Marketing Potential in Orthodontics

The establishment position on advertising aside, orthodontics is a specialty which is closer to bioengineering than dentistry. Here is an area where priorities are frequently based on peer pressure and decisions to purchase are made by individuals other than the patient in most cases. Intelligent use of all forms of communication to explain and persuade would have made eminent good sense for the orthodontist. Apparently his need to be a member of the dental establishment outweighed his need to attract patients.

Suddenly, however, the orthodontist can have his cake and eat it. The kind of promotion which has made sense for the past 50 years is now socially acceptable. His need to persuade has now been declared a legal right. But still he hesitates. Why? He is venturing into a new world, one for which he is ill prepared, and is understandably cautious. What sort of advertising? In what? Costing how much ? The questions come faster than the answers. The position of the dental establishment is still unclear. The hardest vice to eradicate is one which masquerades as virtue. The self-righteous deliberations of the local ethics committee will stonewall plans to take advantage of radical legal decisions and, anyway, everything takes time.

Fortunately his caution is justified -- not because of potential sanctions by invidious colleagues-- but because the true intent of the Supreme Court decision is still unclear. Were they protecting the consumer's right to know or the dentist's right to promote? Both, say the experts. Freedom of information and restraint of trade were both considerations. If this is true, then advertising alone is not the answer. Advertising will inform, but it takes much more than advertising to persuade.

To understand this, we must recall the amazing growth of advertising in this century. According to a study conducted by General Foods some 20 years ago, commercial messages to an average family of four have increased in this century from one a week at the beginning of the century, to over 1500 a day at the time the study was done. Undoubtedly, the present impact rate is considerably higher, but the defenses are also stronger. A combination of skepticism and selective perception makes it increasingly difficult to get attention for any message no matter how vital. To hold attention long enough to convince someone of the desirability of a major purchase is almost impossible-- given our present knowledge of communication processes-- and economically prohibitive. Further, there are simpler and less expensive ways to achieve the same objective.

The Humble Origin of Marketing

People have been developing and employing patterns of persuasion ever since Eve. Basic elements include benefit and consideration-- something of value for something of value. Because comparisons call for judgment and tend to be subjective, complications arise. At the heart of the problem lies suspicion that the benefit to the seller is of greater value than the cost to the buyer. Resolution of doubt is easier among members of the same family or residents of a given community. Transactions between total strangers is fraught with considerable hazards. The Romans coined a phrase "Let the buyer beware", and commercial activity ever since has underlined the wisdom of this caution.

Business started with barter, mostly of agricultural products for which a value could be established based on personal knowledge of time and effort involved in production. Introduction of intrinsic value and then debased currencies, use of machinery and proliferation of complex technologies make value judgments impossible today, even for the most educated. The solution lies not in attempting to place a value on the product or services, but in establishing the veracity and credibility of the seller. A succinct summation of the process is provided by a Japanese proverb--

"If you cannot buy people, buy service; if you cannot buy service, buy product".

Marketing is both the art and science of selling ourselves. In its simplest terms, it is understanding others and getting them both to understand us and accept our willingness and ability to provide a product or service in a satisfactory manner. Simple as this may appear, the obstacles to consumer understanding are formidable indeed and anyone who underestimates the complexity of the task is doomed to frustration. This includes the Justices of the Supreme Court and anyone simplistic enough to believe that paid insertions in mass media will accomplish the objective.

Cynicism and mistrust appear to be inevitable characteristics of our affluent society. Perhaps the more we own, the more we fear to be deprived of our possessions. The more educated others are, the more we fear they will use their knowledge and skills to victimize us. Real or not, these fears have produced mistrust of government and business alike. Accusations and evidence of self-serving abound, and trusting indeed is the customer or patient who does not look for guarantees or at least assurances. Increase in cost and intangibility of benefits add considerably to this instinctive fear and suspicion.

Recent research has advanced the theory that products are sold most effectively by establishing a favorable image for the producer: "You can be sure if it's Westinghouse"; "Better things for better living through chemistry" from DuPont; "Progress is our most important product" from General Electric, etc. These images are abstractions which will eventually be verified by the product.

But what about a service? This is already an abstraction. An image of a service organization is an abstraction of an abstraction. Clearly, images will not sell services; in fact, the wisdom of investing in trying to build an image of a service was questioned. It only takes one snarling stewardess to destroy the myth of "The Friendly Skies of United". Services, the research revealed, must be sold by evidence. Success is everything done right; failure may be one thing done wrong. Service resells itself each time it is provided. There are no unimportant details in a service operation.

Marketing a service poses special problems. Marketing a high-priced deferable service with intangible benefits for a third party increases these problems exponentially. Any orthodontist who plans to survive in times of adversity or to prosper in spite of increased local competition must learn more about marketing than a simple awareness of its existence.

An Anatomy of Marketing

As a formal branch of learning, marketing began in the 1930's. Bibliographies begin in 1939 and by 1975 number over 20,000 entries. At the present time, two new books on this subject are published every day of the year. Predictably, the rate of learning is so rapid that most works are obsolete before they hit the bookshelves. Constant surveillance of periodicals and present practice is needed to keep abreast of the current state of the art.

Increasingly today marketing is defined as communication. Expressed more formally, it is "the ability to understand the needs and wants of present and potential patients and to get them to

understand and accept our willingness and ability to provide lasting satisfaction of selected needs under conditions agreeable to both." To do this we must first understand how purchasing decisions are made and then determine what marketing can and cannot accomplish to influence the favorable outcome of this process.

All purposeful behavior, including purchasing, begins with a need or needs. These may be physical or psychological and generally combine aspects of each. Forces, both internal and external, act on these needs to develop both awareness of their existence and to create conscious wants for a product or service. Once the existence and availability of the product or service is determined, action on the part of both purchaser and seller will be undertaken which, if appropriate, will result in satisfaction of the original needs. The degree and extent of needs satisfied determines if the experience is likely to be repeated or recommended to others.

Of the six phases enumerated above-- needs, forces, awareness, wants, actions, and satisfaction-- marketing can directly influence only the middle four. Marketing research can, in some form, monitor all six, but the so-called "output" activities of marketing will provide part of the forces, shape the awareness, meet the want, and provide part of the action. Presumably, if each phase is conducted properly, satisfaction of need will occur, but no method has been uncovered to date which will ensure this happening.

Four basic functions are generally assigned to marketing.

Since no two practices are alike, a comprehensive but custom-tailored marketing plan must be

developed for each practice. Such plans will vary considerably depending on whether the objective is growth, increased profitability, maintaining the status quo, increased leisure time, etc.

Blueprint for Growing Practice

Given the diversity of possible objectives, a single illustration will be developed which will serve as a model of how comprehensive marketing plans should be constructed. Let us assume a practice would like to double in size over the course of the next five years. We will define size as patient starts and say that the practice will grow from 250 to 500 patient starts per annum.

This relatively modest goal can be achieved by any practice provided several key assumptions are accepted. (1) The practice is well managed. (2) Young adult patients are solicited. (3) Practice hours and operating conditions are modified to suit adult preferences. (4) A communications supervisor is hired and trained to handle patient/parent consultations and maintain contact with patients past and present. (5) There is no catastrophic economic downturn within the next 3 years. (6) Fees are not unusually high (over $2,000 per case) and (7) the local market is not oversaturated with orthodontists.

The key objective of the practice could be expressed as "To start a minimum of 500 cases a year, while providing a quality of care equal to or exceeding present standards, in the most effective manner possible". Current standards should be added in terms such as, "Significant progress towards this objective will be achieved in 1979 if (a) 300 patients are started, at least 100 of them young adults, (b) all cases are treated to centric relationships, (c) costs do not exceed 50% of gross fee.

Critical performance areas will include clinical, communications, laboratory, and financial section. Each should have competent supervision and clearly written objectives understood and accepted by supervisors and staff. Since the goal of any growing practice must include increasing non-professional referrals (preferably to at least 80% of new patients), every aspect of the practice should first be examined to ensure that all personnel and procedures project genuine caring and concern for patient welfare.

Marketing activity should cover four separate areas-- research, personal communications, non-verbal communications and practice promotion. Suggested activities in each of these areas should include the following:

(a) Marketing Research. Determine the number of potential patient starts among mixed dentition and young adult patients within 20 minutes driving time of the office. Subtract estimated starts of other orthodontists in the same geographic area. (Consider opening a satellite if the market is overserved.) Survey sources of information on appearance and hygiene for young adults. Identify mechanisms used to influence health and beauty purchases.(b) Personal Communication. Set up a program of positive communication between the practice and parents or patients by appointing a poised, socially mature person to act as prime contact between the practice and the rest of the world. Train her to handle consultations and initiate regular

written or telephone contacts with parents to report progress, etc. Have her record patient starts and identify sources exactly. Entrust supervision of receptionist to her to ensure courteous handling of all contacts.(c) Non-Verbal Communication. Survey all physical aspects of the office and its surroundings to project maximum concern for patient safety and comfort. Clean, efficient, well-maintained, aesthetic areas enhance the image of the practice. Frequent monitoring of parking, reception and clinical areas is needed to maximize favorable impressions.(d) Promotion. A most effective form of practice promotion appears to be slide-illustrated lectures on facial balance. Presented as an educational activity to groups of community influentials, and followed by a tastefully designed practice capabilities brochure sent to those who request it, the lecture sells both orthodontics and the practioner. Personal contact with general dentists, periodontists and key figures in the community should be maintained. A parallel program involving children, school nurses, teachers, etc., should be developed by the communications supervisor.

Estimated cost of such a program, assuming a minimum of 5 practice hours per week and valuing a practice hour at $200, would be $40,000 to $45,000, depending on the number of weeks worked in a given year. Fifty starts would generate $75,000 or more of added revenue depending on fees charged. A return of almost two dollars for one. No outside investment opportunity comes even close in potential earnings. In the second and subsequent years of the program the return increases substantially on the same basic annual investment.

Of course the foregoing is only one illustration of the potential uses of a marketing program.

The Marketing Future

And, the promotion-minded orthodontist, may turn out to be the real savior of dentistry after all. We know people will do things for vanity that they will not do for health or reason. Dentistry has been conspicuously unsuccessful at selling health in the oral cavity. Perhaps orthodontic treatment can succeed where dentistry has failed .

Selling orthodontic treatment as a practical and rewarding introduction to preventative dentistry, stressing social and aesthetic benefits rather than occlusal relationships, may be the stimulus that for so long dentistry has needed.