JCO Interviews Roger L. Rusley on Practice Stimulation

GOTTLIEB Roger, Is there a general slowdown in orthodontic practices across the country?

RUSLEY Yes. I believe that right now there is-a deferral of services. People are putting off having orthodontic treatment, but there is at least a lesser impact on orthodontists than on general dentists. The reason may be that parents today still feel guilt if they have a child who needs orthodontic treatment and doesn't get it. They'll defer expenses for themselves first.

GOTTLIEB It is not supposed to be that way with the "Me Now" generation, but I think you are right. Parents in this generation are basically like those of the past. They may have changed their life style to some extent and they may indulge themselves more, but not at the expense of their children. Still, as you indicate, it is deferrable. It is an optional service for many.

RUSLEY But, it's not the same option it was even ten years ago. It's so prevalent today; and today you may miss some patients as children and pick them up as young adults.

GOTTLIEB What do you think orthodontists could be doing, but are not doing, to try to at least hold their position or to improve it?

RUSLEY Well, there are at least three things they can do. For one, orthodontists have gotten a little lazy and haven't been doing what they ought to by the traditional standards of practice promotion. That is the most obvious one--to go back and review those things you do to promote missionaries for your practice--back to basics. Number two is that probably the single biggest area of future expansion in orthodontic practice can come from adult treatment. We don't see enough being done to develop that area of practice. Specifically, I think there is either a lack of awareness that this is a different type of practice than the child and adolescent practice, or an unwillingness to make many practice adjustments or to spend the money I feel is necessary to stimulate an adult practice.

GOTTLIEB You are not referring now to treatment techniques, but to public relations.

RUSLEY Obviously, there are treatment skills that enable the individual to treat certain adult patients better, but I am not qualified to discuss that. I am sure there are technical differences in the manner in which you treat and the level of skills needed to do it. If orthodontists do not have those skills, they should get them, because to my mind they want to promote in the community the idea that they are especially skilled or especially interested in treating adults. I am not sure that the average practice gives that appearance.

GOTTLIEB Do you mean limiting a practice to adults?

RUSLEY I don't know if there are any, but I wouldn't be surprised if there are some. I would see it as a natural evolution. One of the problems today is that the older the orthodontist gets, the older his referring dentists get, and the older the GP's patients get. On top of that, there is a reluctance on the part of the older orthodontist to cultivate referrals from the young dentists. He doesn't communicate as well with them as with people of his own generation. For that reason, many older orthodontists are bringing a young associate into their practice.

GOTTLIEB What adjustments and expenditures were you referring to in order to build an adult practice?

RUSLEY I think orthodontists have to create another environment within their practices to accommodate adults. It might even be a separate office, although that provides a lot of scheduling and management problems, and it is expensive. But certainly they ought to provide a physical separation of children from adults within a single office facility. It could be done through scheduling adults and children on different days, but that is a poor alternative, because it is difficult for both practitioner and patient.

GOTTLIEB It restricts you.

RUSLEY Yes. I don't like that idea. The better way to do it is with a physical separation within your office. I think anyone designing a new office, who doesn't take this into account, is missing a good opportunity. The problem most often is that the practitioner has his office set up and it is somewhat expensive to transform it. But, I think he's still missing a bet if he doesn't do it.

GOTTLIEB Do you mean more or less dividing an office down the middle?

RUSLEY I am talking about a separate reception area--furnished differently, more comfortably, much more softly, more of an adult environment as you would a living room for example. I can see doing this very simply by having the reception area separated, at least most of it separated, still allowing the business office to serve both portions of it.

GOTTLIEB You would need a lot of space to divide a reception room down the middle with a partition and have two comfortable areas out of it.

RUSLEY It would be hard to do if the reception area is small, but many practices have large enough reception areas, which could be separated.

GOTTLIEB The reception areas would be separate. The business area would be common. What about the treatment area?

RUSLEY Treatment areas would be separate. I don't believe in common treatment areas for a number of reasons. First of all, the design is atrocious for most adults--juke box playing, colors wild, cutesy type things that don't suit most adults.

GOTTLIEB Most orthodontists would say, "You're wrong. I've asked my adult patients and they love being in with the kids. They like all the action, the youthfulness. Not one person has complained about this to me, and everyone we've asked has said it's agreeable to them."

RUSLEY That's funny, because every orthodontist I've discussed this idea with has agreed with me. It is just supposition, but based on an understanding of people. Now, 25-year-old adults may be in the middle. They may like the action. They may still go to discos and this may still suit their image. I'm talking about the 35- or 40-year-old housewife, who is an important segment of the adult patients. This is a trying time in her life and orthodontic treatment has to be one more traumatic situation. I can't believe that the vast majority of patients in a medical or dental specialty would not enjoy a comfortable, nonthreatening environment. I've got to believe that even the children wouldn't be opposed to coming into a comfortable, secure, quiet environment. I could be wrong about that, but I am convinced that adults would prefer a comfortable environment, an adult environment, a reassuring environment. If orthodontists have gotten the opposite feedback from adult patients, it may be due to a natural reluctance to criticize the doctor or his office environment.

GOTTLIEB Orthodontists aiming to encourage adult patients ought to try to resolve this question with feedback from adults through some third party arrangement, so that the questionnaire doesn't come from and go to the doctor's office.

RUSLEY Bud Ham does this type of survey for orthodontists. The doctor tells him to whom to mail the questionnaires, and they are returned anonymously to Bud.

GOTTLIEB What should be asked?

RUSLEY First, how they feel about being intermingled with younger patients--teenage or preteenage patients. Secondly, do they prefer a totally private environment or one merely shared with other adults. I can envision a two- or three- or four-bay treatment area with dividers in between the chairs for adults.

GOTTLIEB Floor-to-ceiling dividers?

RUSLEY Not necessarily. If the room is carpeted, sound transmission is quite small. Most orthodontists recognize the need for a separate, private, quiet examination area and records area, and the need for a private consultation area. I think the same reasoning applies to separate treatment areas.

GOTTLIEB For children as well as adults?

RUSLEY I don't think the kids would mind it either. Although children may interrelate more and enjoy that, I'm not sure that all of them do.

GOTTLIEB Would you go so far as to have some cubicles in which only adults are treated and separate cubicles in which only children are treated?

RUSLEY Yes. But the adult area could be used for children, when no adults were present, while the children's area would hardly ever used for adults. Yes, I would try to have an office big enough to permit this use of space.

GOTTLIEB You don't want the adults to even see a child?

RUSLEY Preferably not, but it might be necessary, as a practical matter. Adults might enter the children's reception area and walk through it to the adult reception area. The business area in the middle would serve both areas. However, in going to their separate treatment areas, adults would use a passage down one side of the office and children down the other. A middle hallway available to doctor and staff would access either area. This would be an efficient configuration.

GOTTLIEB And there would be two different environments in the two separate areas?

RUSLEY It's the noise that gets me. I don't believe that most middle-aged women want to hear rock 'n roll playing when they can't stand the child playing it at home. And the cutesy costumes and similar ideas that are supposed to appeal to children. I just don't buy that is what adult women want. I also criticize what the practitioner wears when seeing adult patients. I really don't think that wearing a polo shirt and hush puppies is proper professional attire to treat adult patients. I don't see anything wrong with not wearing a tie, but I do think there's an adult method of dress in an office that is different than dress for kids. Children are not going to mind if the doctor wears a long-sleeved sport shirt and slacks and nice shoes. And for case presentations, we are talking about important dollars; and even children's case presentations are made to adults, their parents.

GOTTLIEB Who should do the case presentation for adult cases?

RUSLEY I don't believe in having an assistant do much of the case presentation to adult patients or to parents and child. I know I am outvoted on this, but I think I am right. I know that I resent a case presentation by someone other than the doctor. I don't object to the communications supervisor doing a small portion of it. My objection is to the case presentation in which the practitioner is hardly ever involved. Not only is he the knowledgeable person, but he loses out on this important first contact with the patient and the parents. He may never see that father again, and hardly ever see that mother again. So, I think he should be involved in the case presentation and for as long as it takes. Case presentations need not usually be long. Twenty minutes should suffice for most, but if it requires a half hour or an hour, that's just too bad. That's the way it is. I object to delegation of this totally to an employee and not having the doctor involved in the case presentation.

GOTTLIEB Only if the doctor was bad at it, I think. If the doctor was not as good as the employee, it might make some sense. But, most orthodontists are good at this, and I agree with you that the doctor should do most of it, if not all of it. Particularly since expanded duty auxiliaries in orthodontics are doing the technical tasks very well, this should free the doctor to do the personal professional things.

RUSLEY I think practitioners should always do that which you cannot delegate for someone else to do as well. I contend that you can't delegate the whole case presentation.

GOTTLIEB I look at this as one of those traditional practice builders. If a doctor is not doing this, and he is concerned about building his practice, getting involved in the case presentation is one thing he's going to feel good about.

RUSLEY Absolutely. I tell doctors, "If you are not getting 100% acceptance or in the 90's, you better get yourself involved in case presentations." I can't see any justification for anything being done in an adult case presentation by anybody other than the doctor; and, as we said, whether it is a child or adult patient, you are dealing with adults at the case presentation. And, certainly it should be a very sophisticated presentation without seeming to be slick. In this regard, most employees in orthodontic offices are young, younger than most of the adults they might be presenting cases to, and often are likely to be intimidated and do a poor job of it. Another point is that slide and filmstrip presentations should be very sophisticated and suitable for adults. For example, adults should be shown in these materials. The same is true for office literature. A cartoony brochure showing how toothie moves just isn't appropriate for an adult. Right now, we have the maximum number of treatable adults that there ever will be. How many of them are hesitating to go into a child practice? How many would welcome a practice that specializes or pays special attention to adults?

GOTTLIEB Are dentists referring adults?

RUSLEY More GP's and pedodontists are doing more orthodontics in their own practices, but orthodontists need to do the same kind of job educating the referring dentist about adult orthodontics as they did to stimulate referral of children.

GOTTLIEB What fee policy do you advocate for adult orthodontic patients?

RUSLEY I think adult fees should be in the area of 50% more than child fees, for two reasons. It is my understanding that treatment time is longer for adults; and, secondly, I'm convinced that there has to be more hands-on the adult patient by the doctor than there is with the children.

GOTTLIEB In these uncertain times, many orthodontists are holding back on fees altogether.

RUSLEY I see a great tendency, whenever there is a business decline, to lower fees or to hold fees longer. I think orthodontists who do this are putting themselves at a competitive disadvantage. In our country, there is a direct correlation in the mind of the consumer between quality and price. They assume if you charge more that you must be better, and if you charge less you must not be as good. I really feel that you have to have the nerve to increase fees and have above average fees, to present yourself as being superior. I still don't think there is that much shopping for the cheapest price. People want to go to the most competent doctor in their area. They don't want some amateur treating their mouth, or their child's mouth. Patients can't measure your ability. They can only measure the quality of the referral and what they see in you. If the appearance of the office or the fee are under par, you are making your job more difficult in gaining acceptance of the case. So, I think it is a comparative advantage to charge a little bit more than anybody else charges, within reason. The office environment and how people perceive you is a crucial part of practice promotion. And these days, you want to develop the perception among all the people around you--referring people, staff, patients--that you are something special in adult orthodontic treatment. You are not only a children's orthodontist, as most people may tend to think.

GOTTLIEB Do you think that advertising will play a role in a "quick fix" type of attempt?

RUSLEY I think individual advertising would be suicide for the average orthodontic practice. It doesn't fit the majority public image of a high class professional.

GOTTLIEB One other thing an orthodontist has to think about is the extent to which advertising would alienate his GP and other professional referrers who strongly oppose individual advertising.

RUSLEY Yes, I don't see much of a place today for direct individual advertising in orthodontics. I never heard of a case of a dentist advertising, but what someone else would say, "Look what that fellow is doing. Isn't that the pits." It also tells me that the practitioner isn't successful enough developing a practice in the traditional professional manner.

GOTTLIEB You said there were three things that orthodontists could be doing to stimulate practice growth. Number One was practice building in the traditional sense. Number Two was developing an adult practice environment and encouraging adult patients. What is the third one?

RUSLEY The third area, and the only one that has a chance of being a quick resolution is satellites. I think that satellites are overlooked by most practitioners. Some few states restrict the number of offices one can have, but most do not.

GOTTLIEB How do you describe a satellite office?

RUSLEY I refer to a satellite as a non-full service office. Therefore, it does not require a large investment. If you can avoid doing records, and possibly banding, in the satellite, then the cost of the satellite is insignificant.

GOTTLIEB How big a distance from the main office would be all right for that type of arrangement?

RUSLEY If it is too far, you have to do banding in the satellite. However, if you go a hundred miles away and you are reaching out to an area that has no other alternative near it, coming to the main office one time wouldn't be terrible. You might do records and consultation at the same time. In most cases, you are talking about a relatively short distance, within 25-30 miles. If it will be a one-time or two-time visit to the main office, I don't see a problem. Of course, emergencies have to come to the main office. The easiest way is to locate on the periphery of a rural area. Then there is really no choice for the patient. Anyway, if you go out to meet them part way, they don't really mind coming into the main office occasionally, because the alternative is all the way all the time.

GOTTLIEB How do you select the satellite location?

RUSLEY You look at the demographics of the area and the number of competitors there. Competition alone wouldn't prevent you from going there, if the area was big enough. There is one other consideration, which is whether to have a separate office or to sublet in someone else's office. There is no question that if you are located in someone else's office and that someone else is a GP, that office will be your sole referrer in town.

GOTTLIEB It's all right if he is the only dentist in town.

RUSLEY Yes. Nevertheless, it will cut down on dentist referrals almost entirely. That doesn't mean I wouldn't put a satellite in a GP's office if he has a big enough practice, or with a group and they refer many of their patients to you. In that case, the situation is the reverse. Their patients are not likely to go elsewhere, if you provide them with a quality service. Usually, one GP cannot support one orthodontist. So, it would have to be a pretty large practice, a regional practice. And, you don't go there very often. You can go as little as a half a day a month.

GOTTLIEB What do you think of the general atmosphere of this type of office--subletting, possibly using portable equipment? Isn't it just as significant to have a professional, comfortable office in a satellite?

RUSLEY I don't think it is a crucial problem. The alternative is to equip your own office and use it a limited amount of time. It is possible to share an office with a different specialist and have it done tastefully. But, chances are that most satellites are not going to be as efficient or as desirable as the main office. You couldn't have separate facilities for adults and children, for example.

GOTTLIEB One could have an office at home, some distance from his main office.

RUSLEY I haven't seen one, but it is a possibility.

GOTTLIEB It used to be popular, but I don't see too many of them these days either. It seems to be out of vogue, but it is a way of having a satellite reasonably.

RUSLEY Since nobody uses his office all the time, the easiest way is to move into someone else's established office. There is no capital investment to speak of. You just pay rent, and usually the rent is at a bit of a premium for the furnished office. Of course, paying a premium in rent is also a way of showing your gratitude to the GP for the referrals you are receiving.

GOTTLIEB And, perhaps, for covering emergencies at the satellite location.

RUSLEY Yes. Also, scheduling is a problem out there and it might be done by the practitioner's office personnel. The orthodontist could offer to pay the GP's secretary for that service, say a half a day's pay or day's pay a month. Well, that locks in her loyalty. I think this is one of the most subtle, yet direct, things one could do to help a satellite practice.

GOTTLIEB You say you would even consider a satellite on a half a day a month basis, and I know there are many of them on that basis. What kind of a service can you render if you are not available for emergencies or at convenient times for the patients?

RUSLEY Just being there makes the satellite a convenience for the patients, and it is a selling point to the GP that it makes it more convenient for his patients. I would only do examinations and adjustments there, unless it was a long way from the main office. The services you are doing there are not that sophisticated that the quality of treatment would be jeopardized.

GOTTLIEB Unavailability might still be a problem.

RUSLEY Yes, but assuming there is no one else around that they can go to, whatever you are giving them is better than what they had before.

GOTTLIEB I guess a 25- or 30-mile trip for an emergency is not very great these days.

RUSLEY It might even be a negative incentive against appliance breakage, if there is a long trip to repair the damage.

GOTTLIEB The big problem about satellite offices, and some consider it to be the biggest, is transportation of personnel and records.

RUSLEY Yes, you have boxes of supplies and records that are dragged out with you.

GOTTLIEB Personnel do not like to travel to satellites.

RUSLEY That's right. They don't like it. None of them like it. Let's face it. Nobody likes the satellite. So, you only do it when you are trying to expand your practice. When you have all the patients you want, you don't do a satellite. On the other hand, it is a source of income that is hard to cut off, and I don't know anyone today, with the use of auxiliaries the way it is, who has more practice than he can handle. You might pay staff a little premium because they work longer and harder that day. You see a lot of patients in an inefficient environment. A bit of a premium in pay might help the staff get over their feelings about it. Certainly, they shouldn't travel out there on their own time. It is a bad mistake not to pay them for their travel time.

GOTTLIEB I know many practitioners who lose personnel because of satellite situations. They have a big turn over in personnel, because staff doesn't like to go to satellite offices.

RUSLEY Of course, when an employee comes into a practice with a satellite, part of the employment basis is that they know that on the appointed day you go to the other office.

GOTTLIEB What do you think about buying a practice as an alternative to establishing a satellite office?

RUSLEY I am not sure that too many people know how to buy a practice and what to do with it. It may be the most dangerous alternative of all. You can get a consultant to walk you through it, so I wouldn't rule out exploring that possibility, but only after the other alternatives have been explored. The others are easy to do. You could open a satellite tomorrow afternoon, if you get a GP to let you use his office. That is an immediate solution. Of all we talked about, that's the one I'd consider Number One, because it is the easiest to do in tandem with the practice promotion and the adult factors.

GOTTLIEB Outside of the satellite situation, how do you recommend promotion of dentist referrals?

RUSLEY I think that far and away the soundest, safest source of referrals is patient referrals. Dentist referrals can be jeopardized by beating him at golf or other personal animosities that have nothing to do with dentistry. It can go overnight. Dentists can be fickle. So, I don't prefer dentist referrals. Yet, the quickest way you can get started is to get a busy practice referring to you. You should not ignore that, and stay after it. But in final analysis, I don't want any one referrer to do too much for my practice. The solidest referrals are patient referrals, and there is safety in numbers.

GOTTLIEB Do you have any advice for orthodontists on practice evaluation? How do they begin to find out what's wrong?

RUSLEY I really feel they have to bring someone in from the outside. No one evaluates his own situation objectively. You have your own defense mechanisms and ego to interfere.

GOTTLIEB How do you choose a consultant?

RUSLEY Dissatisfaction with consultants has resulted from trying to tie consultants to needs that are not suited to their particular talent. I am excellent at financial planning and corporate planning, so I am not really an expert at practice promotion. Someone else is better at practice promotion, but not at the financial end. So, I would look for the consultant with the specific knowledge and qualifications you need, and get references from people he has done this job for.

GOTTLIEB Does a financial evaluation come first?

RUSLEY As with patients, you would start with a general survey. A person who isn't feeling well doesn't know what specialist to go to. He has a generalist or an internist look him over first. In the same way, an orthodontist needs a general review of his practice. This need not be very expensive. Generally, it might be the equivalent of one case fee. The orthodontist has to be certain that the person he hires for this will refer him to other people for problems to which he does not have the best answer. The job is usually too complex for one individual to do it all himself, let alone the orthodontist himself. But, I wouldn't hire a consultant unless you really want to do something about what is wrong. Some people do not have the real desire to follow through and do what is necessary to do.

GOTTLIEB There may be hard solutions.

RUSLEY They shouldn't expect the solutions to be easy. They almost never are. If they were that easy, the orthodontist would be able to work them out himself. If he isn't sure what to do, chances are there is no easy answer. I don't believe in gimmicks or simple solutions, but most of the things we are talking about are just common sense. But there is also a fear factor here. Doctors may become so fearful that they become irrational and self-doubting. They need someone to come in from the outside and sometimes the best thing we can do for him is to tell him it's OK, that he's doing what he can do and to relax.

GOTTLIEB Confidence in any human endeavor is so important, whether you are trying to hit a golf ball or gain acceptance of an orthodontic case.

RUSLEY Confidence comes from success. Successful practice should be the constant building on a solid base of success. I see too many practitioners looking for easy answers to their problems, and they aren't doing the fundamental things correctly--treating well, running the office well, presenting the case well. Practice can be an organized success story or a very disorganized, haphazard enterprise or lack of enterprise.

GOTTLIEB Consider an orthodontist whose practice is declining, let's say 10%.

RUSLEY And put inflation on top of that.

GOTTLIEB Yes, a 10% decline plus the effect of inflation. In that event, how many of the things we have been discussing should he be doing?

RUSLEY All of them, but I would especially do a satellite whenever I wasn't busy full time. I don't care if you are growing in the main office. Any time you don't have enough practice where you are, or don't see it coming in the near future, do a satellite. If you have need for the patients, you almost cannot do too many satellite arrangements.