JCO Interviews Avrom E. King on the Successful 1990 Orthodontic Practice

GOTTLIEB In our previous interview (JCO, November 1979), you discussed three tiers of dentistry and orthodontics emerging as a consequence of radical cultural change. How does that look two years later?

KING I am not aware of any responsible student of the future who does not agree that ''pivot periods" do in fact occur, and that we are now in the middle of one. Indeed, most futurists would agree that we are a bit past the midpoint of today's pivot period. Every person is being affected by this profound change, not just orthodontists. This is not a phenomenon reserved for people with a college education or an annual income above or below a designated amount, or only certain occupations, or only people who live in a certain area. All of us are affected, here and now, and the effect in dentistry and in orthodontics has been and will continue to be an emergence of three tiers of practice as I described in our last interview.

GOTTLIEB We have to discard the old chestnut that "the more things change, the more they stay the same"?

KING You bet. As a result of the pivot period phenomenon, we are beginning to witness a degree and quality of change that is without precedent, at least for the past 500 years. The change which we are now contemplating is not sequential; it's not an extension of what was; and it goes far beyond a change in technique, materials, or equipment. It is an attitudinal change, which reflects and expresses change in the fundamental value system of the culture. What's happening today is, by reason of magnitude and unpredictability, an historically unique experience. The disjointed, sometimes frantic, quality of this experience is generated by a perception which most of us already share--an erosion of continuity and of predictability in many important aspects of our life.

GOTTLIEB In this unpredictable period, how can we know what the future environment will be like?

KING Through the use of advanced futuristic techniques, it is now feasible to largely define the emerging value systems. For example, let me discuss the VALS program, a three-year study undertaken by Stanford Research Institute. VALS is an acronym for Values and Lifestyle Study. No doubt you're aware that Stanford Research Institute is one of the world's great research facilities. Their presence as the designer of this study and its field-research agent imparts great credibility to the overall program. I think it's important you also recognize that nearly 100 corporations such as Citibank, Ford, General Telephone, R.J. Reynolds, Sears, Time, and Xerox have underwritten the cost of this program--a program that is in fact the largest and most comprehensive study of social attitudes that has ever been undertaken. I think the results of this study are compatible with the idea of a pivot period, as I discussed earlier, and if you come to accept the VALS representation of both the world that is and the world that will soon be, you will have defined the social environment in which you will be practicing orthodontics.

GOTTLIEB That would be good to know. How does VALS define our present environment?

KING Beginning in the early 1800s, those who already lived here were joined by a fast-increasing stream of immigrants who shared a sense of what we call the American Dream. Life was not easy for most people, but most people had a vision of the possible, not merely the probable. The VALS people tell us there was a Darwinian principle at work here. Many who wanted to immigrate didn't or couldn't or died in the attempt. The mortality of those who did arrive was unbelievable by our present-day standard. Learning New World survival skills and coping strategies required a high level of energy and shrewdness in what was often an unsupportive and sometimes a hostile environment. But even as they lived in ethnic ghettos, these survivors had a motivating sense of the American Dream.

The Great Depression was another ultimate test of personal resiliency and resourcefulness, but this time of the individual, not his personal possessions or material trappings. The result was an alteration of values--the difference between what Stanford Research Institute calls "survivors" and "sustainers" The VALS data indicate that these sustainers and their value systems are the progenitors of the society that we now know. When the virtues of the middle class became the cultural ideal in the 1910s and '20s, these sustainer values became inseparable from a formal class structure. But the leveling of that class structure and its material possessions by the Great Depression caused a reformulation of sustainer values in the late 1930s and the early 1940s.

GOTTLIEB What remains of the American Dream today?

KING VALS data suggest that the American Dream can be likened to an island in the middle of the river which causes the river to split. Both parts of the river flow around the island before they join together. One of these branches, VALS indicates, is wider than the other; it attracts and can accommodate substantially broader remnants of the sustainer values. The other branch is narrower and, at least initially, less favored by those who hold sustainer values. Let me draw you a diagram of that.

GOTTLIEB What kind of people are in the wide branch of this river?

KING Those who were attracted to this course as a way of absorbing the American Dream reformulated their sustainer values into membership in what VALS calls the "belonger" group. Belongers feel a heavy identification with traditional middle-class values. They are strongly home-oriented. Group membership is important to them, and they tend to maintain visible evidence of their group identity through conspicuous purchasing decisions--for example, their home, their car, their clothes, where and how they travel. They are conformers.

In this wider branch of the river, VALS tells us there is another group called "emulators" who aspire to follow the life patterns of those who are seen as more successful. Although some individuals spend their adult lives as emulators, data indicate that most emulators are in a process of transition from belonger to "achiever" status.

The achiever group has a strong work ethic, and achievers are greatly inclined to find the same work ethic in others, especially their children and their employees. Members of this group tend to be technologically innovative; they manifest a high level of self-confidence; they are competitive. For them leisure as well as work must be busy and productive. To do nothing, or to create a situation in which one can respond with spontaneous abandon to the desire of the moment, is somehow seen as a waste of time--perhaps even immoral. Achievers manifest a high need for control.

GOTTLIEB Would you say that many orthodontists belong to the achiever group?

KING Yes, I think so. Achieving the best is what achievers mean by success, and their lives as achievers are importantly oriented to being successful. For them, home and office are simultaneously both display and symbol--that is, home and office are a symbol of attainment and power, often a symbol of security, but home and office are also a display, a quietly conspicuous statement that is discernible only to other achievers, who understand the nuances of achievement and who recognize from them that the owner is a worthy person.

GOTTLIEB But, doesn't VALS find that achievers are more a symbol of yesterday than tomorrow?

KING Isn't that remarkable? For those of us who share achiever values, it may be difficult to accept, but the VALS data are quite specific. VALS finds that these three groups--the belongers, the emulators, and the achievers--represented about 71 percent of the adult population in 1980, and that by 1990 that percentage will have declined by 12 percent to 59 percent of the total--slightly more than a majority. A shift of about 16 million adults over only a 10-year period.

GOTTLIEB Are they moving to the narrow branch of the river you described?

KING Yes. There are three groups in the narrow branch. VALS refers to the first group as "I-am-me"--a fiercely individualistic and highly narcissistic group whose members delight in satisfying personal whim. The I-am-me group is an early, developmental phase for many, but the data suggest that only a few linger here for more than a few years.

The second group identified by VALS in this branch of the river is what they call the "experientials". Experiential group members are opposed to vicarious, second-hand or nonparticipative input. Members of this group are extremely future-focused, and they tend to be ideational trend-setters. Unlike the first group, the experientials have a broader sense of relationship, a greater awareness of and sensitivity to the needs and the integrity of other people.

The third group in the narrow branch of the river in the VALS study is called "socially conscious". Members of this group have extended and refined the community sensibility of the experientials into a true cosmology, which gives them what one commentator has called a "Spaceship Earth" orientation. Their identity with a local community is no less than yours or mine, but unlike most of us, they extend their sense of identity to the whole of the earth and beyond.

GOTTLIEB How rapidly will movement in this direction take place?

KING VALS found that in 1980, 15 percent of the total adult population was primarily influenced by one of these three groups; but that in just 10 years, that percentage will increase from 15 percent to 26 percent, an attitudinal shift which involves nearly 15 million people.

GOTTLIEB Are you suggesting that even though the groups in the narrow branch of the river are a minority, they are becoming increasingly influential?

KING Yes. The VALS data overwhelmingly suggest that even as the numerical majority of the population will remain in the belonger, emulator, and achiever groups, the dominant cultural ideology will be established by the minority in the narrow branch of the river. Seen in this perspective, many of the conflicts of contemporary life begin to make more sense. For example, our political leaders still generally represent achiever values, but the politically sensitive, politically aware, politically involved segment of the total population increasingly represent experiential and socially conscious values. The result is predictable: fewer and fewer people become involved with the political process as the frustrations of those who are aware become more and more dominant. I'm using the phrase "political process" in the broadest possible way--for example, how dentists see themselves in relationship to organized dentistry, or how clients see themselves in relationship to dental offices.

Here's a series of parallel comparative statements prepared by the VALS staff which summarizes the values shift they perceive as under way: "from quantity toward quality; from the group toward the individual; from abundance toward sufficiency; from formality toward flexibility; from fads toward fashion; from complexity toward simplicity; from spendthrift toward frugality; from waste toward conservation; from the phoniness of role toward the authenticity of genuineness; from the traditional toward the experimental; from the mechanical toward the personal; from the efficient toward the pleasing; from the impressive toward the meaningful."

GOTTLIEB But then the branches in your diagram come together.

KING Yes, and as the two branches flow together, there is another group--the "integrateds". Here are some of the words and phrases which VALS uses in describing these people: "an inner sense of what is fitting and appropriate; balanced; psychologically mature; accepting of self; high level of integration relative to foibles and flaws, strengths, aspirations, and relationships; altruistic; strong sense of mission; global perspective."

GOTTLIEB How does all this relate to orthodontic practice in the future?

KING I think that this study is extremely pertinent to the 1990 practice of orthodontics. We can argue that individuals who in their own lives share the values of the achievers, experientials, socially conscious, and integrateds will best support the growth of an orthodontic practice during the next decade. If the material I've shared with you is essentially valid, it points toward a set of very practical and concrete considerations. The changes that have occurred in the past in orthodontics, clinically and managerially, have been sequential extensions of what was. Now, however, because of the pivot period phenomenon, orthodontics is rapidly becoming less molecular in its techniques and much, much more integrative in its processes. Now this is an easy hypothesis to prove. Suppose I asked you to ignore all practical considerations and bring together a group of 20 or 30 orthodontists whom you greatly admire. Imagine that I asked all of you to privately record your responses to a series of questions. Let me share these questions with you, and you speculate about how you or the members of your group would respond.

Do you think that over the next 10 years, you and the orthodontists gathered with you will become more occlusally sophisticated? Will you become increasingly aware of the periodontal implications of your work? Is it likely that you will have more shared communications and joint clinical efforts with prosthodontists, oral surgeons, and crown-and-bridge dentists in your communities? Will you and your colleagues find an increase in the percentage of children in your practice with mixed dentition? Will you tend to become clinically involved with children at an earlier age in 1990 than in 1980 or 1970? Will you see an increase in both the number and percentage of adults in your practice? Will surgical orthodontics become more common? Do you anticipate that treatment plans prepared by you and your colleagues over this 10-year period will make more use of functional appliances? Would you anticipate that you will become increasingly sensitive to the influence of airway impediments on the finished orthodontic result? Is it likely, therefore, that your utilization of ENT consultations will increase? By 1990, will you and your colleagues make greater administrative use of computer technology? And will you clinically be utilizing computer technology? I believe it is virtually certain that you would respond affirmatively to all or most of these questions. Our research data and the projections which they support indicate that an affirmative response is absolutely appropriate to every one of these questions.

Now assume also, if you will, an average 10 percent rate of inflation over the next 10 years, 100% inflation in 10 years. Is it likely that your practice gross will double? And if it does, consider what impact that increase would have on the organization and management of your practice. Do you think that the number of orthodontic procedures undertaken by other than orthodontists will increase over the next 10 years? I do. Our data also tell me that, expressed in 1980 dollars, a $750-900 orthodontic fee will be broadly available through Tier I and Tier II dental offices. What does this mean to you and your practice?

GOTTLIEB What does that mean for an orthodontist who chooses to have a Tier III, fee-for-service practice?

KING At risk of oversimplification and perhaps overstatement, I think that in another 10 years or so, we'll not be able to find very many examples of modest or average productivity in Tier III dentistry--especially Tier III orthodontics. You know, orthodontists are confronting new competitive agents and agencies. But these new competitive factors are cultural, not merely economic. If we respond on the level of economics by, let us say, only striving to reduce fees or increase patient flow or concern ourselves only with the industrialized measurements of efficiency in the delivery of an orthodontic service, then we misunderstand the problem and we will inevitably corrupt our attempt to find a solution. The solution is conceptual, not technological.

Of course, there is another danger. When we respond to a cultural challenge with an economic response--reduction of fee or expansion of patient flow or augmentation of efficiency--the ultimate result is that we reinvent the closed panel or the contract dental office or the retail practice. Our primary opportunity is to first create a practice model which encourages the propagation and prosperity of these emerging values I discussed and then, second in position but not in importance, to do so with a high sense of economic efficiency and productivity.

GOTTLIEB When you speak of efficiency and productivity, it's clear that the staff will play an important role in establishing a successful 1990 practice. But, how does one go about finding a staff that is in tune with the emerging social values you've mentioned? Is there a key to identifying these people?

KING Yes, we have been able to discover a characteristic life theme which is highly predictive of this capacity. We call this theme "discriminatory response". Discrimination, as I am using that word; refers to a process by which a person has a set of concrete experiences that are refined and purified and ultimately extended and applied to another set of concrete experiences. Our data indicate that the presence of discriminatory response is a function of how a person makes choices, and so we identify this response in those aspects of a person's life where the potential for choice is the greatest--that is, in personal activities, interests, and opinions.

GOTTLIEB How do you identify that discriminatory response?

KING To show how, let me share with you interviews I had with two dental hygienists. Both ladies had the same professional training, and both responded to my questions with a shared interest, but in very different ways. These will be condensations of interviews which actually took about a half-hour. The first lady is Sally, a 27-year-old hygienist who, at the time of the interview, had been part of a large orthodontic practice for four years. She was one of nine staff members. I began the interview by saying, "Sally, tell me a little bit about what you enjoy when your time is your own". Almost immediately she responded, "You know, I'm really interested in food. I love to cook. For me, it's a creative experience, not at all the dull drudgery which some people talk about. I've come to think of herbs and seasonings as I imagine an artist must think of light and shadows. Even when a meal's quick and simple, it can still be special. And, you know, lately I've become fascinated by nutrition. Even the biochemistry of nutrition has become interesting to me."

"When did your interest in food begin?" I asked. "Well", she explained, "I was just a little girl, probably only 6; my mom had been terribly sick--she was in the hospital for nearly a month, and then she was confined to bed for another month. During that time I remember helping my dad in the kitchen. It was a very special time for me. There was extra closeness between us, not only because we were both scared about my mom, but because preparing meals was a shared activity. I remember him bringing a chair over to the drainboard so I could help clean salad greens, and I remember him letting me stir a pot of soup. When my mom got better, she was really surprised at what a good kitchen helper I had become, and so I just started to help her. We were a simple family" Sally continued, "and we ate simple food. I never really got involved with anything fancy until I went away to college. My first serious crush was a senior in the school of architecture. He has leaving the next year for a year of study in France, and so he was really interested in French culture. He was the one who introduced me to French cooking, and I just loved it--a whole new world that I hadn't known about. I started reading about French cuisine, and that brought me to northern Italian cooking. You know, I can still remember my surprise at finding out that Italian cooking was something other than pizza and red sauce. After I got married, the Air Force sent my husband to Spain--what an experience! New food, new seasonings, new combinations. After we returned and I completed my hygiene degree, I got really involved with the science of nutrition, not just the esthetics. That's when I started to wonder whether I could, find a way to adapt some of the classic dishes of European cuisine to present-day nutritional knowledge.

"That's sort of become a hobby of mine. I get a lot of pleasure in creating a dish that preserves classic taste and appearance and aroma, but is nutritionally sound. Until a couple of years ago, I'd mostly cooked for the pleasure of myself and my family, but then I started to share these recipes with friends. My doctor suggested putting some of them in a binder in our office, and now, when somebody's interested in a particular recipe, we photocopy it right away on our own office machine.

It's really neat for me to see a person's gratitude, and I love talking to people about their experiences with recipes. It's fun getting their feedback and sharing in their satisfaction. As a matter of fact, I'm hoping to quit work in a year or so to have a baby, and when that happens I have a secret plan: I think I'm going to write a cookbook. Won't that be a kick?"

GOTTLIEB It sounds as if Sally would get high marks for discrimination.

KING Definitely. What Sally has said is indicative of a high discriminatory response. This lady's experience does not involve fixed obligations of work or family. She's describing a series of choices which she makes in her personal life. The experiences are concrete; more important, each set of experiences represents a process, each set of experiences has a beginning, a middle and an end, but the end isn't really an end--the end of one set of experiences marks the beginning of a new set of experiences for Sally, each set of experiences becoming a further refinement and purification and extension and reapplication.

Note also, please, that these experiences have a certain narrative quality to them. They are not fragmented; they are not isolated; they are highly integrative, each with each and each with her life. Notice, too, that many areas of her life are involved. She talks about childhood memories, a college romance, experiences shared in her marriage; her professional education becomes interactive with these antecedent experiences, and this gives her a new set of activities. Observe that she's future-focused, that the set of experiences she's now enjoying have a reference point beyond today. She's thinking ahead of today's reality in a way that joins today to tomorrow. I think you'll agree that her experience, as she relates it, is not linear--there's a certain spatial quality to it. Overall, we sense a certain direction, but it's not fixed or formal. Notice, too, that her speech is picturesque and evocative; her conversation is visual; she creates images in our mind. This seems to be a characteristic of highly discriminating people.

Her experience reveals a couple of very important personal characteristics. While there is an overall direction to her life, her behavior manifests a capacity for spontaneous response and, as well, a toleration of ambiguity. She is able to merge new locales, new environments, with the reality of her own identity, as she did when she accompanied her husband to Spain or as she contemplates leaving employment that is clearly important to her for a new status as a mother. In this regard and throughout her narrative, notice that those activities which satisfy her have two dimensions: first, her satisfactions are internally satisfying to her, her cues are from within, not outside of herself; second, she is truly a helper--her satisfactions are also importantly related in reaching out to others; she feels good when they respond positively to her work, her efforts.

GOTTLIEB How much of that is ego satisfaction--a desire to be seen as a significant person?

KING That is involved, but much more; there is also an altruistic, even a spiritual, quality that is part of her satisfaction. Of course, she enjoys the recognition accorded to her. But I suspect that she would rather publish her recipes anonymously than not have them available to people who are important to her. Finally, her narrative reveals a certain quality that we can call existential: her behavior suggests that Sally functions marvelously well in the here and now. Oh yes, she remembers the past and she plans for her future, but to Sally there is value in today which goes far beyond its transitional value to tomorrow. As part of this existential outlook, I sense that Sally finds her life an array of choices. She did in school; she did in Spain; she does in her dental office; she no doubt will in her motherhood. It's not that her environment is enriching; it is instead that she enriches her environment.

GOTTLIEB Of course, Sally sounds like an exceptional person.

KING I freely acknowledge that Sally is an exceptional person. Indeed, she is a prototypic representation of what I mean by a discriminating response. As we listen to her and observe the choices that she makes, it's easy to see in her life an ongoing process of experiential refinement, purification, extension, and reapplication. I think you'll enjoy the contrast of the next interview. As I relate it, please keep in mind what you've just heard in Sally's remarks, compare your impression of both ladies with staff members whom you have known over the years, and consider how they would feel about each of these hygienists. This will, again, be a highly condensed version of the interview. This one is with a hygienist named Louise, age 44, who also was employed in a large orthodontic practice.

As with Sally, Louise is prototypically exceptional. She demonstrates, to a degree that is seldom found in a person, what we would call a low, or flat, discriminatory response. I began in much the same way. "Louise" I said, "I'd really like the opportunity to learn a little about you as a person. I wonder if you'd share with me some of the ways in which you enjoy spending your own time" She paused and said, "I'm not sure what you mean by 'my own time' I guess all my time is mine". I replied, "It certainly is; I agree. But in my life, I find that I have more choices open to me during some hours and some days than during other hours and other days. Has that been your experience?" "Well", Louise told me, "when you have a husband, three kids, and a full-time job, all the hours and days seem to get pretty full". Let me pause for a moment and ask you to think about these few initial words which Louise offered me.

What is she really saying? What does she seem to be telling us about herself, her attitudes, the way she sees the world and her place in it? Of course, it's not fair or feasible to reach a firm conclusion based on just her two sentences, but here are some of the tentative thoughts which her remarks prompted in me. Louise seems to be distancing herself from me; she's holding me at arm's length. She is not sharing. She chooses to be closed instead of choosing to be open. She's using words and word games to build a wall between us. I sense a certain rigidity in her. Her mildly argumentative posture suggests just a bit of hostility.

GOTTLIEB That's a lot of interpretation to put on a couple of sentences.

KING Yes, but I learned later on from our research findings made after this interview that, if my initial impressions about Louise were strengthened, there is only a remote possibility that we would find evidence of significant discrimination in Louise. Later on I'll tell you why.

GOTTLIEB Is Louise an appropriate person to have in an orthodontic practice?

KING Regardless of whether Louise was an appropriate person to have in a 1950 or a 1960 or a 1970 practice, I think you will soon come to understand that there are reasons why, in 1980 and 1990, Louise should not be employed in an orthodontic practice. For now, let me continue with the interview.

After some more preliminary conversation, mostly distancing maneuvers by Louise, she said, "Sometimes I enjoy cooking." "Tell me about it," I encouraged her. And she quickly said, "Well, I don't always enjoy it". Now let me interrupt Louise for another comment. Do you hear what she's doing? She gave me a feeling, begrudgingly and with modification. "Sometimes I enjoy cooking." But then, having given that feeling to me, she took most of it back. Instead of responding to my invitation to tell me about it, she further modified her statement: "Well, I don't always enjoy it."

At this point, my impression grows that Louise is not comfortable in sharing, that she's not expansive, that she is not in charge of herself, that in fact she is not a free person. She seems to have anger within herself; the range of options which she sees as open to herself is apparently narrow and drab. I don't find effervescence or happiness in her. My feeling is growing that Louise cannot determine her own future, that she is manifesting what some commentators have called a "victim mentality': in which she perceives her future as largely already determined by fate and circumstance, not choice and opportunity. In the actual interview, I chose to not respond to her further modification. Instead, I said, "I'd like to hear about your enjoyable experiences in cooking" She began with another modification: "We eat pretty plain and simple food; I suppose you'd call it American food or maybe Midwestern small-town food, but I do get satisfaction at having a nice meal on the table and not taking much time in doing it."

I wanted to be supportive of her effort to share, and so I said, "I sure can understand how that would be satisfying to you, what with your full schedule. How do you do it?" "With systems:' she told me, "and organization." Her response was quicker and contained more feeling than anything she had yet said. "On Friday night I prepare the menu for the whole week, right down to the kids' school lunches and our breakfasts. I do all my shopping on Saturday. Every evening I usually am able to prepare at least part of the next day's supper, maybe a soup or a prepared salad or at least a salad dressing." Again, let me comment. Her enthusiasm centers upon effectiveness, not affectiveness, on external structure--for example, the clock and the calendar--not internal feelings. I asked, "Do you remember when your interest in cooking first started?" "Sure', she said, "as a kid it was one of my chores." Again, external structure. A chore is something imposed upon a person by an external agent or agency. I asked, "Are there certain dishes which you especially enjoy preparing?" Her immediate response: "Not really." Then she said, almost as an afterthought, "But we almost always have fried chicken on Saturday."

It surely is possible to think of Louise's systematic organization as an aspect of refinement. But unlike Sally's narrative, which was expansive, what Louise is telling us is constrictive. There is a process to the experiences of Louise, but it is a fixed and rigid process rather than spontaneous and circumstantial. The weekly regimen which Louise describes does not lead to a new set of experiences; her regimen only leads to a new week, in which the prior regimen is then repeated. As I listen to Louise, I sense that a high level of imposed order is important to her, that the absence of that order would be disorienting, even disabling.

GOTTLIEB Orderliness is useful in an orthodontic office.

KING But don't you agree that our first lady, Sally, was also organized in her life? Here's the difference: the organization which Louise is displaying is linear rather than spatial, fixed rather than spontaneous. It is an organization which is imposed on an isolated set of kitchen experiences. There is no doubt in my mind, having completed this interview with Louise, that she has other organizational systems in other aspects of her life, and that each of them is quite comparable and similarly isolated. We've come to recognize that lack of integration is indicative of the absence of meaningful discrimination. Throughout Louise's interview--certainly in the part that I've shared with you--I don't find a concern with growth, change, adaptation. She focuses instead upon control. In the place of adaptation, I hear a dependence on repetitive, almost ritualistic behavior. For example, "We're having fried chicken for dinner tonight; well, it must be Saturday." Spontaneity and the toleration of ambiguity do not seem to be acceptable behaviors to Louise. Her attitudes do not suggest or support warmth. For her, life seems to involve the need to satisfy a series of fixed and sometimes heavy obligations. I don't hear the level and quality of warmth and personal satisfaction which literally radiated from Sally's recitation. In summary, Louise does not seem to offer us in her personal choice-making examples of global and integrative refinement, purification, and extension of experiences. She represents what we have come to recognize as a low or flat level of discriminatory response.

GOTTLIEB Is a person born with this discriminatory response?

KING What I am calling discriminatory response is a learned behavior. We do find that the identification of one highly discriminating person in a dental office greatly raises the probability that we'll find others in the same office. And when we find an office in which the dentist and the staff are highly discriminating, we invariably also find a discriminating clientele, a very high level of economic productivity, and remarkably much less evidence of interpersonal stress than is found in typical offices of average productivity.

Now, this is very important. What I'm here calling a discriminatory response directly relates to economic productivity. Virtually by definition, a discriminating person is more open to the benefits of a discretionary service and more inclined to subjectively value it. We see this everywhere in the world. Why not orthodontics? For example, the rather large difference in retail price between a Cadillac and a Chevrolet cannot be explained by the rather small difference in cost of manufacture. When an orthodontist grasps the fact that value is largely determined by subjective perception, a remarkable series of changes occurs in his perception of practice management. Perhaps the most basic is this: Productivity is not primarily an economic phenomenon. Productivity is attained as a consequence of relationships. The consequence of relationships is economic; but the cause of productivity is social.

GOTTLIEB If discriminatory people naturally flock together, then wouldn't a discriminating orthodontist attract a discriminating staff without even trying?

KING Our data indicate that in personal and peer relationships, a discriminating dentist will almost certainly select discriminating friends, associates, and staff. However, some otherwise discriminating dentists do unconsciously seek out nondiscriminating staff members. The explanation for this seems to relate to a dentist's preferred management style and his or her need to maintain an authoritarian relationship by propagating a passive, submissive, and dependent staff.

GOTTLIEB With a staff as talented as you've described, could the orthodontist simply attend to his orthodontics and let the staff manage itself?

KING No. In fact, we can now show that the historic separation of the clinical and the managerial aspects of practice, a tradition derived from the industrialized medical model, is really a spurious separation. A British management expert, Charles Handy, in an article in the January/February 1980 Harvard Business Review entitled "Through the Organizational Looking Glass', identifies what he calls the three failing assumptions of the industrialized era. There is no doubt that the history of the industrial revolution is a working out of what Handy regards as the first now-failing assumption--the formula which tells us that "concentration plus specialization equals efficiency". His discussion of the second failing assumption--that labor is a cost--is for me pure magic. He's correct, of course. By tradition and training and inclination, we do regard labor as a cost, and by tradition, training, and inclination, we seek to minimize cost. A highly discriminating staff is a primary asset for a 1990 successful orthodontic practice, and like all assets it should be maximized, not minimized.

Handy tells us that our traditional need to assume that hierarchy is natural is the third failing assumption. Dentists, especially orthodontists, tend to be compulsive, and it is a clinical truth that compulsive personalities. have a high need for control. That's why it's so difficult for dentists to consider an alternative to this third assumption. In the active presence of these assumptions, which Handy has identified as failing, the managerial attitude is certain. It is what we have come to recognize as being part of the industrial model. But, if Handy is correct and in today's world the assumptions are failing, then it follows that one's managerial attitude must also change.

In the March/April 1980 issue of Harvard Business Review, in an article entitled "Managing the Paradox of Organizational Trust', the author, Louis B. Barnes, who is a professor of organizational behavior at Harvard University's graduate school of business, finds that managers whose selection, training, and role models have been importantly influenced by the assumptions of the industrial era tend to make three assumptions, that each of these assumptions is singly defensible, but that in combination the synergy of the three assumptions is today organizationally devastating. First is the "either-or" assumption, which tells us, he says, that all important issues naturally fall into one of two mutually exclusive territories. The implication of this assumption is that every hard or important question has one and only one hard or important answer, that if one searches with enough energy and tenacity one will ultimately find the single right answer. Sometimes we find orthodontists who are so submerged in the either-or syndrome that they focus compulsively on occlusion--either it's optimally right or it isn't optimally right--and they do so at cost of forgetting that the occlusal relationship is part of someone's face.

The second assumption, which is clearly related to the first, tells us, according to Barnes, that "hard" data is always to be favored and is always intrinsically superior to "soft" ideas and speculation, and that, further, in the real world hard drives out soft. The third assumption is also related to the first two assumptions, but less visibly. It's sometimes called the "nice guys finish last" assumption. This assumption teaches us that it is reasonable, practical, and justified to have a pervasive mistrust of the world around us. Barnes talks about a distortion of the golden rule which he finds prevalent in organizations. This distorted rule states that "people will soon do to you what they perceive you doing to them". That one statement is the most compact and efficient argument which I can offer in favor of organizational trust.

GOTTLIEB How does one develop organizational trust?

KING Behaviorally, we know that your willingness to disclose a bit of yourself will be quickly sensed on an intuitive and an active level by others who share this willingness. Invariably, those dentists who are able to be genuine have a remarkable ability to attract staff members who manifest the same ability. No one is born with this ability; it is a learned trait. The presence or absence of it is usually an indication of how, as very young children, we learned to interact with the world and whether we learned to regard the world and those who live in it as deserving of our trust. We also know, based on literally tons of hard data, that warm, empathetic, accepting people are attracted to small groups in which there is open, authentic sharing. And we know that these kinds of people are repelled--that's right, actively repelled--by small groups where they sense they cannot find this quality of sharing.

GOTTLIEB What about an orthodontist who finds it difficult to share himself or herself with others? How does this kind of person attract warm, empathetic staff members?

KING Several years ago, I remember functioning as a facilitator with a dentist and his staff who were attending a participatory management workshop. About midway through that three-day experience the dentist said to his staff, " I have an awful lot of difficulty in sharing with you some of the feelings I have about you." At that moment, the message and the medium were one! Simply by telling them that it was difficult for him to share, he was in fact sharing. The statement he made was simple and honest; it was an act of true intimacy, and it was a point of beginning for this practitioner and his staff.

There is a developmental managerial principle that tells us, "It is more time-efficient and cost-effective to help people learn to amplify their strengths, rather than learn to remedy their weaknesses". This is a basic principle of developmental management. Should your readers want more information about it, they can review your interview with Dr. Charles M. Sorenson, which appeared in JCO in October 1980. The validity of this principle has been proven in the private sector over and over again. I accept the principle as an operational truth of enlightened management. As a dentist and staff learn, within the dynamic of small-group interaction, to concretely identify each other's strengths, each of these people is also identifying and sharing those skills and abilities which are relatively not strong. As I suggested through the example of my friend the dentist, the process by which strengths are identified is an act of intimacy. But there is this related point: the process of team-building facilitates each person learning to manage his or her relative weaknesses within the group. If I am able to share sufficiently to tell the group that sharing is difficult for me, we can together create a team in which the ability of others to share supports my own relative inability. This is much, much more effective than striving to remedy that deficiency by an alteration of my behavior, which is a thankless, difficult, inefficient, and perhaps impossible task.

GOTTLIEB If an orthodontist and staff can learn to work together as a team in this way, what are the tangible benefits for the practice?

KING A very important and influential study appeared in 1974 in the Columbia Journal of World Business. It was entitled "Organizational Innovations in Sweden" and it was an attempt to find shared principles which were predictive of success in organizational innovations. Success was defined by the authors of this article as an increase in productivity, an increase in the quality of the work that was produced, and an increase in the happiness of workers, based both on their subjective reports and on such objective criteria as job turnover, absenteeism, and the learning of new skills. Let me give you the five principles which the authors found in those organizations which did achieve success through the introduction of innovative management concepts. First, participation in the decision-making process increases the commitment and motivation of participants to carry out the decision even by those workers who do not favor the decision that was made. Second, the small group, not the individual worker or the individual supervisor, is the most efficient agent of change for producing improvement in productivity and worker happiness. Third, the team has unity of purpose because team members have come to share goals and objectives. Fourth, for this unity to be optimally productive, the team must have responsibility for tasks--the definition of them, the allocation of them, the prioritizing of them, the scheduling of them, and the means for accomplishing them. Fifth, a sense of completeness and satisfaction with a task is enhanced when members of a team participate in the total task.

Our own research and a careful study of managerial innovation in the United States and Canada leads me to offer these additional principles. The structure and climate of the small group should encourage members to have a client relationship with each other as well as with clients. The individual's personal and professional growth are intimately related; they cannot be separated or treated as isolated entities. Each individual, through the team, should have responsibility for costs as well as production. Synergy within the group is amplified when each team member has uniquely distinctive as well as shared skills and resources. And synergy is also amplified when the individual members of the group perceive a relationship between their rewards and their achievements, and between their achievements and the achievements of the team. Growth cannot be ordered; it cannot be required; it cannot be installed or coerced. But growth can be encouraged--first, by selecting people with a high capacity for growth, and second, by creating an organizational structure and climate which favor behavior that leads to growth.

GOTTLIEB So, productivity in the orthodontic office cannot be discussed only in economic terms.

KING As I said earlier, productivity is a social, not an economic, concept. The economic virtues of productivity are a highly desirable, but secondary, benefit. It is also clear that the ability of the manager to influence productivity is greatly limited by a dependence on techniques and systems--what Barnes calls "hard data" In comparison, the soft ideas which Barnes described are potentially capable of greatly amplifying productivity. I believe that productivity is a social--that is, a relational--benefit of free enterprise; and that free enterprise, in turn, is an organizational concept which extends and enhances human freedom, dignity, and creativity. This begins to suggest to me that the mode of compensation--not simply the amount, but the mode--must be reconsidered, because the mode of compensation conveys a nonverbal message to your staff. The idea of wages is derived from industrialized factory management. It is a mode of compensation which tends to isolate people from their efforts and to deny their individual differences in favor of constructing externalized standards for the objective measurement of a quantitative work process. The idea of wages is derived from fixed job descriptions, short-term assessment, and marketplace determination of cost. The result is that people who favor compensation by wages are inclined to manifest low discriminatory behaviors.

In comparison, the idea of fee is inherently appealing to people with a highly developed sense of discrimination, because the mode of compensation affirms individual differences and supports the integration of people and their efforts. It seems to me that the successful person-centered orthodontist must--I repeat, must--look forward to creating a work environment in which the staff person and the orthodontist learn to be comfortable at negotiating an annual fee for services. The frequency of payment is not the issue here. The fee can be paid at whatever interval is mutually satisfactory.

GOTTLIEB Would you develop the fee/wages idea a little bit more?

KING The act of one person paying wages to another person implies that the payer has the right and the responsibility to establish standards of performance. When you pay wages to a person, you are probably imposing a quantitative standard on that person's sense and expression of excellence. You're measuring the quality of his or her output in terms of 60-minute hours or eight-hour days or four-and-a-half-day weeks or 52-week years. Of course, I understand that you aspire to excellence and that in every way you share that aspiration with everyone else. But, I'm asking you to consider whether there is a basic incongruence in challenging a staff member to become responsible for attaining excellence in self, and then paying for their effort quantitatively--so many dollars for so many hours. You say to an employee, "If you come in at 7 A.M. and stay in the office until 4 P.M., and if you take no more than two 10-minute breaks and a 50-minute lunch, and if while you're here

you complete the assignments listed on this job description, and if you do all this without excessively annoying me for four days a week, 50 weeks a year, then you'll receive a gross salary of $185 a week". As a matter of fact, the payment of wages generally creates the need for a job description, which is externally manifested and objective. But the payment of fee generally creates and supports a task orientation that is internally derived. When I ask for a fee, I'm contracting to give, not get; I'm contracting to give the best and the finest level of care, skill, and judgment which I can provide. It's also clear that the idea of wages involves a short period of assessment compared to fee. In only a few weeks, we claim to know whether an employee is worth his or her salary, but consider how much longer is required for a client to know if an orthodontist is worth his or her fee. Of course, what we're talking about here involves the relative presence or absence of what we defined earlier as the discriminatory response. That is, people who manifest evidence of high discrimination in their lives will feel better about the notion of fee than wages.

GOTTLIEB Many of the concepts you've been discussing may seem difficult to put into practice for a practical-minded orthodontist. Is there anything concrete such a person could begin working on today to prepare for the 1990s?

KING Fortunately, we can begin quite simply--with the office. First, in my opinion, an orthodontist who aspires to a Tier III practice must in every way separate him- or herself from the medical model. Were I an orthodontist, I would not consider having my office in or near a hospital or as part of a medical center. Everything I've learned tells me that my best opportunity for growth is with those people who are most discomforted by the traditional medical model of sick care.

GOTTLIEB What else can an aspiring Tier III orthodontist do about his or her office?

KING It is also my opinion that the tooth fairy has a cousin who, as an interior decorator, specializes in bland dental offices. Perhaps that tooth fairy's cousin is the reason why so many offices suffer from a deadly dull sameness. It's quite usual to find furniture in the reception area of any office which could be lifted intact and put in any other office without disturbing the decor or attracting the attention of either staff or clients. Most offices have been designed to be pleasant, comfortable denials of individuality. They are intended to mask, even deny, the personality of the orthodontist in favor of a certain blandness that is universally inoffensive and assures anonymity. Genuineness, authenticity, and congruence are the foundation stones of trust; coolness, distance, and anonymity are, within the emerging culture, personal turn-offs.

GOTTLIEB How can an orthodontist let a patient sense genuineness and authenticity through office decor?

KING I'm familiar with one office in which one wall is papered with photographic blow-ups of geodesic survey maps. This dentist, who loves backpacking and mountain climbing, has used a red felt pen to mark on the wall the routes he has hiked and the peaks he has climbed. I know of another dentist who has placed a computer in his office and, because he enjoys the activity of programming, has created a series of special, dentally oriented electronic games. As each child enters the practice, a file for that child is opened under his or her name, and a staff member shows the child how to bring up that file, enter scores into it, and keep a running record of dental progress. Kids even leave messages for each other in the computer. So do the dentist and staff members.

If you're bored by backpacking, it wouldn't be congruent to put topographic maps on your wall. But for each of these practitioners, what they have done is authentic. These are acts of intimacy, not tactical maneuvers. The list is endless; the ways are infinite. Large expenditures and a professional decorator are not required. What is required is a desire to share a bit of yourself as you really are, not merely in your doctor role. I cannot tell you how you should decorate your office, unless I choose to impose upon you the matrix of techniques that has been the mark of industrialized dental consultants. Since it's clear that the fixed order of how-tos has not been effective in the past even in the industrialized cultural environment, there is no reason to expect that these old ways will be any more effective in the emerging values I've talked about.

GOTTLIEB Let's say that my office is genuine and authentic and that I have hired a discriminating staff. Am I destined to be better off than other orthodontists in the emerging culture?

KING I think so. As I, the client, begin to perceive, nonverbally and preverbally, these qualities about the physical facility and the people within it, I am separating your practice from what I thought I knew about all practices. Already, you see, a process of subjective enhancement of value is under way. It's what separates the Cadillac Seville from the Chevrolet Caprice; it is what imparts a distinctive aura to your practice which in the eyes of the perceiver means that you are not offering the same or comparable service as other orthodontic offices. Of course, what I am describing here is the starting point of an ongoing and complex process. If I begin to perceive new value in your service, and then a week or a month subsequent I have a jarring, inconsistent, or incongruent experience, I will probably react very, very strongly. I will feel a sense of betrayal as well as disappointment. It's important to me that you understand the risks. When you seek to transform orthodontics from a set of clinical procedures into a unifying and joyful experience, incongruence becomes a serious offense which will probably stimulate my energetic adverse reaction.

GOTTLIEB If my practice is so distinctive, what does that imply about the way I charge for my services?

KING In the absence of pain, bleeding, or swelling, the decision to accept the services of a dentist is a discretionary decision. This means that those dentists who choose to provide other-than-necessary services--and surely that includes orthodontists--do not primarily compete with each other. Instead, they compete with others who provide discretionary services--with realtors, kitchen remodelers, travel agents, automobile dealers. Acceptance of fine dentistry involves a subjective desire much, much more than an objective need. Well, when dentistry is perceived in this way, the behavioral dynamic of dentistry is radically different than either the history or the tradition of the profession. While members of the dental profession are fond of insisting that they are professional people who individually provide a professional service, there is an overwhelming industrialized tendency on the part of dentists and orthodontists to price dentistry and orthodontics quantitatively, by the procedure or by the unit or by the minute or by the service or by the visit.

GOTTLIEB But, the crux of Tier III practice in all of its features is the public's perception of difference between my practice and all other practices, is it not?

KING Ah, that is the nub of it. By reason of the three-tier delivery system, as well as the social and cultural changes that we have been discussing, it is imperative that the aspiring Tier III orthodontist not offer a service which the public perceives as essentially identical to the service offered by other providers. It is imperative that the aspiring Tier III orthodontist learn to provide a service which some people will happily choose to purchase because it fulfills, even elevates, their expectations. If my subjective perception of the services you offer enhances the value of that service to me, I'm glad to pay for it. As a matter of fact, people love to pay for what they want. Ask any jeweler, travel agent, or owner of a camera shop or stereo store. Perception of value creates attitudes which lead to behaviors that are manifested in purchasing decisions. Not discretionary income, not educational level, not social class, not sociological data about family of origin--it is perception of values which creates attitudes which lead to behaviors that are manifested in purchasing decisions. That is a cultural fact of life today. This formulation is not immoral or unethical; it is not manipulative. The indisputable fact is that people love to pay for what they want. The open question is whether you and your staff can learn to better provide a service which is unique, distinctive, and culturally pertinent, and which is a congruent expression of who you are, in a way that will be greatly valued by your clients and your potential clients.

GOTTLIEB At this point, many a successful orthodontist may be thinking, "Why should I make such radical changes in my office, my staff, even my personality? I've been successful in the past and I have changed with the times in the past. Why wouldn't I naturally continue to succeed?" What would you say to that orthodontist?

KING I would say this: I know that over the next 10 years, you'll no doubt redecorate your office, learn new clinical skills, change banks, buy a computer, expand your staff, perhaps seek an associate. I don't belittle the worth of these kinds of changes. I simply ask you to ponder whether changes of that caliber would likely be enough in the midst of a pivot period.

We can now largely define the emerging value system. With this understanding, it is also feasible to develop modes of accommodation. Please understand, accommodation does not mean compromise. Accommodation does not mean giving in. Accommodation involves one's individual capacity to integrate--not abandon--to integrate his or her values with new realities. What I am calling accommodation will, in coming years, correlate highly with success--however you want to define that elusive word. Some people will stubbornly hold to old ways; other people will uncritically embrace new ways. The probability is that neither of these groups will prosper, the first because of a lack of resiliency, the second because of a lack of integrity.

GOTTLIEB Does this have special implications as the number of adult patients increases?

KING Yes, because when adult clients are served by a discriminating staff, their potential as missionaries is beyond compare. They want your service; they freely chose your service, and they will be energetic in recommending your service both to adults and children. For example, we now know that the presence of adults in an orthodontic practice that is appropriately managed actually stimulates the flow of children into that practice because of the missionary zeal of the adult client.

GOTTLIEB You believe that the best way to attract adult patients is simply to hire a discriminating staff?

KING Our initial field work with orthodontic staffs and a great deal of subsequent data strongly support this conclusion. The presence of high discriminatory response in a staff member's personal choice-making is highly indicative of her capacity to interact effectively with adult orthodontic clients, regardless of her age. The converse statement is also true: The absence of significant discriminatory response in a staff member's personal choice-making is highly predictive of her inability to interact effectively with adult orthodontic clients, regardless of her age. Please accept my assurance that the data supporting these statements are overwhelming. The correlation simply cannot be denied.

You see, the decision by an adult to begin orthodontic treatment is never an isolated decision. It is almost always a decision which is part of a comprehensive life-change process. When we listen carefully to what adult orthodontic clients tell us, their decision to begin orthodontics relates to other, non-dental considerations--for example, the decision to return to school, re-entry into the employment market, mid-life career change, divorce or remarriage, and so on. The decision by an adult to seek and accept orthodontics is, in itself, an example of discriminatory behavior. As a group, we find that adult orthodontic clients share a high level of discriminatory response in their personal choice-making. Orthodontics is merely one example in what we've come to recognize as a continuum of personal choices. Now, you see, it's much, much clearer why staff members with high discriminatory response interact effectively with adult orthodontic clients. It is because these clients, by reason of seeking and accepting orthodontic treatment, are acting upon a discriminatory response. They feel good about each other; they relate effectively to each other. With an adult client, the discrimination of the staff is the primary basis for enhancing the value of orthodontics.

GOTTLIEB Does the same formula hold true for children?

KING This process of enhancement of value is much more complex with young people. Dentists, especially orthodontists, begin the clinical processes as quickly as possible and hope somehow that along the way that person will come to understand that the doctor really does have his or her interest in mind. Furthermore, in dentistry--especially orthodontics--the fix-it mentality of most practitioners applauds this process in the name of a clock-derived efficiency. Perhaps the most blatant example in all of dentistry is the orthodontic tradition of offering a solution, quoting a fee, and asking for a commitment after allowing the relationship to ripen sometimes for only 10 or 15 minutes. This quick, industrialized procedure is especially dangerous with young clients, who lack the maturity and the commitment of the adult, whose psychosexual development leaves them temporarily uncertain of their own identity, and who are not using their money to pay you for your professional services. This procedure is rescuing, not helping; it involves you, the orthodontist, accepting ownership of my problem of malocclusion, and it invites you to impose the solution upon me.

GOTTLIEB How does one help rather than rescue young patients?

KING Rescuing is a process by which the rescuer accepts ownership of the problem in order to impose on the client a solution which is favored by the rescuer. Helping, in comparison, is a process by which the helper assists the client to determine whether there is a problem and then to understand the range of solutions that is available and what the likely cost of each is, and then finally to challenge the client to take an appropriate action. Appropriate to whom? Appropriate to the client, not the helper. This process is complex, and when the helper strives to help prior to the client deeply feeling the empathy, acceptance, and warmth of the helper, the helping process is seriously jeopardized.

GOTTLIEB How can an orthodontist establish this empathy, acceptance, and warmth with young patients?

KING All right, assume that my son is your client. Assume that prior to case presentation, my son will be appointed to spend 15 or 20 minutes in your office on two separate occasions. Assume that on both of these occasions, the same member of your staff will be available to work with my son. Assume that on the first of these appointments your staff person will remain with my son, and that together they will have a real-life opportunity to watch you work in lots of different mouths, that on this visit my son will have the opportunity to talk with lots of different young clients in your office who are at varying stages of treatment. Assume that on the next scheduled visit, my son and your staff person, who have now started to become friends, will have the opportunity to sit together in a corner of your office, and that my son will develop a tactile familiarity with the materials of orthodontics--the wires, the bands, the brackets, the elastics. Your staff person will help my son to self-discover some of the physical characteristics of these materials prior to their being inserted into his mouth. Assume that when I first brought my son into your practice, I and my son together heard you or a capable staff member explain the importance of his knowledgeable participation in orthodontics, and that therefore these two appointments were to give him an opportunity to better understand what would occur in his mouth should he and I decide on treatment. Now my son is concretely learning that you and your staff do truly care about him, that you're open to receiving his feelings. And he and I both know that you accept him as he is, because at this point neither he nor I have yet authorized treatment. Something else is happening during these two appointments: the staff is learning to assess the likelihood that my son will be a noncompliant client.

GOTTLIEB In our last interview, you mentioned a correlation between compliance and future-focusing, the ability to envision the future in concrete terms. Is that what the staff would be looking for here?

KING Yes, it's important that the orthodontist and staff strive to quickly identify those youngsters with a low capacity for future-focusing, because these are the children who need special support and attention. We find that a mentor relationship with an individual staff person often helps them gain a sense of security, and that this staff person, in her relationship with the child, can provide reinforcement by compressing the time frame between event and a reward to a degree that the more future-focused child would find obnoxious. Often--not always, but often--during the two years or so that the child is in active treatment, the staff can stimulate extraordinary development in the child; this is, of course, spiritually satisfying to the staff, and it constitutes the single most significant form of job enrichment--helping another person to grow. It also assures you and the staff of a more compliant young client and, therefore, a more satisfactory clinical result.

GOTTLIEB Earlier, you said that functional appliances would be used increasingly over the next ten years, and there is evidence that that is so. This is going to make identification of noncompliant children even more important.

KING If our opinion is verified over the next 10 years, then certainly the orthodontist and staff will want to become more and more expert at the early identification of noncompliant children, since the success of the functional appliance so much depends on the cooperation of the young client. What I am advocating is that the orthodontist and staff learn to avoid the classic situation of saying to a child, "Steve, have you been wearing your elastics?': clinically knowing full well that the child has not. That question presents a lose-lose situation. On a preverbal level, the child reasons, "If it's so important that I wear them, how come the doctor can't see that I've not? And if he can see that I'm not wearing them, then why is he asking me such a stupid question?"

GOTTLIEB What else can the orthodontist and staff do to be successful with young patients?

KING Let me return to the assumptions I was making about my son's involvement with your office. Assume that he will be present with me at the time of the case presentation. I think it's very important that he is. If he is not, then we are nonverbally emphasizing his passive and subordinate role in an endeavor which requires his active participation to achieve optimal success. Or if he's present, but you talk only to me about my agenda, then you're sending him a mixed message. He and I have related, though different, needs for information. Suppose that early in his treatment, my son is introduced to a graphic representation of where his teeth are now and where you hope they will be at the completion of treatment, and suppose that at regular intervals and using a large scale that will easily demonstrate a small movement, that progress chart is updated. This graphic representation supports and enhances his capacity to future-focus, because he now has a realistic means for envisioning the course of therapy. Suppose that a staff person has the regular responsibility of participating with my son in the updating of this chart, and suppose this staff person has the innate skill to facilitate his expressing his questions and concerns. Suppose that at regular intervals--our experience indicates that every five to eight weeks is appropriate--I am invited to come into the office with my son for an updating of his progress. Suppose that using the chart, he learns to report his own progress, that a staff person is present supportively, but that increasingly he learns to internalize responsibility for attaining health, and that during the course of treatment, he becomes less and less dependent on externalized authority. Suppose that you, the orthodontist, briefly visit with us as a way of confirming h is progress and, equally important, as a way of affirming the wisdom of the decision which we made to place ourselves in your practice.

GOTTLIEB And--equally important--enhancing him as a referrer.

KING Yes. You see, every major purchase creates what marketers call "post-purchase dissidence"--the after-purchase wonderment by the client of whether he bought too quickly, whether the price was right, whether the supplier is competent, whether he should've sought another opinion. The well-planned progress meeting in which a parent sees his or her child as an active participant in a creative process is a telling way of reassuring parents that they made an appropriate decision. Recently a friend of mine paid $34,000 for a Mercedes-Benz. We were at lunch with a group of people, two of whom also drove Mercedes. My friend immediately questioned them about the reliability of the car, the integrity of the dealer, availability of parts, mileage, and so on. Now, these are all appropriate questions before accepting delivery, but after delivery they constitute post-purchase dissidence. My friend was seeking confirmation that he had made a good decision. The parents of young clients do likewise. When the efficiency of their decision can be subtly affirmed and confirmed, they hold great potential as referral agents.

GOTTLIEB We have been talking about techniques that could be considered tactics. Yet, you have said that tactics won't work.

KING But, you see, I am not offering these techniques as tactics and strategies. I'm offering them as examples of what some orthodontists are now doing, because these actions, for them, are authentic expressions of their individuality. If you want a factory model for orthodontics, it is available, but not through me. What I am proposing in its place is a person-centered practice that is consistent with the emerging social and cultural values and that permits you to create a physical and a relational environment in which value is enhanced. I cannot offer you the proverbial recipe book which emphatically tells you, "Do this, do that, do something else, and fame and fortune will surely be yours" Instead, I am telling you that if you do this and that because someone tells you to, fame and fortune may follow you, though that's much less certain than even ten years ago. But, if you want fame and fortune, and if you achieve it based on the tactical maneuvers of others, I think you will pay a dreadfully high price for it. You cannot slow by a millisecond the vast array of cultural changes already under way. You cannot bring back even one yesterday. But you can understand what is happening. You can lose your fear in the certain knowledge that an informed, aware, caring person will surely prosper--especially when so many others are devastated by the very changes which offer you potentially both challenge and opportunity.

GOTTLIEB Avrom, on behalf of our readers, I want to thank you for once again showing us an aspect of orthodontic practice with which most of us are not familiar, but which will undoubtedly have a crucial influence on practice success and happiness as we pass through the 1980s and into the 1990s.