JCO Interviews O.A. "Bud" Ham on Practice Management

GOTTLIEB In a JCO Interview last month, Avrom King discussed the Tier III orthodontic practice that he believes will be successful in 1990. Do you have a similar vision of the future, and how will the orthodontist's ability to manage his staff affect his success?

HAM I've become a little more pragmatic and say that the successful orthodontist will have a high-fee, high-quality practice. This will require a commitment to excellence in every part of the practice from facility to continuing education. The orthodontist who chooses that level of practice cannot do it alone. The doctor cannot really use himself well in his practice, if he does not have staff people who have developed a high degree of ability to manage themselves. In the really well-managed practice, the orthodontist is spending his time doing that which is most productive in terms of his education, training, experience, and expertise--the things that only he can do.

GOTTLIEB Is there a particular style of management that works best in this kind of practice, or is there a variety of appropriate styles? Will the authoritarian style of management traditionally favored by orthodontists be successful?

HAM Authoritarian style in an orthodontic practice is somewhat different than it is in business and industry, because the manager in business and industry has typically had much more management training. If he wants to be an authoritarian, I think he is better able to get his mission accomplished because of this training. it makes him a better manipulator. If you talk about the style that would work best for an orthodontist, I think you have to examine his basic philosophy--what he wants his practice to become, how he wants to use his staff. There are still some orthodontists who, in my opinion, use staff people as tools. They're for a specific function and purpose, and if they fulfill that expectation, he's happy. The authoritarian style of management is still quite common and has worked well in past years. It is less successful today, I believe, primarily because of changes in the expectations of certain socioeconomic levels in our society.

GOTTLIEB Whose expectations are changing?

HAM The worker's expectations. An unskilled laborer can probably, even in today's culture, be managed successfully in an authoritarian way. Some of the same would apply--maybe to a lesser degree of effectiveness--with a semiskilled worker. I suspect it is even less effective with highly skilled workers--such as many orthodontic staff members. I think the truly successful orthodontic practice of the future must have skilled people who have a long-term commitment.

Certainly some of the factors that cause turnover are outside the orthodontist's control--a staff person becomes pregnant and decides to quit, or her husband is transferred. Some of those factors are changing today. If the staff person is very well paid, her salary becomes a serious consideration in the decision on whether the family should move.

In the successful practice of the future, the doctor will understand managing today's people in today's value system and culture. Some orthodontists aren't after the top-line, high-caliber, heavy committers; they're after a short-term commitment on the part of the staff person. I think that this ultimately influences and perhaps dictates the level at which they practice. If the orthodontist has a highly trained staff working with him, and if he has learned how to orchestrate that group--to help them manage themselves--then the practice is maturing nicely.

Part of this has to do with salary, and today I strongly believe the orthodontist is competing directly with business and industry. If the health profession is going to deliver excellence, then not only must it pay competitive wages, but probably it should pay more than business and industry. To me, there is more of a necessity of having highly dedicated, highly competent people in the health professions, because they are directly influencing the quality of people's lives. I think we could build a case that it's almost immoral not to have the best talent available in health practices.

GOTTLIEB Are you advocating, then, a participative management style for this practice that is dedicated to excellence?

HAM We hear a lot today about participative management, but I think we still have a lot to learn in terms of how it's best applied in today's culture and today's working situations. I believe that participative management is different in each practice. Every orthodontist is different in terms of his comfort level, in terms of his ability to communicate, in terms of his ability to work with other individuals. Those factors have to be coupled with--and even multiplied by--the competence, maturity, and commitment of the staff. I think that if the orthodontist can come to understand that "effective levels of participative management" is just another way of saying that you have developed teamwork to a high degree, then he can understand how the members of that team are involved in managing themselves.

GOTTLIEB How does participative management work in the operatory? For example, I know one very successful orthodontist whose state law permits him to let his assistants look at the mouth, decide what needs to be done, do it, and then at their discretion call him over to see if they did it right.

HAM What that's saying is you have a well-trained, well-educated person--educated in the sense that she understands the dynamics of what's going to happen if she changes the archwire--and you're letting her exercise her talents. When we talk about utilization of chairside assistants, we must consider legality of activity. Perhaps equally important is the comfort level of the doctor.

GOTTLIEB I can see participative management in the administrative end of the practice. But after all, the operatory is where the major activity of orthodontics goes on.

HAM Yes, that's where the action is. We were talking about the career chairside assistant, the long-term employee. This person may reach a burnout point where it's no longer interesting and challenging and fun, unless she's permitted to actively participate. Orthodontics, in my judgment, has an edge over other dental practices in the opportunity to do challenging, interesting, active things, and so there's the potential, at least, that the staff person can be highly motivated for a longer period of time. The staff person works to satisfy her need for money, status, recognition, but the bottom line is self-esteem. Self-esteem can start to diminish if she's bored with her job.

GOTTLIEB Would rotation of jobs help in this scheme of things?

HAM It can be useful provided the person is doing it because she wants to do it, rather than because she's assigned to do it. Rotating the lab technician to the front desk as receptionist is probably counterproductive. But there might be some other combinations where rotation would be genuinely useful. What we can have with cross-pollinization is an increased understanding of the problems of the other departments, and it can provide some flexibility of coverage and some value in terms of the staff people being motivated by a new challenge.

GOTTLIEB Does the mere status of working in an orthodontic office compensate for low salary or an authoritarian environment?

HAM To some extent; that's one of the reasons why, in my opinion, the health professions have gotten by with paying lower salaries than other businesses--because the persons who are attracted to work in the health profession achieve a lot of personal satisfaction from what they do. In the past nine years, I've interviewed well over 2000 staff persons in dental offices. One thing that becameabundantly clear is that most of the staff people in dental offices work there because they like it. So the professions haven't been pressured to pay more.

If we go back and talk about motivation, we would be talking about anything that contributes to the self-esteem or feelings of self-worth of the staff person. I think it can be very clearly said that if the staff person likes himself or herself better because they work in that particular practice, he or she will be a high producer--a motivated individual. Conversely, if what they do there diminishes their feelings of self-worth, that has a devastating impact on their ability not only to produce, but to learn.

GOTTLIEB What contributes to their feelings of self-worth?

HAM A lot of things, and salary is certainly one of them. If every time the staff person thinks about--and I'll say "herself', because the vast majority of staff persons is female--if she has a negative feeling every time she thinks of her pay, that reduces her ability to produce. By the same logic, if every time the orthodontist thinks of his income, he gets a gut ache because he's unable to afford some of the things he believes he should be able to afford, it reduces his ability to deliver excellence. So the staff person's ability to contribute to the excellence of the practice is, in part, affected by how she feels about her pay.

GOTTLIEB Are you saying, in spite of Herzberg and others agreeing that money isn't motivational, that it's still a Number One measure of success in our society?

HAM I agree with Herzberg that money is not a motivator, but he also says that it is the single most important hygiene factor. In other words, unless it is maintained at a satisfactory level, it decreases the employee's ability to produce. Significantly increasing the salary above that satisfactory level will not increase productivity.

GOTTLIEB Would you say that the disparity between what an orthodontist takes in from the practice and what his staff is paid does not lead to a healthy relationship?

HAM I don't believe that's nearly the problem most orthodontists think it is if we're talking about a staff person who likes her job and sees herself as a career-oriented individual. These persons do not have bad feelings about their doctor driving a Mercedes. On the other hand, if they are having trouble buying gas for their rusted-out Volkswagen, there's a problem.

I think we underestimate the ability of the staff person to understand money and finance and economics. They may not be very well versed in those areas, but they have a basic understanding that the doctor has invested years of his life and tons of money. I don't think an orthodontist who earns $150,000 a year has a thing to be concerned about in terms of his staff's attitude, if they know they are being paid fairly for the community--if they don't have buddies working in a like job with like talents who are significantly outdrawing them. But there can be serious resentment if the dentist is earning top pay in his profession and the staff person is just barely above the poverty level.

GOTTLIEB Do you believe that a doctor should be as stand-offish as maybe a hundred percent of orthodontists are about what he earns? Would he gain anything by opening up and involving his staff in the finances of the practice?

HAM I have to answer that two ways: yes and no. Yes, if he has career-oriented, highly committed people working with him. They develop a sense of proprietorship in that practice. What we're after is a practice that is really seeking excellence in the utilization of people--and that includes the doctor and all the staff. A major factor here is that all of them have adopted the concept of integrated goals. There are a lot of different ways of explaining what an integrated goal is, but the bottom line is that if the staff person believes that "if the practice does well, I too will do well" then we have integrated goals. I consult with several practices in which the doctor and the staff sit down at the end of every year for a planning session; in this session they assess all the things they accomplished in the past year and all the significant failures of the year. Then they identify all the things they want the practice to achieve in the ensuing year, and they try to be specific. Part of these objectives have to do with how much money they're going to earn. If we're going to talk to the staff about the dollars the practice needs to produce to meet its objectives, the staff people must understand where that money's going. It's a sad thing when I ask a staff person how she feels about her doctor's fees, when she doesn't have enough information to tell me how she feels about them.

Part of the staff person's motivation has to do with money--no question about that. They need to have a feeling of comfort with the money side of the practice; they need to be comfortable discussing money with parents of adolescents and with adult patients, and even with juvenile patients if they should ask. It's almost impossible for a staff person to be comfortable discussing fees, if she has no concept of the financial system in the office.

GOTTLIEB You've been speaking of a committed, highly motivated staff. What if the practitioner decides his staff isn't really functioning the way he wants it to, and he either doesn't know how to upgrade their abilities or he has better people readily available? Should he have any qualms about firing inadequate personnel and trying to hire better personnel, as against limping along with what he has?

HAM Oh, I have very strong feelings about that. I believe that when you hire someone, you have a moral responsibility to help that person succeed, because it is terribly damaging to almost anyone to be fired. If they cannot succeed or will not succeed, then you have to take other actions. Let's say the doctor has an existing staff that in his assessment is mediocre, and he says, "I'm going to go for excellence" I think the wrong thing for him to do is to dismiss his staff as quickly as he can and hire a new one. The right thing for him to do is to employ some good, well-established principles of management.

GOTTLIEB Of course, the practice that is in that boat probably has a doctor who hasn't paid much attention to managing his staff. Does it follow, therefore, that he has to do something about himself before he can significantly improve his personnel?

HAM Yes, it does. He needs to improve his basic understanding of management concepts. I don't mean that he needs to become a psychologist or that he needs to have the understanding of a Peter Drucker, but I don't believe it's difficult for the average orthodontist to understand some basic principles; I think they can be laid out rather clearly.GOTTLIEB It's interesting that in the JCO Practice Study, the biggest influence on growth from a management standpoint was found to be the use of consultants.

HAM I'm not surprised at all. I know specifically of practices where the consultant contributed unbelievably to the growth of the practice, to the systems the staff people work in, and to the orthodontist's peace of mind. That's another big factor: If the orthodontist has a clear understanding of his alternatives in handling a given situation, then he has greatly reduced stress. The most uptight people I know are those who have the fewest alternatives when they're confronted with a problem.

GOTTLIEB In putting together this ideal staff of highly motivated people with little turnover, it must begin with selection.

HAM It certainly does begin with selection of people. I know a lot of orthodontists choose to work with the 18-to-22-year-old age group. Some of the reasons, I suspect, are that typically they learn quicker; they have great finger dexterity; and in a largely adolescent practice they seem to communicate better with the adolescents than somewhat older women do. Perhaps there are also more of that age group available in the labor market. I suggest to my clients, however, that if they want to get rid of the turnover problem, they start looking at the 28-to-32-year-old age group. The person who is 28 to 32 has a greater probability of having her life in order, of being a little more stable. It's entirely possible that the person in this group has already had whatever children she may want to have, and that her husband is more stable in his job. The 18-to-22-year-old also has, generally speaking, a lower level of personal maturity. I think you need to go for a little older group of people, some of whom have had considerably more experience in the work place and have developed some good work habits. If they haven't developed good work habits, it's important to be able to identify that and not hire them. On the plus side, the older person is probably looking for a more stable employment situation and has a much greater probability of being long-term. On the down side, you have to pay them more, and it will probably take them longer to develop new skills.

GOTTLIEB Which side do you fall on in hiring experienced or inexperienced personnel?

HAM I don't think that should have nearly as much weight as it's typically given. If an orthodontist has two or three chairside assistants, and for some reason in a very short period of time they're all going to leave, then I can see why he would press to hi re an experienced person, who doesn't have to start out at ground zero. But I think that in most situations, where you're going to replace one employee or add an employee, there should be far more emphasis put on hiring people with talent and maturity than with previous experience. I don't think it takes very long to bring that kind of person up to where they're a profitable, contributing member of the practice.GOTTLIEB You talked about how to find maturity, but how do you find talent?HAM There are a number of ways to do that. I believe the Selection Research, Inc. system of Dr. Chuck Sorenson is, without question, the most sophisticated method of selecting talented people. There are some other ways the orthodontist can improve his batting average in hiring people. I think the orthodontist, or the staff person who does the screening and interviewing, needs to write out the questions they want people to respond to. There are some rather obvious ones, but unless they're written out, in the heat of the interview you'll forget a lot of them.

GOTTLIEB What are the most important, least obvious questions?

HAM I think there are two. The interviewer should ask, "What are your strong points?" I know SRI agrees that immediately the person should be able to list two or three strong points. Very commonly a candidate can't do that, but if the person can say, "Oh, I am a good worker; I really am a happy person, and I'm orderly' right off the top of the head, that indicates that here's a person with a fairly high level of self-awareness. I believe a person with a low level of self-awareness will always have a fairly low level of personal maturity. On the other hand, a high level of self-awareness doesn'talways indicate a high level of maturity, but I think there's a pretty good correlation. Then, after some other questions, I would ask, "Now, what are your weaknesses?" Again, they should give you one or two. If they can't, it either indicates that they're not being completely honest, or that again they have a low level of self-awareness. Either way it's bad.

GOTTLIEB How seriously would you take their answers? For instance, you ask, "What are your weaknesses?" and they say, "Well, I really am pretty shy; I have trouble conversing with people"

HAM If you were thinking of hiring that person as a receptionist, that eliminates her. If you were hiring that person to be a lab technician, however, that might not be all bad.

GOTTLIEB You believe, then, that you need a good set of questions to ask prospective employees.

HAM Yes, but the orthodontist can work with other practitioners in a study group, or with his own staff if they're fairly mature, and develop his own list of questions. There doesn't have to be a hundred of them, but there should be 15 or 20 such as, "Why do you want to come to work in our practice?" "How does your husband feel about your working full-time?" or part-time or whatever the situation might be.

GOTTLIEB Shouldn't the staff have more to do with hiring this new person than the doctor does?

HAM Oh, absolutely. Let's say whoever does the interviewing says, "She's a good candidate; we really would like to have her considered for this job" Even if there is only one candidate, I recommend that you have that person come in and spend a day--or at least half a day--in the practice. She finds a way to arrange her schedule; I don't believe I would hire anyone who is unwilling to do that. But they must come with a clear understanding of what the purpose is: "The purpose is to see whether you like us and like what we do, and we want to find out whether we think we would like to have you be part of our team." Pay them a nominal fee based on what you consider reasonable for the time they're taking. All the candidates should come in within a fairly short span of time. Immediately after the last one has left, you have a staff meeting and discuss, "Which one do we want? Which one do we feel the best about?" If there is no consensus in favor of one person, find more candidates.

There are some exceptions to this process. If you have a staff of people with a low level of commitment, a short-term attitude, who aren't enthusiastic about their work and their future in orthodontics, then maybe they shouldn't be involved, because perhaps they don't give a damn. Maybe they're looking at purely selfish reasons such as: "She lives down the street and I could ride to work with her" So I think it's essential that the staff have a high level of commitment to their jobs.

GOTTLIEB There are different kinds of jobs in an orthodontic practice, requiring different skills, but sometimes several of these are combined in the same person.

HAM One of the best examples of that is what happens in a smaller practice, where the receptionist, who is the front line of public relations, also is the person who collects delinquent ac counts. We may be talking about two different personalities if we're talking about a person who likes to collect money or a person who really loves to greet people. The receptionist must also have the courage to say "no" when scheduling; but she still has to have, I believe, a need to greet people. When the phone rings, instead of saying, "Oh, damn, there it goes again': she says, "Oh, goody, I get to talk to somebody else" if you have an individual who has an accountant's orientation, someone who is very happy working with long columns of figures and gets all excited when they balance, that person doesn't want the phone to ring. Or if the lab technician has to cover the front desk for a lunch hour, they don't want the phone to ring. Conversely, you don't see many receptionists who want to be lab technicians. So there is something really important about having the person derive satisfaction from the work itself. This, incidentally, was Herzberg's third positive motivating factor, which he identified in his research on motivation: did the work itself provide satisfaction for the person performing the task?

GOTTLIEB How do you hire people for the jobs requiring dexterity in operatory and laboratory?

HAM If you are filling a job which requires manual dexterity, you can ask them what their hobbies are. If they say they play the piano, they do needlepoint, or when they were a child they built models, that would give you some indication about dexterity and hand-eye coordination. There are also dexterity testing kits available that I think have some usefulness. The down side of that, of course, is that a nervous person might not show up well on that test, but if the test upsets them, probably a lot of things would be upsetting to them in the work place.

GOTTLIEB Let's talk about something I know you are concerned about, and that is the question of future-focusing. What would that mean to you in hiring somebody?

HAM The problem with that right now is that less than 5 percent of the people in our society have one or more written goals, so it isn't very likely that your prospective staff person has some written objectives, or at least has preferred future events clearly identified. If, however, she did have, I would see that as a tremendous plus. Anyone who is positively future-oriented has a higher level of self-esteem today. This is one of the reasons why, as I'm lecturing around the country, I try to knock what I call the "gloom-and-doomers" If a doctor buys into the gloom-and-doom approach to the future of orthodontics, that has a terrible impact on his level of self-esteem, how he feels about himself and his future, and his ability to do his job today. I usually ask the audience, "How many of you will agree with me that in 1990 and 2000, there will be a significant number of orthodontists who are practicing the way they want to practice and are receiving the rewards from their chosen profession?" And everybody shakes his head, "yes' there will be. We know that in 1990, and for any period of time you want to ,talk about, there will be those in the profession who are practicing the way they want to and are successful at it. I believe that one of the significant factors in terms of who's going to survive this difficult period is who is positively future-oriented and who is negatively future-oriented. Self-fulfilling prophecy is very real.

I only work with 10 percent, at most, of the profession. Those who are not progressive, who are not really out there charging, who are not committed to learning and to becoming themselves as persons, they're not the people I work with, so I can't comment much about them. But I can say pretty clearly that the orthodontists I do work with don't have that gloom-and-doom vision of the future. Sometimes I think I've been instrumental in helping them turn that around, because I just deal with some realities, which are that we have 250 million people and how many orthodontists? Sure, I know there are a lot of general dentists doing orthodontics and a lot of people who live with crooked teeth, but I think the market isn't all that bad.

I think the way to become a dinosaur is not to change with the changing environment, which includes cultural changes, economic changes, changes in competition. I really believe that for anyone to succeed in any free-enterprise situation, that person must have adaptability, must be receptive to change. We all know that we have some built-in resistance to change, and that probably the older we become the more resistant we are. Those who are going to survive what Drucker calls "turbulent times" are those who will continually be seeking small changes in the way they manage their practices, to keep pace and to adjust to some of these changes that are taking place. One of the keys to being adaptable is to identify needed changes and identify these as preferred future events. You can't change yesterday, and for a lot of things you can't change today. But you sure can change things six months down the road, if you plan to change. Let's go back to our example of an orthodontist who has said, "I have a mediocre staff, and I don't want a mediocre staff" He can get that changed, if he can go through a process of identifying some of the factors necessary to produce the change. It may be a year or two from now before it happens, but part of it will be increasing his own level of understanding and his own ability to identify what he really wants; then he must go through some step-by-step process to decide when he's going to have these things happen.

GOTTLIEB How does he even know what changes he needs?

HAM He cannot have too much information about how he is doing, and he finds out some of that from his peers; he finds out some of that by going to lectures and hearing you or Avrom or mespeak and deciding, "Hey, I'm not doing that, and these guys have maybe a little broader picture than I have" He needs to have a relationship with his staff whereby they can give him feedback on how he's doing, and they can give him some insights about things patients say to them rather than to the doctor; I think that's vital planning information.

My company has been conducting patient opinion surveys for orthodontists and for all of dentistry since 1974. Rather early on, I designed a questionnaire that I thought would be useful to the orthodontist. I talked to orthodontists all over the country, I read suggested questionnaires in the journals, and I boiled it down to what I thought were the areas that needed surveying. One, it's important how the patients and the parents view the doctor professionally or technically. Another important area is how they feel about him personally--does he really communicate well with people? Thirdly, they have some strong opinions about his staff; he may be working in the back and not see a whole lot of things that are happening in terms of the way people respond to his staff, so he needs that information. I also feel that he needs to know how people view his facility. We have a statement in the survey that says, "I believe my orthodontist's office has functional good taste"--people can agree or disagree with that.

GOTTLIEB Is this a third-party survey, or does it go from the doctor to the patient and back?

HAM There's very good evidence that says even if the doctor uses the same survey instrument, the response he gets back directly will not be as valid as if it had been conducted by a third party, which in this case is us. We give the doctor no information at all about where these responses came from, even though some people sign the survey or put their return address on it.

GOTTLIEB How often do you recommend surveying?

HAM My recommendation would be that any time there is a major change in the practice--moving the practice or bringing in an associate or whatever--would be a good time. But even if the practice is fairly stable, I am recommending now that it should be done every two years. Of course, the orthodontist can conduct his own survey and have the data fed directly back to the practice . He shouldn't expect to receive as candid responses, but the PR value is excellent because people do respond, and they think, "We're glad you asked us; here is someone who really cares"

GOTTLIEB What would be a satisfactory response to one of these surveys?

HAM We get up to 70 percent return on our survey, which in the world of surveying is phenomenal. We send surveys to 50 adolescents, 50 parents of adolescents, and 50 adult patients, all in different households. An orthodontist who conducts his own survey should expect a 25-to-30 percent response. However, when we conduct the surveys, we have found that if more than that don't respond to the survey, then the doctor and the practice are in trouble in terms of people's opinions.

GOTTLIEB The JCO Practice Study found that less than 15 percent of orthodontists use patient opinion surveys.

HAM And of that 15 percent, almost all of them just send out little questionnaires they designed themselves. I wouldn't want to say that's bad, but the way the questions are worded and designed is crucial if you want to get useful information. I think I have learned a lot about conducting surveys by working with the University of Denver on this from time to time since 1974. They say, for instance, that you don't ask a question that a person can answer with yes or no or even an essay response. The best way to get information is to make a value judgment statement, then allow the respondent to agree or disagree on a seven-point scale--0 to +3 to agree with the statement and 0 to -3 to disagree. That way you also get an intensity factor in their responses. Also, you have to have both positive and negative statements, to keep the respondent from having what is called "response set': where they give the same response to each statement. If you word every third or fourth statement negatively, it stimulates their thought processes. The only exception is with adolescents; we found that you shouldn't confuse them by making both positive and negative statements.

GOTTLIEB What are the most significant things that you're finding out from your survey?

HAM We're finding some very interesting things about how people feel about finances. We survey only parents and adult patients about fees, and one statement is, " I believe my orthodontist's fees are reasonable" Usually, about 60 percent of the parents agree with the statement; about 18 percent score 0--they're indifferent, ambivalent, or have no opinion; and about 22 percent say the fees are not reasonable. We have a comment section at the end of the survey where we say, "Now go back and review your responses and elaborate on any response that you have made" A typical comment is, "On No. 9 I said that the fees are not reasonable, but everything costs too much nowadays" So even though 22 percent may have said the fees were not reasonable, they ameliorate the impact of that in their comments. When we survey adult patients--even though the fees are typically higher--it's not unusual at all to have 80 percent agree with the statement.

We have another statement about fees that says, "I am satisfied with the payment arrangements for my treatment: and a third that says, "Financial arrangements are clearly explained at the time treatment is decided upon" If you get a high percentage of agreement with the financial arrangements being clearly explained, then it doesn't seem to matter what the fee is--they will almost always say it is reasonable. A lower agreement with the other two statements results in a lower acceptance of the fee. This leads me to conclude that the openness and the thoroughness of the discussion about fees are very, very important

That leads to another somewhat philosophical premise about post-purchase dissonance, which may be explained by how you feel the day after the encyclopedia salesman really manipulated you and got you to buy--and you wish you hadn't. It's a factor in orthodontics, too; it's what happens when the orthodontist sells a case, rather than explaining it and having the parent or adult patient accept it. If that's the basis on which the person is going to pay the bill--because the orthodontist is a good salesman--then there will be other problems that creep up later.

GOTTLIEB Prices of almost anything are not precise, and that seems to be hard for orthodontists to understand. There is no such thing as a "fair fee"; fair is what the patient thinks is fair, not what the orthodontist or anyone else thinks is fair. Would you agree?

HAM Yes, it's like the price you pay at an auction for a painting: a fair fee is what the patient will pay with gratitude without financial hardship, and for some that fee may be very high. Many doctors seem to think that it's immoral to charge varying fees. I personally have a strong bias the other way. After my first daughter had orthodontic treatment and I saw the results, I would willingly have paid $5000. I think the failure of the profession is that it has not done an adequate job of educating people. You can't put your values on me, as you know, but you can certainly influence my values. First, I have to understand the circumstances of my malocclusion from the professional's point of view. Then I need to understand the alternatives and the consequences and the costs. Then I can make a decision based on my values.

GOTTLIEB What you're saying is that if you have a high-fee, high-quality practice in which the people you deal with understand what they're getting, get it, and appreciate it, then they're going to find like-minded people in the community who will come into your practice.

HAM In our society we hear that opposites attract. In terms of personalities that may be true, but insofar as values are concerned, like attracts like. You choose to associate with people who have compatible values systems. If you have a lot of people in your practice who don't pay their bills regularly, what kind of people do they refer? If you have a practice where you have, over a period of time, weeded out those who have a low appreciation of your service so that you can charge a good fee for a good service, then it upgrades the quality of your practice.

GOTTLIEB Does this apply to your dentist referrers as well?

HAM Oh, absolutely so. Those dentists who aspire to excellence are the ones who will refer to the orthodontist who aspires to excellence, because those dentists have upgraded the level of appreciation of their patients, and they don't want to send them to a mediocre orthodontist.

GOTTLIEB Speaking of the level of appreciation of people in the practice, do you think most parents underestimate what the orthodontist has done, even in severe cases?

HAM That's one of the major reasons why I believe there should be a post-treatment consultation--because after two years the parent forgets what was happening in the mouth. I think it's important to have photographs to show the before and after. I can't imagine that there's a more powerful marketing tool available to the orthodontist than the post-treatment consultation. It provides valuable feedback, but even though we've talked about it and lectured about it and read about it, most orthodontists still don't do it, and they rationalize that some people don't want it. Another benefit is that it gives the orthodontist and his staff the opportunity to accept some of the accolades that they well deserve.

GOTTLIEB Should the doctor perform the posttreatment consultation?

HAM I think it's less important for the orthodontist to be involved in the post-treatment consultation than it is in the pretreatment consultation. In the post-treatment consultation, the staff person can brag about the treatment result more than the doctor can. He should come in and welcome them and say, "Janie's going to review the case with you; I am available for any questions; I'm sure glad you could come in". And then he should turn it over to her.

GOTTLIEB You must also believe in a well-structured, careful case presentation.

HAM Very much so. The orthodontist who is successful at this must have another quality, and that is that he can accept deferred reward, rather than the instant gratification that comes from closing the sale. He'll lose a few patients by saying, "Look, I'm not sure that you're really convinced this is what you want to do, and I don't want to work with you unless you thoroughly understand our philosophy, and the fee must be completely acceptable to you. This is a team effort; we cannot succeed without your cooperation". But every orthodontist has 10 percent of his practice that he wishes he'd never seen, and a lot of those are people he sold, rather than people who openly and thoroughly understood and then said, "I want that".

GOTTLIEB I'd like to know your opinion of a statement I often hear: "The father is a very busy man; all he wants to know is what it's going to cost him, and he's not interested in spending a half-hour or so finding out the ins and outs of orthodontic treatment."

HAM I believe it's very appropriate to invite the father to the case presentation. It may well be that it's not convenient for him, so he doesn't show up. I think you could help that situation somewhat by immediately sending him a letter explaining the philosophy of your practice, saying that you really are concerned about the long-term commitment of the patient--that, without the cooperation of the patient and the parents, the result will not be the same. The orthodontist who is delivering a high-fee, high-quality service must understand the importance of letting the parents know his philosophy. I think every time the doctor has an opportunity to discuss something with a patient or a parent, he has an opportunity to influence that person's values regarding health. The primary responsibility of the orthodontist is to thoroughly explain the circumstances in the mouth; he's the expert. I think it is also necessary for good practice building that he talk about what the alternatives are, because there are always alternatives. Then he needs to talk about the consequences if nothing is done at all; people have a right not to buy his treatment. Then they make the decision, and if he has done a good job there is a good chance that they will base that decision on the right information and on their values, rather than on some sales approach. If so, he'll have a lot less problemcollecting the fees later on.

Unfortunately for the orthodontist, he has little time to build a good relationship with the parent who's paying the bill. It's very helpful if he has a personality that leads to instant rapport, and some do. But if he decides that he doesn't want to improve his communication skills, then I think he needs to hire someone who has those skills. That still doesn't excuse him from some input in the case presentations; there are some things that he really must say. The staff member whose primary responsibility is communications is an emerging position in the upper tier of orthodontic and dental practices. The trade-off is that the orthodontist has more time to do the things that might be more productive, but less time to create that important relationship with the patient or parent. Many people have complained that they don't have enough information or enough follow-up contact with the orthodontist. But they don't seem to care whether they get it from the orthodontist himself; they just want to be kept up-to-date. Let's say that you have a six-month progress review, and at that time you make a special effort to get the mother or father in to talk. If you have a staff person whose primary responsibility is communication, then she can, without overdoing it, find other valid reasons to communicate with the parents. Perhaps it's three months after the previous progress review and the child is really cooperating in terms of improved oral health and wearing headgear; it's three months more until we're going to have the next progress review, so--send them a letter.That's a positive contact, and I think positive contact can be a practice builder, as well as creating a positive image in the mind of that person.

GOTTLIEB Does the practitioner have to settle for what he is, or can he improve his communication skills?

HAM Speech communication departments at major universities have proven that it is indeed a learned skill; it may take more effort for some people than others. In almost every city there are counselors available who, for a fairly reasonable fee, could coach the orthodontist on his communication skills. One course that I think can improve these skills is the Dale Carnegie Human Relations Course. I have a number of orthodontic clients who participated in it, and I have yet to find one who said it wasn't useful.

GOTTLIEB Getting back to your patient opinion surveys and feedback, what do you find out fromchildren?

HAM Here are some of the items in the children's survey: "My orthodontist's receptionist always greets me in a friendly manner." "The staff seem to like each other." "Someone at my orthodontist's office has discussed diet and nutrition with me." "The staff makes me feel welcome." These are directed toward how they feel about the staff. Some other statements are: "My orthodontist has concern for me as a person." "I feel that my orthodontist likes me." "My orthodontist has a good sense of humor." I believe we could find a correlation between "My orthodontist has a good sense of humor" and "My orthodontist likes me." Others are: "I am pleased with the results of myorthodontic treatment." "My orthodontist is usually on time for my appointments." "My orthodontist seems to enjoy teaching me about oral health." "I would recommend my orthodontist to others." "My orthodontist is gentle when working on my teeth." "If I have pain, my orthodontist seems very concerned." There's a place for them to respond with general comments, then "one thing I think could be improved" and "additional comments" We report these comments separately, and exactly as we received them; we don't change spelling, grammar, or anything.

GOTTLIEB We've talked about hiring staff, feedback, post-treatment consultations, and case presentations; are there other areas in which an orthodontist can improve his ability to deliver excellence?

HAM I think there needs to be an orientation toward excellence--not toward opulence--in every part of the practice. Don't have plastic plants sitting in the reception area; I cringe when I go into a health practice and they have plastic plants. Or you sit down, and the magazines are dog-eared and there is last August's Time magazine.

GOTTLIEB Have you ever thought that there should be audiovisual materials of various kinds to use the captive audience time in a waiting room for educating people about health?

HAM Yes, you could at least give them the option of learning more. But there are some other things that can be done rather subtly. I think there should be a scrapbook with pictures of the staff, the doctor, and his family, and their hobbies and activities, and it should be kept up-to-date. It helps people have more of a feeling of familiarity. I'm also a strong advocate of having an 8-by-10 glossy of each staff person in the reception area, with their name under it in large enough letters that it can be read where people are seated. There are so many things that can be done to make the practice more human.

GOTTLIEB You probably don't deal with any practices that are even on the verge of advertising.

HAM No, I don't, and those that advertise are not, I think, on the cutting edge of excellence. Not all of dentistry is high-fee, high-quality, of course, and there is a very legitimate midground that delivers a fair value for the price they charge. I have no problem with that; a lot of people are price-conscious, and they have a right to seek out the lower fee.

GOTTLIEB You discussed the staff in a high-quality practice already, but we should bring up another area of participative management that I know you are concerned about--the staff meeting.

HAM I think it is an important part of any participative management scheme, but there has to be a purpose for the meeting. To have a meeting every Tuesday afternoon just because it's Tuesday afternoon is a very poor reason for a meeting. There's no-such thing as something for nothing, and so I think there has to be an agenda, or at least a format for developing an agenda within the meeting. To have an effective staff meeting, generally speaking, you want to maximize participation. However, if you have a meeting for disseminating information--which is not too common in orthodontic practices--that's not an invalid reason, either.

There are several categories of staff meetings. One would be a problem-solving meeting where any member of the staff or the doctor can say, "Here's a problem we need to have a meeting about and see if we can come up with a solution" Or it can be a staff meeting to improve some aspect of the practice; maybe someone says, "I know we can do a lot better with scheduling" Then, scheduling would be an appropriate topic. There can be educational staff meetings where we seek to learn something new, and often the content of these meetings comes from some resource outside the practice. Avrom King has a set of tapes for staff meetings, and my own set has frequently been used. I've also developed staff meeting formats that I distribute to all the participants in my team development workshops, and each issue of my newsletter, Alternatives, contains the instructions for a staff meeting. You might also have a training staff meeting where the content comes from within the practice; I have attended meetings that were developed around one member of the staff making a presentation about something in which she had a particular skill. One of the best formats that I'm aware of was developed by the group at Cox in Canada, and it's called a "Right to Share" staff meeting. It's designed to give people the opportunity to participate, and it's a never-fail way to have a good meeting. Each staff person identifies something that he or she would like to talk about; then they go through a system of selecting which one they're going to talk about first. It's an effective way to develop an agenda for problem solving.

As for when a staff meeting should be held, my thought is that a tough time to hold a two-hour staff meeting is at the end of the day. It's convenient to have it then, but sometimes people are tired and they don't have as much energy to put into the meeting as they otherwise might. Another time is at lunch. You need a facility that's conducive to that; it's almost a terrible waste of time if you go out to lunch. Something can be said for eating together and coming down off the emotional high of the morning's hectic activity, then clearing away the debris and going ahead with the meeting. It's important that you minimize the interruptions.

An idea that I and a number of others have been espousing for a long time is that if you have a busy practice, you need a half-day of nonpatient time every week. No one has ever shown me that it costs them any money; you learn to work smarter instead of harder, and it contributes to the productivity of the practice. This is the time when you make sure that all the bins, the drawers, the wires, and everything are right where you need them. This isn't something that someone does Friday night when she's tired and wants to go home. This is the same time the orthodontist can use for some specific training for staff people. Sometimes, it seems that the need for training a new staff person drags on and on until finally they have to shut down and provide the training, and by then a lot of that new person's incentive might have been lost. This same half-day a week would also be used for staff meetings, which would take up only a portion of the time. But it has to be something that everyone is committed to. Some of my orthodontic friends see it as an afternoon when they can leave and play golf, and that's not what I'm talking about. I'm talking about hard-work, nonpatient time, when the doctor and the staff are all there and are able to do a variety of management and relationship-building, practice-efficiency kinds of things they can't do when patients are there.

GOTTLIEB How do you catch up new employees if you have an ongoing program of interpersonal relationship building?

HAM A team that really is functioning well has improved their ability to confront conflict and deal with each other more openly. As Peter Drucker says, "happy marriages are noisier marriages"--people argue more and communicate more. Most people are not used to working in an environment like that, so the new staff person is initially going to be rather shocked. But she'll find out very quickly that the relationships are stronger where interpersonal things are dealt with.

One of the staff meetings that I distribute in my workshop series is called "What's My Bag?" It's a meeting on self-disclosure in which each person seeks their own comfort level in what they want to talk about. It requires a number of magazines with some scissors and tape, and people go through the magazines clipping out things that remind them of something about themselves, then they tape them to grocery sacks. After about 20 minutes, somebody starts up by saying, "OK, I'll go first, and here's my bag. This package of cigarettes reminds me of when I quit smoking. Here's a picture of an outdoor scene, and I really love the outdoors. Here's a picture of a horse, and I'm really into horses" I have practices that do this every time a new person comes in, and the new person gets integrated into the staff very quickly because the more you know about another person, the greater is the likelihood that you will care for them.

GOTTLIEB Do you think that the staff and the doctor together should write out practice objectives?

HAM We have an exercise that we go through to participatively develop a mission theme. It requires about two hours to complete it. Let's say we have seven staff persons and an orthodontist. Each person writes out two or three paragraphs on the mission or purpose of this practice. I don't give them any more instructions than that, because I don't want to bias their thinking about what I mean by mission or purpose. The second step is for people to work in pairs, read their mission statements to each other, and combine all the salient points; then we have four statements. In the third step, these pairs double up again. That produces two mission statements; and finally, the total group combines these two statements into one. Each person then has a feeling of ownership of the mission statement. Many practices have it printed up and put on a plaque in the reception area.

GOTTLIEB This would be a written practice philosophy; do you believe in written job descriptions?

HAM I believe that each person periodically--at least once a year, more often if there's a major change in the practice--needs to make a list of everything she does--a job description. People have to understand that a job description is not limiting. My first principle of team membership is that everyone must be willing to do more than their share as they perceive it. That means that sometimes the receptionist may be cleaning the lab sink, even though that would never be on her job description. It's very important for teamwork that each member say, "Yes, I do have my responsibilities, but first I'm a team-worker, and I will not take care of my responsibilities at the expense of the overall good of the organization" People have a need and a right to know specifically what their assignment is. Good team workers seek the opportunity to assist others without jeopardizing fulfillment of their assignment. It's not uncommon for a practice to have a staff person who is immensely talented, but disruptive in terms of the team. I don't care how talented she is; if she is not a willing team worker, I don't think you can afford her. Often her behavior can be corrected if she understands the penalty for not being a team worker, and she may find that she really likes it even though she's considered herself a loner all her life.

Avrom has a good technique in which people write out their lists of duties and hang them up for a while so everyone can see them. Then they hang up a second list that says, "These are the things I do that I like, and these are the things I don't like to do" Then they have a staff meeting where they try to trade duties. I did this once in a shortened time span, when we went through the listing and the negotiating of trading duties all in one session. The most vivid example was that the receptionist said, "I don't like to water the plants" The practice had moved just six months before, and they had spent a ton of money on a gorgeous interior decorating scheme with many plants, and those plants were looking sad. One of the other staff people said, "I know you hate those plants; I want to water them" And so they worked up a trade. That's the kind of thing that can happen if you have free communication between people.

GOTTLIEB In addition to the job descriptions, should you have a written office procedure manual?

HAM Maybe, but my bias is that if you give people the information they need for the conduct of their jobs, you don't need a big rule book. I often find, when I see a procedure manual that the orthodontist and staff worked hours and hours to put together, that it was done four years ago and today it is meaningless. I think you do need a personnel policy manual. The staff people need to clearly understand, for example, what the vacation policy is. It's amazing to me that policies generally do not create employee dissatisfaction, if they know what the policies are.

GOTTLIEB There is one more subject I'd like to discuss, and that is performance appraisal.

HAM This has always been a particular area of interest to me. Unfortunately, I think performance appraisal is often used as a tool to get more production out of the employees. But if the philosophy behind the appraisal is to help individual employees improve the quality of their contributions, then we've got a different ball game. It's very important initially that the doctor and staff person come to an agreement on the responsibilities to be evaluated. It can't be the job description, because there may be dozens of items. So, we need to limit evaluation to major areas of responsibility. For example, let's talk about a receptionist. She does, indeed, have many responsibilities, but major areas of responsibility include greeting people, keeping the schedule, accepting accounts receivable--probably six or eight areas at most. If she and the doctor agree that these are her major responsibilities, then you've got Step 1 out of the way. Next we come to a little tougher part, and that's to agree on standards. My position is that the standard should always reflect reasonable excellence. Of course, reasonable excellence may be different for each person. If I were to sit down with the receptionist and define reasonable excellence in terms of greeting people, I would expect her to use the person's name in conversation; to greet everyone with a smile and with warmth and friendliness; and to be smiling when she picks up the phone.

GOTTLIEB How do you know whether she's doing these things?

HAM That can be difficult. Your own observations and patient opinion surveys can help you, but you have to rely on her to manage herself. Other staff members often tell me how their peers are doing when I come into the practice as a consultant.

GOTTLIEB Would they be likely to tell the doctor if there were no consultant present?

HAM They might, but sometimes that's more damaging than beneficial. My second principle of team membership is never to say uncomplimentary things about another team member behind their back. If it's bothering Staff Person A that Staff Person B is slow in some operatory procedure, then the ideal way for her to approach it is to go to B and say, "Hey, B, I notice that you seem to take a lot more time with this procedure. Do you agree with that?" B may answer, "Yes, I sure do" Then Amight say, "Maybe I could help you learn how I do it and help get you r speed up. Would you want me to do that?" B may say, "It's none of your business. I'm doing the best I can; get off my back" Typically what happens then is that A goes to the doctor and says, "We've got a problem with B" Then the doctor's got another burden dumped on him that he didn't need. It's far better for A to come to the doctor and say, "Doctor, I'd like to sit down with you and B and have a discussion" The doctor's going to ask, "What about?" and she should say, "Well, let's sit down and talk about it all together" Ideally, then, the doctor sits down with A and B, and A says, "I have a problem, and that is that I see our production slowed way down because B has trouble with this procedure" Maybe B cries, maybe all sorts of things happen, but the probability of resolving that problem is much, much greater. Another thing that can happen is that perhaps a staff person walks up to the front office just as the receptionist says, "I don't give a damn where you go" and hangs up the phone. So the staff person can hardly wait to tell the doctor. She goes to the doctor and says, "Oh, you can't believe what I just heard Julie tell a person on the phone. She's turning people away" Maybe Julie was talking to her teenage son about where he was going to take his car to have the battery charged, but here A went to the doctor instead of going to B. Even if the receptionist did tell a patient to go to another practice, that's much better dealt with in terms of teamwork and cohesiveness and harmony and maturity in the practice if A goes to the doctor and says, "You and I need to sit down with the receptionist"

GOTTLIEB You're saying that performance appraisal has to be conducted in a sensitive manner and with the right philosophy about what the appraisal is intended to accomplish.

HAM First, you identify the areas in which the person will be assessed. There needs to be agreement with the doctor on that. Then there is a need to agree on the standard--what a good job is. Then, after a reasonable time interval in which the person has had an opportunity to adjust to this standard that she may for the first time really understand, you have the performance appraisal. I suggest that it's best handled by having the staff person write out a narrative about how she thinks she's doing. If the orthodontist has eight or 10 staff people, and he tries to write out a performance appraisal on each one of them, it's a major job and he probably won't do it. Have the staff person write a narrative and rate herself as less than satisfactory, satisfactory, or more than satisfactory in each major area. Then she tells you why she rated herself that way, and the doctor must tell her candidly and honestly whether he agrees with her, and if not, why not.

GOTTLIEB Do you relate performance appraisal to reward?

HAM Absolutely. I think performance appraisal should precede salary evaluation by at least two months, and that gives the staff person an opportunity to correct the deficiencies, if there are any.But I'm coming to believe that an even better way to do performance appraisal is to have the staff person write out her own objectives for the next period of time. The doctor would have to review those and maybe clarify them or add to them. If she concurs, then they become her objectives, and you assess her performance on whether or not she met her targets, which were acceptable to you.

GOTTLIEB What would be a typical objective?

HAM A new chairside assistant might say, "Between now and March 1, I want to improve my ability to take impressions. My objective will be that I can take nine out of 10 that are acceptable the first time I take them" Another staff person might say, "One of my duties is to make sure that we have all the archwires we need, so my objective is that we'll never run out"

GOTTLIEB Could performance appraisals be done in a group if you had a smoothly operating team?

HAM Yes, if you have a team that is really functioning well, with a fairly high level of relationship and maturity. What I'm leading up to is that the ultimate objective is for the members of that practice to become each other's consultants on a continuing basis. Then the receptionist will make it a point to go to the chairside auxiliaries and say, "Hey, how am I doing with the schedule? What are the places where in your opinion I might do a better job?" She has to want to know, or she shouldn't ask. Or any member of the staff can go to the doctor and ask, "How am I doing? Do you have any suggestions?" It then becomes his charge to take that question seriously and give a really thought-out answer; if he doesn't have time to give her a comprehensive answer right then, he should arrange to do so later. It is a totally different dynamic for the staff person to go to the doctor and ask, "How am I doing?" than for the doctor to say, "Susie, stay after work tonight; I've got to talk to you about your job" The ability of that person to receive the information she needs is greatly improved if she's asked for it. We'd even like the trust level to develop high enough so that the doctor can go to a staff person and say, "How am I doing? Do you have any suggestions for me?"

GOTTLIEB I imagine that it's fairly rare for relationships to develop to that extent.

HAM Yes, but I've seen it happen.

GOTTLIEB Perhaps if more practices used your thoughtful approach, they might build up to that level of teamwork. Bud, I want to thank you for your insights into participative management--what you have also called self-management.