Orthodontic Hangover
Many years ago, an orthodontist named Bercu Fisher looked at his practice one day and found that he had more cases paid up and unfinished than paying ones. Dr. Fisher's solution was to treat only Class II, division 1 cases for which he felt he could have a predictable timetable. In making that decision, he put his finger on the only workable solution to "hungover" cases. Most of us today can apply a fairly predictable timetable to a wider variety of cases, but the essential idea of a timetable is still the best solution.
Many orthodontists have elected to solve this problem with a contingency fee. In its usual form, parents are advised that the monthly fee will continue if treatment beyond estimate is necessary due to lack of patient cooperation in a whole menu of areas, including keeping appointments, wearing headgear and elastics, and maintaining appliances in good condition. The contingency fee is intended to recompense the orthodontist for additional time spent on a case, but also to be motivational for patient and parents to achieve a higher level of cooperation in order to complete the case with the fewest extra monthly charges. When cooperation does not increase, as is often the case, the orthodontist derives less and less satisfaction from the contingency fee and more and more frustration with a "hangover" that is becoming a nightmare. Both patient and parents become increasingly unhappy and, in most cases, can be written off as sources of referral. The extra treatment and contingency fee have only served to drive a wedge further between parents and child, and between all of them and the practice.
A great many orthodontists have no solution to the problem of paid-up, unfinished cases, and just continue routine visits accomplishing nothing until the patient requests that the appliances be removed. In such practices, the number of these cases increases until it becomes a substantial part of the case load. Along with the increase in number comes increase in expense for space, equipment, supplies, utilities, and staff. More than that, a very unsatisfactory and unsatisfying practice has evolved.
Hungover cases are a PR disaster for a practice, because they usually involve growing antagonisms and assignments of blame: "It's your own fault. You didn't cooperate in doing what was required of you, and I have a copy of my original letter outlining all of that." There is small comfort in documenting how right you are. Or in washing your hands of the patient: "It's your mouth. If you don't care, I don't care." The orthodontist must always care.
Prevention is the better part of cure, and the fairly predictable timetable for treatment is the control system that can prevent a great many cases from going beyond time estimate. The first step is to set up a fairly predictable timetable based on how long the steps in treatment are actually taking in one's own practice. That requires spending some time in the files, profiling various kinds of cases, and recording average times for treatment steps. As previously outlined (see Editor's Corner, April 1984), these time intervals are prerecorded on the treatment card and are signals for an evaluation of progress. In this way, lagging cases are picked up in a minimum amount of time and corrective measures can be taken early. The method will not abolish lagging cases, but it will avoid the problems that accompany a much later identification and presentation of treatment beyond estimate.
Early identification of slow progress or no progress leaves all your options open from efforts at motivation through change of treatment plan through temporary interruption to termination of treatment. But what to do about the cases in every practice that are already beyond their estimated treatment time?
Every practice should prepare and continue a "cases beyond estimate" report, identifying who they are and what their status is. Many of these are cases that have been underestimated or have been delayed by broken or cancelled appointments, for which the practice does not have a scheduling system that avoids several weeks of delay for each BA or CA. Both the estimates of future cases and the scheduling system should be adjusted, but these cases will finish satisfactorily. Special attention might be paid to see that finishing is not prolonged. Then there are the problem cases, with or without a cooperation problem. They may need a change of treatment plan to finish reasonably well in a reasonable length of time. And there are cases that are simply beyond a perfect result. With the concurrence of the patient and parents, they should be terminated as quickly as possible. People are far readier to accept a great improvement that may be short of perfection than the orthodontist is.
A "cases beyond estimate" report should not be limited to cases that are going beyond the total treatment time estimate. It should include cases that have not kept up with the intermediate goals in treatment. A useful device for this is a progress graph or fever chart.
Some orthodontists criticize a fairly predictable timetable and call it a cookbook approach to treatment. Contrary to popular opinion, the best chefs have recipes and insist that they and their assistants follow them. The organization of treatment into a sequence of logical steps is much like a recipe. Consistent ingredients will produce a consistent result. If there is a cookbook problem in orthodontics, it is not with cookbook treatment; it is with cookbook diagnosis.
Dr. Tweed used to say that it is not the number of cases that you start a year that is the measure of your success in orthodontics, but the number of cases that you finish. That is one of the important secrets to running an efficient, effective practice that hums happily along, compared to an inefficient one that clunks along with a growing burden of hung-over cases.
