How Does Your Garden Grow?
I recently received an advertisement in the mail that, at first, I assumed to be a metaphoric put-on because it was so applicable to orthodontic practice. The ad had a title: "How Many of These Fruit-Growing Operations Do You Practice?" It then listed four such operations-- "Selecting", "Cultivating", "Scientific Pruning", and "Rejuvenating Old Trees".
Under the heading "Selecting", the question was asked: "Are you after the most delicious fruit available, or would you prefer greater ease in gardening, or a larger crop?" A group of questions like that gets you to thinking. What is the most delicious fruit available? Is it patients who invariably pay their bills on time? What is greater ease in gardening? Is it easy cases on good growing, cooperative patients? What is a larger crop? Is it the accumulation of the maximum number of patients by never refusing or losing a prospective case?
Believe it or not, there are cases that should not be started on contact. The child who adamantly refuses to wear your appliances is an obvious one. We may rationalize that 10- or 12-year-old kids can't make such an important decision, but they can. Some of them may be refusing out of fear of the unknown or because of misinformation. Education and patient understanding may bring some of these around. But how about the child who decides in his or her heart of hearts not to cooperate, but acquiesces to the decision of determined parents and does start; or the parent who refuses extraction, which you really believe to be necessary, but gets you to agree to try the case nonextraction? There are some cases that are really surgical-orthodontic cases, but orthodontists accept them for treatment without surgery as readily as a mouse nibbles the cheese. There are cases with incipient TMJ signs, but no TMJ symptoms. Orthodontists enter into these as innocently as someone who fails to notice that the top step of the basement stairs is missing. There are patients whose oral hygiene is abysmal, who orthodontists assume will become transformed by a sheet of typed instructions. There are pitfalls in some cases that are just too difficult and some that are just too easy. If people find fault with your fee or make you a counteroffer or agree to start now and pay later, beware. And there are some people that you just don't feel good about. It might be a useful approach to orthodontic practice to go for the delicious fruit and a greater ease of gardening-- and certainly a larger crop-- but with a decent regard for cases that maybe should not be started.
Case selection depends on a mix of dedication to service, ability to recognize problems, ability to evaluate prognosis, ability to get patient cooperation, desire to have an easy practice, desire to make a lot of money, desire to be the boss of the biggest practice in town with the largest office with the most employees, and a good deal more. There are also orthodontists who want to limit the number of patients in their practices or want to cut down on their case load. This may be all right for the orthodontist who has saved enough money, or who can raise fees at will, or who is able to maintain the desired number of patients. For many older practices this is not the case. Once an older practitioner begins to reduce the number of patient starts, the number of patient starts begins to
reduce itself, sometimes precipitously. Fewer dentists and patients will refer to a fading practice. From the point of view of keeping the practice growing and maintaining its sale value, it might be better to consider bringing in a young associate.
Under the heading "Cultivating", the ad asked: "Do you plant vegetables between the trees to improve the trees and to get more out of the land?" Many orthodontists do the worst job of cultivating in the one place where it will do the most good. We send confirmation letters and thank-you letters and complaining letters if cooperation lags. But how many of us let the dentists, patients, and parents know what is happening, what good progress has been made, what a great job we are doing, what a great result we achieved? This is the place between the trees, and this is where cultivation pays off in the form of better results on happier patients, whose treatment is completed in less time. It also gets more out of the land in terms of enthusiastic patient referrals based on appreciation of the good work we are doing.
We think the correction we achieve is obvious to everyone. Yet patients and parents are amazed when they are shown the pretreatment models and photographs, and when they compare them to the treatment result. People don't know how good you are or how good your work is or what great results you are getting unless you tell them and show them. If you don't, you will continue to be amazed and chagrined when patients whom you consider to be among your best cases don't really notice much improvement; or when someone is disappointed by a 5° rotation of a lower incisor in what you consider to be one of your orthodontic triumphs; or when siblings of one of your great cases go to a newly arrived orthodontist because that office is closer to their home.
Cultivating requires constant tilling of the soil with dentists, patients, and parents. Proper case presentations, educational and supportive communications, comfort calls, periodic conferences about progress, patient satisfaction surveys, thank-you notes for referral, progress reports to dentists, dentists' preference forms, post-treatment conferences, practice newsletters are all cultivation tools. Some orthodontists have post-treatment photographs taken professionally and send home a lovely, framed 8" X 10" photo of the smiling completed case. You can bet that it usually finds its way to the mantelpiece or piano and becomes a conversation piece for some time to come.
Under the heading "Scientific Pruning", the ad asked: "Do you prune too much and find your trees produce only leaves and stem growth; too little and lose fruit quality?" Many orthodontists don't seem to prune their practices at all. They usually go along with poor cooperation in the hope it will improve or that some miracle of nature will bail the case out. We may fantasize that the patient might move away. We may rationalize that we owe the patients our best effort in spite of themselves. We frequently continue treatment long past the time when it will do them or us any good. In some practices, most patients dismiss themselves.
Referral is the life blood of an orthodontic practice. It depends on the satisfaction of dentists, patients, and parents with the treatment performed. Cases that are lagging in treatment usually inspire dissatisfaction of all three. Dissatisfied people tell others about it, and their level of
dissatisfaction and the number of people who hear about it might well be directly related to how much time and money they have spent on orthodontic treatment that is less than satisfactory. Pruning may at least reduce their level of dissatisfaction, because it is not renewed and deepened with every visit.
Pruning of an orthodontic practice should be done scientifically and not out of pique or in a sudden splurge of housecleaning. First you have to be able to distinguish between a prune and a plum. Not everyone who displays a lack of progress is uncooperative. Some cases do not respond well; some patients have misunderstood the instructions, even over a long period of time; some patients are inept; some patients have a low pain threshold. At the other extreme are those patients who do not intend to cooperate, and their parents agree. Perhaps they have been worn out and their tolerance level for treatment has been reached. In between are patients whose treatment is lagging, but who insist-- even tearfully-- that they are cooperating, and their parents back them up. You can go through a litany of interrogation: "Do you wear them during meals?" "Am I supposed to?" "Do you wear them 24 hours a day?" "Does that include sleeping, too? You never told me that." "Do you wear them during school?" "I can't. My Spanish teacher won't let me." You can go through all this and these patients and parents still insist they have been cooperating.
Scientific pruning in orthodontics is not just getting rid of the dead wood one day. It is a recognition of cases that are lagging in treatment and in some cases terminating them, but in others instituting procedures that will speed up the process. In others it means modifying the treatment goal or procedures to accomplish what is possible. Many practices are not aware of lagging cases until the estimated time is up or all payments have been made. Many practices never face up to the problem of cases beyond estimate. A method is needed to identify the lagging cases, so that pruning can be accomplished in a way that is fair and reasonable to the patient and the practice.
If a practice has never investigated the problem, a report listing all cases that are past their estimated treatment time will be illuminating, if shocking. It is a basis for pruning action. However, it is not enough to wait for cases beyond estimate. One of the values of progress reports is to identify such cases earlier in treatment. Scientific pruning is intended to reduce the case load by eliminating cases beyond estimate or completing them more quickly, but also by finishing all cases in better time than would be the case if no attention were paid to progress and lack of progress.
The final heading in the advertisement was "Rejuvenating Old Trees", and the question was: "Could you get a larger and better crop from your trees with only a little more work?"
Are you tired of your practice and are your patients tired of you? Is the practice drifting along on its own momentum? A tired practice can be rejuvenated, if the orthodontist can be. Unfortunately, the amount of work involved and how fruitful it may be depends on how tired everyone is. Fortunately, it can be done. ELG