THE READERS' CORNER

PETER M. SINCLAIR, DDS, MSD

The topics include functional appliances and employee evaluations.

1. In what percentage of your cases do you use functional appliances?

Seventy-three percent of the readers reported using functional appliances in their practices. Of these, the largest group (just less than half) used functionals for 5-10% of their patients. The remaining 50% were evenly split between those who used functional appliances rarely (less than 5% of their cases) and those who used them more frequently (more than 10%).

Is there an optimum age or stage for use of functional appliances?

The vast majority of clinicians felt the optimum period was in the mixed dentition. Although there was considerable overlap in the responses, the age range of 8 to 10 years was slightly favored over the 10-to-12-year range.

Which appliances do you principally use?

The bionator was the most commonly used appliance, but it accounted for only 34% of the responses. Frankel (16%) and Herbst (13%) were the next most popular appliances. Activators, Swartz appliances, twin blocks, and sagittal or orthopedic corrector appliances were each used by about 10% of the readers.

How long is your typical functional phase of treatment?

A treatment period of 15-18 months was preferred by a slightly larger group of respondents than one of 12-15 months (40% to 35%). The remaining 25% of the clinicians were evenly divided between periods of 6-9 months and two years or more.

What is your usual treatment prescription (number of hours per day of wear)?

Full-time wear, except for eating, brushing, and athletics, was prescribed by more than 60% of the orthodontists who used functional appliances. The rest prescribed 14-18 hours of wear per day-- in other words, all out-of-school hours.

What have been the major problems you have encountered with functional appliances, and how have you dealt with them?

A majority of the readers (63%) reported that lack of compliance was their greatest problem. Another 28% said that breakage was their principal concern. A few respondents cited loss of appliances and difficulty with speech as problems.

Techniques for dealing with these problems included:

"We tell the kids to wear the appliances for 20 hours per day-- the kids seem to know that some 'rest' time is OK."

"We start with an initial period of 8-10 hours per day as a breaking-in period and move quickly to full-time wear."

"Cooperation is the major problem. We have pep talks, show successful cases, use goal setting and rewards, but no scolding or harassment."

"We have handled lack of cooperation by having long discussions before starting treatment. Communication is the key, along with the orthodontist's belief that the appliances work!"

"Our solutions to functional appliance problems are as follows:

1. Lack of compliance: encouragement, motivation, perseverance, or change to a fixed appliance (e.g., Herbst).

2. Breakage of appliance: repair or replace at cost, change to fixed if repeated.

3. Lack of growth: wait for late mixed dentition or early permanent dentition.

4. Improper fabrication or fit: modify or replace."

2. How do you evaluate employee performance?

Nearly 90% of the respondents reported using some form of employee performance evaluations. About half of them did their evaluations at six-month intervals, and almost all the rest held them annually. A few offices used quarterly appraisals.

Do you discuss your evaluations with each employee ?

Eighty-five percent of the doctors said they personally discussed the evaluations with their employees, but in a few practices the office manager performed this task.

What do you do if an employee is not performing to your satisfaction?

Most of the respondents were quite uniform in their approach. They said they would sit down privately with the employee to discuss the problems, provide counsel, and request specific changes in performance or attitude. They would then outline goals and areas of improvement for the employee and provide a timetable, often 30-90 days, within which this improvement would have to be made.

At what point do you discharge an employee?

Most readers said they would fire an employee only after several discussions, particularly if no improvement was seen in the areas that had been outlined. Significant complaints from several patients were also mentioned as an appropriate cause for dismissal. Other grounds included gross policy infractions, insubordination, dishonesty, failure to adopt a team approach, and inability to carry out required technical procedures.

How do you reward exceptional performance?

Each of the practitioners used a variety of methods. Lavish praise, particularly at staff meetings, was commonly mentioned. Other rewards included extra time off with pay, cash bonuses, and gift certificates.

What is your policy for giving bonuses?

Although 15% of the clinicians did not give employee bonuses, the remainder was equally divided between those who did so on a regular basis, using a specific formula or plan, and those who gave bonuses only when they felt it was appropriate. Some of the criteria for regular bonuses were meeting goals for production, collections, or patient starts, or a set percentage of gross income. Those who gave bonuses irregularly believed that they could be more flexible in rewarding actual performance and thus avoid the expectation of a bonus.

Specific comments included:

"The employees evaluate themselves on paper. So do I. We compare lists and discuss the results, any changes needed, and the timetable for their implementation."

"We evaluate grooming, attitude, knowledge, skills, and attendance."

"Specific points of our annual performance evaluation include: 1) motivation, 2) rapport with patients, 3) cohesiveness with other staff members, and 4) technical ability."

"If an employee is not performing to my satisfaction, I do not give them a raise, and I make future raises contingent on improvement in certain defined areas."

"If an employee is not performing to our satisfaction, we: 1) make them aware of the problem and our expectation, 2) give them further instruction and training where needed, 3) place them on probationary status (one to three months) to allow for improvement, and 4) terminate employment if necessary with a written explanation and signed acknowledgment by the employee."

"We discharge with no hesitation at any time during the first three-month training period, especially for reasons of poor work habits or personality conflict. After three months, we discharge only after completing our formal written procedure."

"We reward exceptional performance with monetary bonuses and with gift certificates to restaurants, sporting events, theater, etc."

"Continued exceptional performance equals a raise. One-time exceptional performance equals a bonus."

"Bonuses should be given immediately. Christmas bonuses are not bonuses, but merely a cash gift and quite often something that becomes expected instead of a reward."

"Our bonuses are based on office income-- the staff gets 20% of the gross income of the practice."

"We set up an annual office goal and a bonus system based on number of patient starts."

"Anytime we gross over a certain amount, I allocate 20% of that to the staff and divide it according to hours worked."

"We give 3% of the fee to a staff member if they are responsible for that patient's referral, or a 3% reduction in the patient's fee if the staff member prefers."

"Biannual bonuses are given based on the amount the current year's gross production (income) exceeds the average of the previous five years' gross. The amount is the percentage of total staff salary to total costs, divided among the staff in ratio to their salary."

"Mostly substantial bonuses are given at year end. Wellness bonuses are given for not missing any days of scheduled work. The best bonus of all is caring about these people, and they know I do."

JCO wishes to thank the following contributors to this month's column:

Dr. Stanley A. Alexander, East Setauket, NY

Dr. William E. Allen, Athens, GA

Dr. Stephen K. Bailie, Indianapolis, IN

Dr. Harvey J. Barbag, Boca Raton, FL

Dr. Michael G. Behnan, Mount Clemens, MI

Dr. Fred H. Bennion, Eugene, OR

Dr. Samuel S. Berro, Chino Hills, CA

Dr. Alfred M. Bongiorno, Middleboro, .MA

Dr. Walter C. Buchsieb, Dayton, OH

Dr. John J. Cavanaugh, Phoenix, AZ

Dr. John D. Cercek, Oregon, OH

Dr. Lynn A. Dettenmayer, Sarasota, FL

Dr. Bruce D. Fiske, Hillsboro, OR

Dr. Anthony J. Furino, New Hartford, NY

Dr. Girard A. Gugino, Buffalo, NY

Drs. James C. Hull, P.C. Hull, Jr., Samuel J. Burrow III, and Jack C. Case, Jr., Charlotte,NC

Dr. James D. Kaley, Greensboro, NC

Dr. Gene R. Kantack, Idaho Falls, ID

Dr. Christopher K. Klein, Mount Vernon, IL

Dr. Kenneth F. Levene, Carmel, NY

Dr. Steven A. Nerad, Pleasanton, CA

Dr. James W. Osborne, Raytown, MO

Drs. Karl Pick and Steven M. Siegel, Glen Burnie, MD

Dr. Charles F. Reed, Denver, CO

Dr. Jack G. Rosser, San Jose, CA

Dr. Wally Ruiz, Midwest City, OK

Dr. Fred S. Schindler, Lavale, MD

Dr. Robert B. Schlamer, Milwaukee, WI

Dr. Edward V. Shagam, Mount Holly, NJ

Dr. Gregory K. Shell, Lenoir, NC

Drs. Gary R. Smiley and Steven J. Smiley, Spartanburg, SC

Dr. Dennis D. Sommers, Minot, ND

Dr. Frank J. Stich III, Coppell, TX

Dr. John L. Studer, Brenham, TX

Dr. Robert H. Thalgott, Las Vegas, NV

Dr. Terry M. Trojan, Albany, GA

Dr. Allan D. Weimer, Steamboat Springs, CO

Dr. Jay R. Wright, Solvang, CA

Dr. David W. Zemke, Minneapolis, MN

Journal of Clinical Orthodonics

THE READERS' CORNER

1. In what percentage of your cases do you use functional appliances?

2. How do you evaluate employee performance?

PETER M. SINCLAIR, DDS, MSD

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