Every 32 seconds, according to the American Heart Association, someone dies of a heart attack. I was one of the lucky ones.
Two years ago, I was a typical 59-year-old, Type A, slightly overweight solo orthodontist and part-time teacher in an orthodontic department, with my wife working in the office and a son in dental school. I played squash three times a week in the winter and tennis three times a week in the summer, but I had a blood cholesterol count of 275 and a primary-care physician who kept saying, "We don't worry about cholesterol."
On the last day of January 1991, I remember feeling washed out and tired as I drove to the office. I hadn't really felt well for several weeks; my doctor thought I had a virus. I decided not to see patients that afternoon. At lunch, the classic symptoms began: burning behind my sternum traveling to the hollows of both arms, nausea, and sweating.
I wanted to take a nap, but my wife insisted on taking me to the emergency room. After two sudden heart attacks, followed the next day by emergency quadruple-bypass surgery, I was a member of the "zipper club". I thought my colleagues might find it instructive to consider the effects of such an event on a busy orthodontic practice.
Aftermath of the Heart Attack
I was fortunate that all the orthodontists in my state were part of a voluntary mutual protective agreement. Some years ago, a small committee of the Delaware Society of Orthodontists investigated various documents of this type, compiled a composite, and refined it over the course of several meetings. A copy of this original agreement is appended to this article.
Such an agreement is only as good as its participants. In my case, they responded magnificently. After a delay of only about a week, my patients were once again being seen in my office by my colleagues. This turned out to be a learning experience for both my staff and the visiting orthodontists; they exchanged a number of ideas that are still being used. Since I had been in the habit of writing on each patient's record what was planned for the next appointment, my colleagues were even able to advance treatment.
I discovered that it was more important to have immediate coverage than long-term assistance, if only to reassure your patients and their families that they would be taken care of. Most of the patients were put on a maintenance program, which meant that less help was needed as time went on.
My wife was my greatest asset; she had been part of the practice for seven years, and she knew the patients, the staff, and the office routine well enough to keep the practice flowing during this difficult time. It may be an old saw, but no one has more of an interest in your livelihood than you and your spouse.
The importance of a mature, stable, well-trained staff cannot be overemphasized. I heard many times from my colleagues how much they appreciated working with my staff.
On the negative side, while I was in bed recovering I lost every new patient on the books--even those who had made initial payments, but did not yet have appliances in place. Collections were down by half in February, probably because families were wondering whether I would return, but in March collections almost doubled when they saw that I would make it.
There was a wonderful outpouring of get-well cards, flowers, and plants that we displayed in the office. When I returned in May to practice two mornings a week, I again received many good wishes from patients and parents.
Another negative was my attempt to collect disability insurance from my nationally recognized carrier. Despite their denials, my representatives did not seem to understand the realities of orthodontic vs. general dental practice in calculating residual (as opposed to permanent) disability benefits.
For example, the examiner asked for cash receipt and cash disbursement totals for the months claimed, along with either earnings from the six months just before the heart attack or copies of my tax returns from two consecutive years out of the five-year period before the disability. I could not convince the company that in an orthodontic practice with ongoing patient contracts, a sudden disability will not materially affect the short-term financial picture. Unlike in general dentistry, where there would be an immediate drop in income, the effects are not completely felt until current patients are paid up and they are not replaced by new cases.
After many months of letters and telephone calls, a field representative offered me $6,000 as a full settlement. I held that check for a month, feeling that once I cashed it I would be forfeiting any claim to future benefits. Finally, rather than face a protracted legal struggle, I accepted the settlement.
Conclusion
By September, I was practicing as much as I wanted to--about half the hours as before the heart attack. Now, I exercise two afternoons a week in a cardiac maintenance center at our local medical center. Eliminating two afternoons a week from an orthodontic schedule forces one to be very efficient with what's left. But I learned that you must listen to your body, and not only practice but live accordingly.
MUTUAL PROTECTIVE AGREEMENT
THIS AGREEMENT made and entered into this_______ day of 19_, by and between the following parties:_____________________and wife,_____________________and wife,_____________________and wife,_____________________and wife,_____________________and wife,_____________________and wife,_____________________and wife,_____________________and wife.
THAT WHEREAS, the undersigned are all practicing orthodontists duly licensed and authorized to practice dentistry by the state of Delaware and currently practice in the county of New Castle, have with their wives joined in this indenture;
AND WHEREAS, each of the undersigned desires to execute an agreement whereunder all will temporarily assist each of the others in continuing their respective orthodontic practices in the event of the illness or disability of one or more of the parties hereto;
AND WHEREAS, each of the undersigned further desires to protect and conserve the practice and equipment used therein for the best interests of the estate in the event of death;
NOW THEREFORE, in consideration of the mutual provisions, covenants, and agreements herein set forth, the undersigned jointly and severally hereby agree as follows:
1. That "illness or disability" or "incapacity" wherever used in this agreement shall mean and refer to any physical or mental illness, disease or injury, or any other disability which shall render a party hereto incapable of carrying on his normal functions as an orthodontist. 2. That in the event that any one or more of the parties hereto suffer illness or disability, the other parties hereto shall maintain the professional practice of such party or parties for a period not to exceed six months, unless total agreement of the members wishes to extend this time. That the date of commencement of the services contained in this agreement shall be determined by the party so incapacitated if he is able; otherwise said services shall commence not more than two weeks after such party is incapacitated. 3. That if one of their number becomes ill or disabled, the parties hereto agree to assume equally among themselves the number of hours of office time required for the proper management of his practice. Each member's obligation shall not exceed eight hours in any one week, and rotation among their number shall be agreed upon as may suit their convenience. 4. That the services to be rendered by the remaining parties on behalf of an incapacitated or deceased party shall be performed at the offices of such incapacitated or deceased party. The remaining parties shall only be required to spend as much time at the offices of an incapacitated or deceased party as may be reasonably necessary to treat the patients of such incapacitated or deceased party, and shall otherwise be free to carry on their own pursuits. 5. That the patients of the incapacitated or deceased party will be divided and allocated among the remaining parties as equally as possible, having regard to the number of patients to be treated and the length and type of treatment involved. Upon such division being made, each of the remaining parties shall assume and care for and treat the patients so allocated to him. 6. That in the event of death or permanent incapacity of any of the parties hereto, each of the remaining parties agree jointly to maintain the professional practice of the decedent as contained in this agreement until its eventual disposal by the heirs of said deceased party, but for a period only of six months, unless there be pending negotiations which portend a favorable consummation of a sale. All proceeds from the sale shall be paid to the surviving heirs of the decedent. 7. That upon the death of any of the parties hereto, the surviving parties shall endeavor to find a purchaser for the ongoing practice, professional equipment, supplies, and office equipment of such deceased party on terms and at a price most favorable to said deceased party's estate. Any party hereto shall be permitted to make purchases from a deceased party's estate so long as said estate thus receives the most favorable price and terms of sale. If the practice cannot be disposed of, the group will assume the liability of finishing all patients of any permanently disabled or deceased member after the six-month period. The group will meet and distribute the patient load evenly and will endeavor in all cases to complete treatment under the existing financial arrangement, the patient being given credit for all payments. 8. That upon incapacity or death of a party hereto, the remaining parties shall have access at all times to the professional records of an incapacitated or deceased party. The remaining parties shall maintain accurate and up-to-date records of all professional services which may be rendered by them hereunder, and such records shall be the property of the incapacitated or deceased party. 9. That the practice of the incapacitated or deceased party shall be carried on as aforesaid in the name of the incapacitated or deceased party. All accounts for professional services shall be rendered in the name of the incapacitated or deceased party, and all fees and amounts received on account thereof shall be payable to and be the property of such incapacitated or deceased party. Should any monies be received by any of the remaining parties for services rendered hereunder on behalf of an incapacitated or deceased party, such monies shall be forthwith turned over to the incapacitated party or estate of deceased party. Any arrangements respecting fees made between an incapacitated or deceased party and any of his patients prior to such incapacity or death shall be followed. The remaining parties shall obtain and the incapacitated party or estate of deceased party shall pay for all drugs and medicines and dental supplies required from time to time to carry on the practice of an incapacitated or deceased party. The incapacitated party or estate of deceased party shall maintain the premises in which his practice is carried on and shall pay all costs and expenses in connection with the operation of said practice as if he were carrying on the practice himself, and without limiting the generality of the foregoing the incapacitated party or estate of deceased party shall pay for bands, materials, and dental supplies as aforesaid, salaries of assistants and other employees, office rent, and other costs and expenses. 10. That the remaining parties shall make no voluntary changes in the office staff without first consulting with the incapacitated party. If any of the remaining parties wish to bring into the office of the incapacitated party their own assistant for their own convenience, they shall be responsible for the salary of this individual. 11. That each party hereto agrees that in assisting in the maintenance of the professional practice of any of the other parties hereto, he shall be governed by the Rules of Professional Conduct of the Delaware State Dental Association and the American Association of Orthodontists, and by the following additional rules: a. That he shall start no new patients, but shall place each new applicant for treatment upon a list of potential patients for the benefit of the party suffering sickness or disability (that in the event any new applicant desires not to await the return of such party, then such applicant shall be given the names and addresses of each of the parties hereto, from which to make a choice). b. That he shall continue the treatment of existing patients in accordance with the best professional standards, at the office of the party suffering the sickness, disability, or death. 12. a. That it is expressly understood and agreed that the rights, privileges, and duties of each of the parties hereto is personal and that this agreement and none of its rights, benefits, or duties may be assigned or assumed without the prior written consent of each of the parties hereto. b. That this agreement shall continue in full force and effect from year to year, and shall be deemed automatically renewed on each anniversary of its execution, subject to the following conditions: Any party hereto may retire from the association created hereby upon six months' written notice to each of the other parties. In the event any sickness, disability, or death occurs during the six-month period after written notice is given, all parties will have the same obligation to the others as before.
13. That should the occasion arise for services to be performed hereunder on behalf of one of the parties (hereinafter called the "Second Party") at a time when services are already being rendered or are about to be rendered on behalf of another party hereto (hereinafter called the "First Party"), the other parties hereto (hereinafter called the "Remaining Parties") shall provide the same services on behalf of the Second Party as they and the Second Party are then performing or are then about to perform on behalf of the First Party according to the terms and provisions of the agreement. In addition thereto, the Remaining Parties shall divide and allocate among themselves and care for and treat the patients of the First Party being treated by the Second Party at the time of the incapacity or death of the Second Party, all in the manner and subject to the terms and provisions of this agreement. It is understood and agreed that services will not be rendered hereunder on behalf of more than two parties hereto at the same time.14. That additional parties may be included in this agreement and will be subject to all the benefits and conditions of this agreement. Any new party to be included must be approved by all current parties to this agreement.15. That nothing in this agreement contained shall be deemed or construed so as to confirm the existence of or give rise to a partnership or corporation of any nature or kind whatsoever among the parties hereto. The parties hereto expressly deny that they are, or are about to become, a partnership or corporation as a result of this agreement.IN WITNESS WHEREOF, the said parties have hereunto set their hands and seals the day and year first above written.
____________[Signatures]___________
The undersigned, the spouses of the orthodontists herein executing this agreement, hereby consent to its provisions and approve the same so far as it may relate to their community interest in the property involved.
____________[Signatures] __________
Author's Note: Several amendments to this agreement have been made since my heart attack. The most important changes are that coverage will always begin within 14 days; that in practices with multiple locations, treatment under the agreement will usually be performed in only one of the locations; that nonexclusive orthodontists will be covered only for their orthodontic patients; and that spouses are no longer signatories. In addition, the disabled orthodontist or his estate can now exclude one member of the group from coverage if desired because of past competition or interpersonal problems.
