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By-Products of an Examination Process

February 17, 2014

Cover of "The Checklist Manifesto: How to...



By far the most important lesson I ever learned in dentistry…one that I wrote a book about…and one that changed my life even more outside the profession than within the profession…was to commit to a comprehensive examination process.   For that I thank my mentors Peter Dawson and Irwin Becker.  That one change in my philosophy lead to the creation of more positive habits, more consistency in behavior and more success than anything else I ever applied.   That’s a bold statement, but if you have committed to a comprehensive exam process then you know how true it can be.   One of the advantages of doing a consistent, comprehensive examination on every patient is that it reduces the number of errors we make in treatment planning our patients.  Make no mistake— planning treatment for patients…all patients…is the most difficult thing we do in dentistry.   Why?   Because regardless of the eventual treatment, we are doing it on the most complex system ever created — the human body…both the physical component and the mental/emotional component.  Dentistry and medicine are complex fields if only because of who we work on – people, not machines.   And so many dentists…and those who have a lot to say about health care in this county – devalue it.   Why?  I’ll let you answer that because the number of reasons is equal to the number of dentists who don’t do it.  That alone is a good reason to do an exam on every patient.   Some years ago I wrote about and praised the book, The Checklist Manifesto by Atul Gawande.  I still recommend it.  In that book I compared his “checklists” to our examination process.  He wrote about complex situations like what goes on in the operating room and in preparing airplanes for travel.  Of course these situations can be a matter of life and death…but that doesn’t reduce their meaning for what we do in our everyday lives.  Checklists lead to better predictability and control.  Is there a goal you haven’t been able to achieve?   In a new book, The Upside of Down, author Megan McArdle refers to Gawande’s book in an effort to explain how to reduce errors by creating a checklist/process.  She reminded me of a quote I once read by W. Edwards Deming:

“If you can’t describe what you are doing as a process, you don’t know what you are doing.”

I firmly believe this, because the examination process for me was the starting point for understanding everything I know about this field.   McArdle then cited University of Penn sociologist Charles Bosk who studied types of errors we make.  His work focused on medical mistakes. This is where it gets interesting.   Bosk classified four types of errors:

  • Technical errors.  These would include things like the drill slipping…these things do happen.
  • Judgement errors.  Includes errors of waiting too long to treat or using questionable techniques.

Both of those types of errors occur with some frequency and although I hate to say it…are expected.  Into everyone’s life a little rain falls.   The next two types are not expected and this is where taking the proper precautions and using a process can keep us on the straight and narrow,

  • Normative errors – or failing to get and use all of the information that is available about a patient.  This one calls into question the personal fitness of the doctor.  This is why dental schools taught us why cheating was so bad.  These are the ethical errors.
  • Quasi-normative errors – these are the ones that dentists do because someone suggested that they do it.  Hmm…who might that someone be?  I call this the Flip Wilson error…the late comedian who became famous for saying “the devil made me do it.”

So why do these last two types of errors occur?  It’s easy to blame people, but if you could build fail-safes into your process, then it’s more likely you will avoid these errors.  No guarantees, but what McArdle says makes sense:

“People who commit normative errors are generally too focused on outcome and result, and not enough process.  They are willing to cut corners, to bend rules, and that is a very dangerous thing.”

So the lesson is,  if you want to minimize the risk of catastrophe, you focus on the process much more than the outcome.   But there’s more.  The examination process even beyond dentistry, helps us understand ourselves better.  It can be a self-development tool…it was for me.  Remember what Socrates said, “The unexamined life is not worth living.”   And he wasn’t talking about teeth.

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  1. A wise man once told me “once you start thinking you have arrived, that’s when your down fall begins” (paraphrased poorly) who told me that? Barry Polansky. Well the Japanese use the word Kaizen. It mean the continuous improvement of processes. Now we can apply that to dentistry and your practice which, believe it or not, is not the same thing and the practice is the most neglected part of practicing dentistry. Even the most successful Dentists probably never think about inventory carrying costs or the cycle time of processing a new patients affects the bottom line. How to do a cost-benefits analysis for buying a new piece of equipment or relocating. How to calculate now many employees you need? You get the point and all of these things can amount to millions of dollars over a lifetime! Growing a practice is more about the business than it is about the dentistry. It took me to not be able to practice dentistry to see that, along with an MBA program half completed. I love Barry’s books. I liked the man before they were written because he has the one thing it takes to truly achieve success. That one thing is………….. PASSION. I only went to C1 at pankey and an accident ended my goal of completing the curriculum. At Pankey they all loved to learn, improve and teach! It was very contagious and I loved being around others with that passion. But to get back to the point. Processes can be Defined.They can be Measured, they can be Analyzed, Improved, and Controlled (sustained). It is better to improve the weakest area 50% that the strongest area to perfection. You must be vigilant and always improving by reducing errors and waste. Do random sample checks on patients you have treated with a process for example an inlay or direct composite and evaluate the success rate. Then analyze, improve and test those improvements. Then measure and analyze again. One day I would like to create first Dentist 3pl company ( 3rd Party logistics) From supply chain management stand point, manage the peripheral business systems customized to each practice owner. Allow dentists to focus on their core competencies and grow strategically based on forecasting and statistics like a fortune 500 company. I would love to see you all succeed in today’s environment and a net increase the population seeking quality dental care. That may sound like a pipe dream. Dentistry has a “Herd Mentality” and they are generally very skeptical. But I have two things going for me. 1. I am a Dentist. and 2. I have passion.

    Comment by Joseph Salkind — February 18, 2014 @ 12:02 AM

  2. Hi Joe— Thanks for the compliments—I still use that quote. You make some very good points– While reading your comment I was reminded just how “complex” the practice of dentistry is. From the business to the skills (hard and soft) it can get quite overwhelmong. At the heart of a long successful career is that word—PASSION. The problem as I see it is that many people don’t understand its meaning and how one develops it. Some think you either have it or don’t have it–some really do have it but can’t get to it because of the “business” issues. Passion is the endpoint—it is what LD was trying develop in dentists through his philosophy.

    Comment by Barry — February 19, 2014 @ 11:27 AM

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