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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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Get Out of the Comfort Zone

January 6, 2014

Filed under: Business of Dentistry,Self-development — Tags: , — Barry @ 10:30 PM



On Friday morning January 3rd, 2014, I woke up to the first snowstorm of the year.  Six inches covered the ground and would be a big obstacle for me to get to my 9:30 hot yoga class.  I could feel the resistance that pressed against my covers, but I pushed them off and began my ritual of showering and drinking 72 oz. of water.  Then I checked the web to see if the class was cancelled…Luckily for my bladder, the class was on.

I live in the woods.  The plows never come down my road…it’s dirt and gravel, so I had to mash my way through the snow to get to the class.  When I arrived I was met by four other hearty souls and the teacher.

The reward:  the best hot yoga class ever—and the heat felt sooo good.

That’s usually the payoff for breaking through resistance.

We face resistance everyday of our lives.  We have this preference for comfort and low stress.  Yet, as I always say, “The insecure path is the secure path in the end.”

Just last week I started a complex restorative case involving ten upper teeth.  The case included an implant, several veneers and crowns, and some pink porcelain.  My patient traveled over three hours for the appointment.  I worked slow and methodically to get all of the information required for the case.

I checked the impression and was pleased that I captured every margin.  I placed the temporaries and sent my patient on his way home.  An hour later, my son Josh who is also my lab technician, informed me that I would have to retake the impression.

“Why?”  I asked.

He said although the margins were great, because we would be using refractory dies that the pulls in the non-strategic areas would not allow him to get accurate dies.  I would have to call the patient back for another impression.

I felt resistance.

My patient would have to take another day off from work, drive six more hours, have his temps removed and have another impression…yes,with local anesthesia.

I felt resistance.

I didn’t want to make that call...yet I was the only one who could make that call.

So I did, and he totally understood.  He wants the case to come out as perfect as possible.  I felt better having broken through the resistance.

Everyday, no matter what line of work we are in or no matter what goals we set for ourselves, we will meet resistance.  When you feel that uncomfortable sensation in your gut, that’s resistance.  Telling you to stay put.  In your comfort zone.

Pushing through is the key to success.  So as we begin this new year…if you have made resolutions, realize that you should still being going to the gym in April…and along the way you will feel lots of resistance.



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