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How to Deliver Bad News

October 19, 2015

Filed under: Case Presentation,Communication — Tags: , , — Barry @ 2:34 PM



As a practicing dentist for over forty years, if there is something I do regularly it’s deliver bad news.  As the GEICO ad tells us…“if you’re a doctor you deliver bad news…it’s what you do.”

Not a day goes by when I don’t have to tell someone that they have a cavity, periodontal disease or worse yet, how much it will cost them.  And it’s not just the dentistry: how about when a case comes back from the lab and the shade is off or worse, we need to take another impression.  In a dental practice the situations are endless.

It’s a rare moment when we get to say “Mrs. Jones…it’s a boy.”

This is not the fun part of a dentist’s job…and many dentists paradoxically try to avoid it.

Think about that for a second.

A longtime patient comes in for a routine cleaning and you discover early decay under a old long-span bridge.  It’s a bridge you made for her fifteen years ago.  She comes in regularly and she has not needed work in years.  You know she’s under the impression that as long as she flosses daily and comes in on a regular basis that she is immune to major problems.  Worse yet, she is recently divorced and approaching retirement.

Tense times…for everyone, unless of course you lack empathy.  That’s another problem, but if you truly want to master the art of delivering bad news better – then this may interest you.

Leadership and communication lie at the center of your success in dentistry.  Present your case in a positive manner and you will get more acceptance, less complaints and most importantly better health for everyone.  In the past I have written blog posts about the charismatic dentist and empathy…delivering bad news better can go a long way to improving your charisma scores.

In a new book, Broadcasting Happiness, The Science of Igniting and Sustaining Positive Change, author Michelle Gielan offers her Four Cs on how to deliver bad news.

If you practice the Four Cs I am sure your dental practice will become more positive in every way and you will never complain about “people” again.

Let’s take a look at the Four Cs in dental practice:

  1. Create Social Capital.  A buzzword being used these days in business and sports, is culture.  But what exactly does that mean?  Dental practices need to build cultures of trust.  Covey, years ago referred to an emotional bank account.  Social capital refers to the resources that we have available to us based on trust and the willingness of practice to support our actions.  For patients of record this trust is built up over the years.  For new patients it is built through the examination process, and how the practice welcomes patients in.  Other resources include our ability to communicate, educate and motivate through listening and clear expression of thoughts and ideas.
  2. Give Context.  How you frame your conversation means everything.  If we frame our treatment in negativity…pain, cost and inconvenience, our acceptance will go down.  Just this morning I entered my hygiene room and my patient sensed my presence and said, “Uh Oh!”  She was joking, but let’s be honest most patients frame their dental visits negatively.  One way to provide context is to use what I call a “reason why philosophy.”  It takes a bit longer but I usually give a thorough explanation about why I need to do dentistry.  Not only what needs to be done but why it needs to be done.  This takes a bit of skill. but it can be learned.  Many dental practices use what author Gielan calls a Band-Aid mentality in delivering bad news- they just rip it off fast so it won’t hurt as much.  I hate when that happens to me…the reason why philosophy builds trust.  This comes up more often than we might think.  Even in the case of a patient who repeatedly refuses x-rays…just saying “because I said so,”  doesn’t inspire trust.  Taking the time to give a well thought explanation goes a long way.
  3. Express Compassion.  One of the strangest things for me to understand is noticing how so many of my dentist friends feel when they are on the receiving side of bad news.  And I mean any bad news.  They especially love to complain about the cost of things these days, yet they have no problem dispensing the bad news.  It’s human nature to not take bad news well.  Just knowing that means we have to step back and show empathy…it’s appreciated.  Dentistry is expensive these days.  If you’re reading this and getting angry because your fees are justified, I get it.  You know who doesn’t get it?  Most patients, so show compassion.  Talk about it.  And it gets worse when it’s your work that fails.  According to Michelle Gielan, compassion not only makes moral sense, it makes business sense. 
  4. Stay Committed.  Earlier I said that delivering bad news was an aspect of leadership and communication.  The leader’s commitment is to the patient and their well being.  Leaders deliver long term value and in order to do that we must remain committed.  In the end delivering bad news starts with being human.  If we remind our patients of what John Lennon once said, “Everything will be okay in the end.  If it’s not okay, it’s not the end.”

So take heart, if delivering bad news gets you down, use these 4 Cs to change the way you look at things—because “if you change the way you look at things the things you look at change.”









Make it Work

July 30, 2013

Filed under: Business of Dentistry,Case Presentation — Tags: , , — Barry @ 10:41 PM



In my last post over at CasePresenter.com I wrote about getting into a mindset that would help dentists to become better influencers.  The mindset enables the dentist to think in terms of implications…leading to the emotional meaning of problems.

When I wrote the post I was thinking in terms of case presentation.  Later on that day I thought about how we are always presenting.  I discuss this thoroughly in my new book, The Art of Case Presentation.  

I overheard a conversation between my son Josh and one of his clients.  Apparently the dentists did not supply the necessary information to complete a complex case.  It was interesting to hear how Josh was describing the implications of not having the correct information.

I began to make a mental note of just how deep one omission can carry through the practice.  It’s a good thing that Josh maintains certain standards in his lab or else those small mistakes could implicate similar issues in his lab.

But let’s talk about the dental practice.  Let’s talk about when the case comes back from the lab and the patient says, “Doctor, are you sure they’re my teeth?”

So now, doubt has entered the room.  There is a loss of confidence…but most doctors handle that well.  They tap dance and blame the lab.  Okay, but what about the staff?  This isn’t the first time it happens.  They may not know exactly why the cases rarely fit…they just know it happens a lot.

And what about the front desk?  They have to deal with the not very enthused patient.

These little annoyances add up.  They affect the morale of the office.  They affect patient relationships.  They become a story that gets repeated (yes…the 4 appointment crown is a popular story).  They affect the relationship with the lab.

And all because of poor planning and shortcuts.

This idea of implications is not new.  Dr. Peter Dawson in his seminal textbook on occlusion discusses the implications of a high filling in the first chapter.  He restricted the the discussion to oral implications…but the real practical implications go much further.  It’s worth revisiting that chapter.

Dentists love shortcuts.  Walk into any lab and see how many triple trays fill the lab cases.  Now I am not totally against triple trays.  They have their place.  But not in complex cases.

Complex may mean more than one tooth…or even just one tooth.

Albert Einstein once said,

Everything Should Be Made as Simple as Possible, But Not Simpler.”

When things just get done simply to expedite a procedure…there are implications.

Strangely it’s those implications that are the main reasons for dentists spending small fortunes on practice management.

I have always said that we can’t separate the technical component of what we do from practice management, and leadership.

I don’t know what came first…chicken or egg, but I do know that there is a strong relationship between the back of the office, the front of the office and the lab...that relationship is implication.

If you find yourself telling someone to “make it work,”  that’s a shift in accountability.





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To Prep or Not to Prep

July 16, 2013



The second a dentist sees teeth he wants to fix them.  I guess it just comes with the territory.  Or is it just good old American pragmatism.  I used to be that way until I took the time to really understand people.

That thought process lead to the writing two books, The Art of Examination and the forthcoming Art of Case Presentation.

The photo on the right was recently posted on Dentaltown. The post was titled, “She Wants No-Prep Veneers–What Would You Do?”  It spurred a slew of comments that caught my attention.

Now…I know the title asked a direct question…but my first thoughts centered around how she knew what “no-prep veneers were.”

The comments answered that question…it was Lumineers she wanted.

I recalled a quote from Theodore Levitt, the ex-editor of the Harvard Business Review who said:

 “People don’t want to buy a quarter-inch drill, they want a quarter-inch hole.”

And so it follows that patients don’t want no-prep veneers…they want…

That’s for the dentist to find out from the patient.  Even the guy at Home Depot asks what I am going to use the quarter-inch drill for.

The comments in the post are fairly enlightening.  Most of the commenting dentists wanted to do bleaching or orthodontics.  Many voted against any veneers at all.

Reading through the comments lead me to some perceptions about the state of dentistry.

One thing I see is that most dentists truly want to stay with conservative treatments…bleaching and orthodontics.  I feel the same.  However the public’s perception is that dentists tend to want to destroy teeth.  I guess that’s why the media portrays dentists as “drilling for dollars.”  The comments confirmed what I have always felt about the dental community…that they are caring concerned professionals who want to help their patients.

Another thought I had was how obsessed we are with whitening teeth.  Have we been lead to believe that whiter teeth equals cosmetic dentistry.  I am sure that if a dentists had a serious conversation with the patient she would come up with a few more things than just whitening.

Stop looking…this isn’t about fixing her…it’s about understanding her.

Who is she?  Dentists should REALLY get to know their patients...it’s part of the examination and diagnosis.  Only then, once we have articulated the problem…can we present the case.

In order to do that we must approach our patients without an agenda…like the guy in Home Depot.

Another thought, which was also expressed by the author of the post, is that the patient came in with a knowledge of Lumineers or no-prep veneers.  Okay, I know the various methods to treat prostate cancer but I will always defer to the professionals to help make my decision.

The state of advertising in health care these days is a blessing and a curse.

Doctors must work through it…by becoming better leaders and staying true to their diagnostic abilities...above all to keep the human component in dental care.

I have faith.







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Here’s to the Crazies

June 24, 2013




During a conversation about cosmetic dentistry, my  patient turned to me and said, “Oh you Americans with your white teeth.”  She is from Belgium and she said it half jokingly.  When I reflected on the comment I realized how uniform dentists and technicians tend to make teeth…People Magazine’s version of cosmetic dentistry.

I used to have a painting on the wall of one of my treatment rooms…A New Yorker’s View of the World. 

Being an arrogant New Yorker at the time (I’ve changed and mellowed significantly), I resented the way the artist portrayed east coast myopia.  But, in both cases, the painting and my patient, I listen now when others suggest to open my eyes and take a different view of the world.

When patients present for cosmetic dentistry I ask them to bring in photographs of what they want their teeth to look like.  They always bring in the same pictures…Julia, Tom, Jenifer and an assortment of the same models hawking different products.  The smiles are very regular, very standard…stock teeth.  When I point out that most of these people have natural teeth, they tell me that’s what they want.

But in the end, what they want is not natural…it’s white, bright and regular…the same look that my Belgian patient was referring to.

What I am suggesting is to break that mold…destroy the status quo and really create beauty by taking a few risks.

That’s what artists do.  They create new things by destroying the status quo…not just teeth, but ideas and approaches as well.

The dentist and lab technician of the future will have to be creative…they will have to see things differently.  Competence will no longer be enough—even expert may fall short…only the masters, the inventors and innovators will compete in the future.

In the book Iconoclast, author Gregory Berns tells the story of Dale Chihuly, a master glassblower.  His work can be seen in the lobby of the Bellagio Hotel in Las Vegas (picture above), The Metropolitan Museum of Art, and in 1986 he had an exclusive showing in the Louvre.    Chihuly’s story is an evolutionary tale of an artist, and a true iconoclast.  The word comes from the Greek eikonoklastes which means “destroyer of images.”

Essentially it is what Steve Jobs referred to when he said, “Here’s to the crazies,”  or “Think Different.”  Yes…we can do that in dentistry.

As Berns tells Chihuly’s story, as a novice glassblower he stuck to the rules.  He only produced symmetrical, balanced pieces.  That was the expected protocol, and it was rarely challenged.  He was always a freethinker and struggled to do things differently, the the available tools only allowed him to produce the same old symmetrical pieces—colorful, innovative but symmetrical.

In 1976 Chuhuly was in a car accident in which he lost his left eye.  He began to wear a patch which cut off his peripheral vision.  His handicap forced him into a new way of working by giving up holding the glass to a gaffer in order for him to get more accurate depth perception.  As a result, this adjust

English: Dale Chihuly

ment allowed him to see the glass from different angles, and his results were asymmetrical, and actually mind-blowing.  He created a new art form—he broke the existing paradigm of glassblowing.

He went from competent, to expert to master by breaking the mold—by breaking the rules of glassblowing.

Dentistry will not move forward without masters—those who break the rules—the crazies.  If our culture continues to reward the same old, same old by confining dentists and lab technicians into creating the “American Smile”  we are holding the profession back and placing cuffs on individual dentists.  They need the freedom to practice.

These days it is the “crazies,” the artists that are breaking the staus quo—and they are meeting lots of resistance.  Maybe then we won’t be making pearly whites for seventy five year old patients.












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What is the Practice of Dentistry?

April 1, 2013

Filed under: Art of the Examination,Case Presentation,Philosophy — Barry @ 10:00 AM



I practice Bikram yoga.  It’s Hatha Yoga on steroids.  We do it in a hot room, heated to 105 degrees and 40% humidity.  It can get uncomfortable if you are not used to it, but once you acclimate it’s really good for you.  Acclimation takes time and practice.

Besides all of the medical benefits I have enjoyed, like lower blood pressure,  more stable blood sugars (I am a diabetic), great looking skin and better balance and flexibility (but I still can’t touch my toes after two years), I have learned a lot about the concept of “practice.”

I always felt that the word practice was sort of a misnomer when it came to dentistry.  I mean dentists don’t practice like pianists, tennis players or even magicians,  consciously and deliberately practicing everyday.  Conscious and deliberate are the operative words.  After graduation most dentists don’t do much consciously and deliberately.  Many dentists get better just because of the repetition.  Yes, my composite resins do look a lot better…but only because I paid attention.

But there are many skills that we use that could bear a little deliberate and conscious practice.  Like communication skills.

I realized the methods of deliberate practice while doing Bikram Yoga.  Every class is the same – a beginner’s class.  Sure people get better…but it takes years to master every pose.  Yoga practice forces me to slow down the mind, like meditation with a purpose.  If you don’t slow down the mind you can’t focus on the complexity of the posture’s demands…muscular and respiratory.

Recently I handled my puppy at a dog show.  My regular handler didn’t get to the ring in time.  I was flummoxed.  There were way too many things going on at the same time.  I blew it.  I wondered if practice would help.  They say athletes need to slow the game down in order to get better.  Football players say the speed of the game is the biggest difference between college and the pros.  Breathing works,  It slows down the heart and the mind.

Just as I set her front legs down she dropped her tail.  When I brought the tail up…boom, there went the back legs.  When I zigged…she zagged.  Then I sped up and lost it.

Does that sound like some your days in the office?

The answer is practice…conscious and deliberate.

It forces you to focus on the technique and continually reduce the effort.  Mistakes are made and tolerated.  When it doesn’t go right, you take a step back, and try again.

It’s interesting that in practice there is always a teacher.  In yoga they call the teacher a guru.  There are semantic differences between the east and the west, but in the end practice should be monitored by a teacher, coach, mentor or guru.

To me the greatest advantage of deliberate practice is emotional control, because it is the toughest to learn and sustain.  I have studied emotional intelligence for years, yet just knowing about it doesn’t correct it.  It’s like knowing about nearsightedness…you still can’t see.

Slowing down the emotional brain or quieting the mind can be done with therapy, drugs or meditation.  Meditation is probably the most effective…it’s also a practice.

That’s why I do yoga.


How to Interpret a Story

June 18, 2012

Mary Osborne is one of dentistry’s greatest treasures.  She is a wonderful teacher and a master storyteller.  I was recently reading LeeAnn Brady’s blog and came across a video of Mary telling one of her favorite stories.  I had heard the story before but this time it took n new meaning.

That is the power of story.  It touches each of us in a different way each time we hear it.  Take a listen.

This time I was reminded of one of my favorite lessons about why I spend so much time with new patients during my comprehensive examination.  When I teach this principle I usually refer to Stephen Covey’s works on trust.  I love when he says, “With people, fast is slow, and slow is fast.”

When I quote that I usually get a lot of blank stares reflected at me.  Think about case acceptance…when you take your time with patients up front, they make their decisions must faster.  And when you rush people through an exam, it seems they never make a decision.  This is what Mary’s story means to me.

What does it mean to you?

I am in the middle of training a new puppy, Annie.  The same principle works with dogs—so it’s just not with people.