We all know how important it is to set goals, don’t we? From the day I began practice, everyone advised me to set production and collection goals, after all goal setting makes perfect business sense.
In the late eighties I was enrolled in a so-called “business school for dentists” with the main focus on establishing monthly production goals.
Everyone on staff was focused on production. We set SMART goals. SMART is an acronym for specific, measurable, attainable, realistic and timely. We set up bonus systems when goals were reached. As time went on we really turned up the heat by setting big “stretch goals.”
But then I noticed something happening: we kept raising the bar until we achieved some unintended consequences.
Goal setting is the standard of operations in the business world. There is a popular study that is cited from the 1979 Harvard Business School MBA program in which 3 percent of the students wrote down their future goals. Ten years later that 3 percent of students were worth ten times the worth of the rest of the class combined.
This study never occurred…it is pure urban myth. Today that myth is being totally exposed by studies that reveal the downside of goal setting. According to a new study from the Harvard Business School, titled “Goals Gone Wild,” there are many side effects from goal setting including:
• Too narrow a focus that neglects non-goal areas.
• A rise in unethical behavior.
• Distorted risk preferences.
• Corrosion of organizational culture.
• Reduced intrinsic motivation.
These studies confirmed what I was feeling during the eighties.
I am a big fan of building culture, and when our entire culture centered around production I became uncomfortable. Although I don’t remember compromising my ethics, I certainly saw the possibilities. I am a big fan of the importance of intrinsic motivation to our well-being. My focus on the extrinsic rewards were the reason I sought guidance burnout years ago. This obsessive desire to focus on extrinsic rewards ended up being the cause of my unhappiness in dentistry.
So what did I do? I turned it around…I focused on process over product.
I still had an idea of a specific result I wanted to see each month, but I focused more on how to get there. In other words, I identified areas of focus that would get me that destination if I diligently applied myself. This was how I developed and committed to my master systems of examination and case presentation.
These two processes are not even “productive,” but they give us the capability to produce more dentistry. Pretty counter-intuitive.
Author Peter Bregman in his new book 4 Seconds, says, “A goal is a result; an area of focus is a path. A goal points to a future you intend to reach; an area of focus settles you into the present.”
When I concentrated more on examination, diagnosis, treatment planning and communication, everything changed.
What we pay attention to is what gets rewarded. We become better, and build a better culture when we take our eyes off of production goals.
Not only will the dentists reach his destination but in the process he or she will become better dentists. The culture will be built around the process instead of the targets.
Through repetition we can get better at preps and impressions but what about the skills that really matter, the ones that make or break the success of a dentist…the non-technical skills…the soft skills.
By slowing down my exam process I was able to see how poorly I was doing at certain things, how well I did at others, what needed improvement and what made the biggest differences. In other words, the exam process is a compilation of many key skills that matter.
Legendary basketball coach John Wooden understood the role of extrinsic goals. Wooden held his drills without a basketball in the player’s hands.
Why? Because the ball tempted the players to take a shot—and not work on the drill. Scoring was so tempting. John Wooden called the basketball “catnip.” Production and collection are the dentist’s catnip.
But the goal is to win…to score a lot and grow. As long as the catnip is present we will never slow down enough to practice those sweet soft skills.
I couldn’t believe what I was reading in your email. It almost brought tears to my eyes.
You are the first person in over 40 years that I have heard in dentistry that has put GOALS in proper perspective.
I graduated dental school in1969 and like you have been exposed to the same production setting gurus and mantras that you have.
I will say that I never have made daily, monthly etc production goals a part of my practice. Instead I always wanted to focus on the wants and needs of my patients and figured that the production will follow. I somehow intuitively felt that the focus on the production goals etc was wrong for the patient’s best interest.
I now feel validated that someone that I have respected all these years has agreed. I have spread the word to many in different professions that the best client, patient always has TAO in what we do.
Thanks again for your thoughts.
Comment by Jerry Zanni DDS — March 10, 2015 @ 7:48 PM
Jerry- I am humbled by your wonderful comment. Dentistry has certainly changed since 1969 (1973 for me). Years and years of treating dentistry like a business have turned the profession into something I don’t feel very proud of. I know many dentists who have practiced “our” way, but so many others who treat it as a job without any sense of mission or purpose. These are high stakes for the profession and the public.
Whn I write I never know how it is received—thank you for confirming my own thoughts and beliefs.
Comment by Barry Polansky — March 10, 2015 @ 11:10 PM
I follow your blogs because I could have written them myself. What you have learned, I have learned; your truths are my truths.
The ‘problem’ as I see it , and who knows, we may depart in out thinking at this point, is that, the America that we grew up in has little resemblance to the America that we currently live in. The ‘beliefs’ that we were taught are not beliefs that currently lead to success (loosely defined) in today’s world. What we thought is the right way is no longer valid or is considered old man’s thinking.
The concepts of:
1. do your best
2. always put your patient’s best interest first
3. treat people right and you will always be successful
4. build a better mouse trap and they will come
5. the cream rises to the top
have all been marginalized and negated , in dentistry, by the insurance driven patient.
It is possible to :
1. be clinically exceptional
2. have exceptional soft skills
3. deliver a 5 star experience
4. have a patient centered office
5. have an exceptional office staff
and no longer be a successful (or even a viable) business.
If the overwhelming majority of patients have been educated to believe that all dentists are the same and cost/price/fee are almost the sole determinant for selecting a dentist then exceptional soft skills are no longer important.
Comment by Gerald Benjamin — March 11, 2015 @ 10:01 AM
Gerald –WE AGREE. Firstly, the above blog post is from a new book I am writing—specifically for the younger generation of dentists who are facing the New America. As a baby boomer it is discouraging to see what is happening to this profession—as so many consultants and educators put their heads in the sand. For over a year I have been researching just what you are saying. I have read books on the change—just yesterday I purchased the new book by Robert Putman, titled Our Kids, which speaks to the dissolution of the American Dream. I have tried to famioliarize myself with the value differences between Boomers, GenX and the Millenials.
I conclude what you are reporting –BUT, and here is where we may differ….I am an optimist who believes in those values of TAO–trust appreciation and ownership. It will require the dental education system to get their heads out of the sand and start teaching leadership in dental school. A fight—sure, but a worthy one for the sake of dentistry.
Thanks for your input—very helpful and appreciated—people think I’m nuts. But I am hopeful.
Comment by Barry — March 11, 2015 @ 12:50 PM
I am an optimist for things that I can control.
I have personally spent thousands of hours mentoring young dentists and few appear to have the prerequisites for success: passion, drive, education and the gene for the pursuit of excellence.
It is not hopeless but the enemy of our profession, the insurance industry and their co-conspirators the ADA and the American dental education system are very formidable opponents.
Time will tell
Comment by Gerald Benjamin — March 11, 2015 @ 10:30 PM
Gerald…yes, the powers that be are actually thwarting the future of dentistry. I believe that a small group of concerned dentists through repetitive messaging can eventually turn the tide. It won’t be easy…and there are plenty of politics…but I believe it can be done. There are groups that believe what we feel that are so tied into their own agendas that they don’t make an effort to change things….unless there is something in it for them.
Comment by Barry Polansky — March 14, 2015 @ 11:57 AM
I commented on the Facebook post about this, but I just had to mention here that I currently see a physician who does not participate in medical insurance. We pay an annual, non reimbursable fee to be members of his practice which covers everything that happens in his office. (Lab fees, specialists, etc. are paid with insurance.) I have written about my experience with them a number of times.
This is not some fancy “concierge medical practice” where they do manicures and make house calls, etc.; just a good, solid internal medicine practice. Doctors who said they would rather not practice than provide less than what they see as ethical, compassionate, comprehensive care.
There is a wait list to get into this practice.
Many patients would not want to join this practice, but many do. They don’t need to attract everyone, only enough people who value their care to make the practice viable. My doctor told me they are looking for another doctor to join them and many are not interested. He also said, “But we know they are out there.” I agree.
Every dentist and physician has a right, and a responsibility to choose the way he or she will practice. They may make different choices at different times in their lives based on their “circumstances, temperament, and objectives.” Like Barry, I am an optimist. I believe there will always be some people who value relationship based care, and some dentists and doctors who are willing to figure out how to provide that in a way that is economically sound and congruent with their values.
Comment by Mary Osborne — March 11, 2015 @ 3:01 PM
Over the years, I’ve seen more unnecessary dental work (tooth enamel removal) than I can remember, by people who have come and gone before me. I’ve seen it evidenced by complete lack of radiological indications for class I, II restorations in particular. Some people diagnose restorations for every pit and groove or discoloration they see. Crown and bridge, in particular, is a big incentive money maker for those people who are on a production based or collection based program for remuneration. Money making is the goal, all ethics be damned in the eyes of many dentists. It is particularly bad with new grads who have that huge debt to pay down.
Comment by Roger — March 14, 2015 @ 11:01 AM
Roger…that unethical behavior is what ruined dentistry. Because so many dentists through the years just fell into those behavioral problems…it created false frames of references for the majority of the public. Dentistry…all of dentistry…every component of dentistry…must change the paradigm that is out there…dentistry hurts, dentistry is costly, all dentists are the same…so that people’s expectations change. It isn’t good enough that a small pocket of dentists do it…and as Gerald says above, there are forces that keep the public misinformed for the advancement of their own agendas.
Comment by Barry Polansky — March 14, 2015 @ 12:03 PM
Significant change occurs in two ways; from the outside via physical or intellectual ‘rock throwers’ or from the inside by infiltrating the establishment. The rock throwers certainly achieve their goals quicker.
For dentistry to change, those of us who want to see a complete overhaul will have to be involved in the process of selecting new Deans in our dental schools. When a Dean resigns, we must ask to be included in the new Dean selection process. The ‘old Dean’s network’ where Deans go from one school to another guaranteeing that nothing ever changes cannot continue. The day when a Dean hasn’t restored a tooth in 2 decades cannot continue. How refreshing would it be for a Dean to walk into a clinic, see a student struggling and ask the student to step aside so that he or she can show them how it is done?
The time when a dental student spends 8 hours a week studying pharmacology or human physiology only to have the school then claim that it does not have an adequate amount of time to teach correct diagnosis, treatment planning, occlusion and esthetics is over. The longer the status quo exists, the quicker corporate dentistry will achieve its goal of widespread, mediocre dentistry.
Instead of retiring, those of us towards the end of our clinical careers and who have practiced superb clinical dentistry must join together to alter the path of our beloved profession. Failing to do so will guarantee that mediocre clinical dentistry will become the norm. Just ask, the Spear, Kois the Dawson or Pankey Institutes if the students of today are as passionate or driven to become the best as they were 20 years ago.
Comment by Gerald Benjamin — March 15, 2015 @ 1:58 PM
You make some great points Gerald. The education system needs to be overhauled. It is under fire at the college level right now. The cost of education is what will bring it to its knees. There must be frugal innovation in education. That said—dental students under current conditions will find it impossible to practice beyond survival levels…not a good outlook.
Comment by Barry Polansky — March 15, 2015 @ 6:39 PM
One more comment on this in the form of a story a dentist friend told me years ago:
My friend attended a seminar in which they suggested that each hygienist should get a bonus for every crown scheduled out of her hygiene appointment. The dentist implemented this system and his production went through the roof. He said he thought it was the answer to his prayers for a successful practice.
Exactly six months later his hygiene schedule was a disaster. When they called to get people scheduled they were asking for their records, saying they had found another practice. They gave a variety of reasons why they were leaving; moving, new insurance, etc.. But the numbers were so dramatic he asked himself what might have happened to cause so many people to leave his practice. He came to believe it was related to the bonus system and I suspect he was right.
Not that all bonus systems are bad, but the dramatic increase in crowns scheduled after incorporating the system leads me to believe that his hygienists were not well motivated. If they believed patients needed crowns I think they would have been recommending them all along.
What is most interesting to me is that his patients did have the crowns done. They did not say they didn’t trust his or his hygienists’ motives. They just went away. Somehow those patients had a sense that something was not right. Even if they could not articulate it, I believe they came to question the integrity of the practice.
The responsibility we have as professionals is to use our care, skill and judgment “prior to any consideration of self interest.” to quote Dr. Pankey. Note that he said, “prior to,” not instead of. There is nothing wrong with profiting from our work, as long as we know where the priority must be placed. That is not a decision we make once, but a challenge we face every day. That is the message that must be an integral part of the future of dentistry.
Comment by Mary Osborne — March 18, 2015 @ 3:05 PM
Thanks for poisting your comment Mary. Finally someone picked up the counterintuitivness of bonus systems. As the blog post sai, they have the potential destroy a culture…and really when we get down to it, all a practice has to fall back on is its culture. As Gerald notes in his comment—is has come down to overselling dentistry. The debate about selling dentistry has been around for years. Persuasion, influence, manipulation? Consumers today have their antennae way up.
There is an old saying: People love to buy but hate to be sold.” When a practice unleashes amateur salespeople with the incentive of bonus’, purely extrinsic drivers…well anything can happen. That is what your story exemplifies.
L.D. was a great salesman too…he understaood the tenets of great salemanship: empathy, storytelling, listening, asking great questions—-he did so much more than just saying, “you need a crown.” This is a great topic because it is so unconventional and so counterintuitive—and as Gerald said, may be one of the reasons fo dentistry’s current demise.
Comment by Barry Polansky — March 18, 2015 @ 8:38 PM
When my hygienist joined my practice 5 yrs ago , she critized me for not wanting to place crowns on teeth. I informed her that it was my job to preserve and not destroy tooth structure. In her previous practice, she too was reward by convincing patients to have quadrants of crowns. It took her a while to convince her that we always put our patient’s best interest above our own. The selling of dentistry has been the death knell for dentistry and may be the reason that total dental expenditures have remained the same since 2002.
Thanks for a great post Mary
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Comment by Gerald — March 18, 2015 @ 4:09 PM