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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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Even a Monkey Could Do It

June 4, 2013



It can be difficult for patients to choose a dentist these days.  The Internet is filled with photographs of beautiful dentistry.  Dentists and technicians share their best work with the world online.

Patients take a look at the photos and judge the quality of the dentist, and the practice by the quality of the photos.

But as they say, “the menu is not the food.”

In a new book, The Art of Thinking Clearly, author Rolf Dobelli discusses 99 ways that we make mistakes by not thinking clearly.  Dobelli does a great job of using entertaining examples of how we think about things that  lead us to making poor decisions.

One such bias, he calls the outcome bias warns people to never judge a decision by its outcome.

Imagine there was a sample group of 1000 monkeys, and you asked them to speculate on picking stocks by throwing darts at the Wall Street Journal.  What happens?  After one week, half of the monkeys show a profit and another half show a loss.

We carry on the experiment until we eliminate all of the monkeys but one.  You know how that works, you’ve seen reality TV.

At the end…the remaining monkey is next year’s Warren Buffet (take a look at the photo).  The media is all over him.  He becomes a guru.  The big guy on Wall Street.

The reason this happens is that we tend to evaluate decisions based on the result rather than the decision making process.  Don’t laugh, we see this all the time on Wall Street.  The analyst that predicted the crash becomes the next guru.

It happens in dentistry as well.  We see these gorgeous photos and believe the dentist is Picasso rather than asking how he got there.  What was the process…because process is what breeds consistency.

Dentistry has evolved to promote this type of thinking.  The cosmetic revolution, advertising and the Internet have allowed snapshots to sway patients to make decisions.

There was a time when patients chose dentists for their wisdom and judgement…two traits that don’t seem to be valued these days.

Process is the key.  In choosing a professional the patient should be more interested in the process the dentist used to get the result rather than the result itself.  All dental practices are based on some philosophical principles that lead to consistent behavior that produces outstanding results consistently.

As a practicing dentist, a teacher/coach and a lab owner, I am convinced that the dentists who are most successful are the ones who create and execute a process.  Anyone can do a beautiful case occasionally.  My advice: commit to an examination, diagnosis and treatment planning process.

That is the key to success.


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Don’t Ignore the Truth

March 20, 2013

Filed under: Art of the Examination,Philosophy — Tags: , , — Barry @ 1:04 PM



untitled-5-3 Predictable results depend on paying attention to a process and not ignoring any steps.  One missed step can follow through the entire case and leave the dentist and technician wondering what went wrong.

As a dentist and a lab owner I get to see some of the innocent omissions that can come back and haunt the dentist.

The other day a new technician brought me a set of study models sent in from another dentist.  She asked me if I thought they were mounted properly because the bite was open and it looked a little funny to her.

I told her to drop the pin and put the casts into maximum intercuspation.  She asked me why the dentist would take an open bite.  Hmmm, I wondered, “Do you know the difference between centric relation and centric occlusion? I asked.

It seemed like a good opportunity to explain what we know about occlusion and how we apply it in the lab.

I could tell tell that she was interested by the eager look in her eyes.  As I went through the explanation she began to understand the reasons for doing everything.  I was reminded of a book I read years ago, The Greatest Management Principle in the World, by Michael LeBoeuf.  In that book the author explains that managers need to go around the workplace and explain to employees “why” we do things rather than just telling them “what” to do.

Invariably, I have always felt that telling people why, always raises their commitment to the work and puts more meaning in the work.

I also believe that employees feel a greater amount of respect when the manager takes the time to explain things to them individually.

This same principle works for patients as well…I called it a “reason why” philosophy in my book, The Art of the Examination.

Of course, it takes time to do this but you will see it is time well spent.

After explaining the process to my new technician, I asked her for the “first point of contact.”

She looked confused.

I said, “there is no way to know if the models are mounted correctly unless we verify the mounting with some information like the first point of contact taken from the doctor’s examination process.

She said he never sent it.  I then directed her to my chart which has a summary of my entire exam process that starts with the mouth and ends with the presentation structure.  I showed her the first question on my checklist ( I am a big fan of Atul Gawande’s book, The Checklist Manifesto).  The checklist showed her the following question: “Do the models accurately represent what you saw in the mouth?”

Now her eyes really widened.  She really began to see the practical application of the knowledge of occlusion.

Now she said she had a job to do.

“What’s that?” I asked.

“I have to call the doctor and get that information.”

Now that’s great learning!






Dental Design the Steve Jobs Way

October 9, 2011

Filed under: Business of Dentistry,Marketing — Tags: , , , — Barry @ 10:08 PM

An Elite GroupThroughout the past week the Internet has been filled with blog posts concerning the death of Steve Jobs.  Like  everyone in America, I too am a big fan of what he created.  For years I have been calling him our modern day Thomas Edison.

Everything that needs to be said has already been said as noted by my friend’s blog post at Spear Education.  Most of the references to Jobs have centered around the world of business…what a great leader, and what a great marketer he was.  And yes, that is all true, but just as Edison was primarily a great inventor, Jobs was primarily a great designer who truly understood what humans wanted and needed at a practical level.

And he delivered.

That is his greatest lesson for dentists.

Steve Jobs understood what “design” means.  He understood “form follows function,” where others just give it lip service.

I will never forget his keynote speech introducing the iPad2.  The entire presentation was designed (yes doctors, his presentations were designed as well), around function; how the new iPad worked.  He subtly mocked his competitors because he knew what his audience wanted and he delivered it—so many improvements over the original iPad and yet all he kept saying was “It just works.”

Clear and concise: “It just works.”

Form follows function.

Read what Steve Jobs said about design in a New York Times article written in 2003 titled, The Guts of a New Machine:

“Most people make the mistake of thinking design is what it looks like. People think it’s this veneer – that the designers are handed this box and told, ‘Make it look good!’ That’s not what we think design is. It’s not just what it looks like and feels like. Design is how it works.”

Design is how it works…makes us wonder about the cosmetic dentistry revolution, and about what Peter Dawson has been preaching for the last thirty years.  People really want dentistry that works, that lasts…quality dentistry.

First you have to design it…then you have to sell it ( the idea, I mean).

And Jobs was good at that too.  He was a master presenter, an impressive storyteller who painted crystal clear images with extraordinary graphic design.

So what can dentists learn from Steve Jobs?

Hopefully I have given you two things…become a great dental designer by deeply understanding examination and treatment planning skills and second, take your presentations very seriously.

I have created another blog called Casepresenter.com which explores all the nuances of effective dental case presentation.  Please visit and contribute your thoughts and ideas.

One more thing.  I am a frequent visitor to Amazon.com.  Some months ago I noticed that Walter Isaacson, the author of Ben Franklin’s  and Einstein’s bio’s, was writing the first authorized biography of Steve Jobs.  The publication date was March 2012.  Over time I noticed the date was moving forward.  That combined with his departure from Apple in August should have tipped me off to his imminent death.

I can’t wait to read Isaacson’s book, due out at the end of October 2011…that will surely tell dentists what we could learn from Steve Jobs.

The End of Tooth Whitening

September 12, 2011

Filed under: Marketing — Tags: , , , — Barry @ 11:02 PM


There was a time when tooth whitening was all the rage.  Everyone wants white bright teeth.  Dental practices focused on bleaching…big companies jumped on the bandwagon and created tooth whitening products from toothpastes to white strips to tooth whitening gels.  Tooth whitening systems  became big business…and dentists considered it their domain.

We bought lights and made deals to buy bleach in bulk.  Tooth whitening in dentistry became as common as dirt.  Today we have created the ultimate dental commodity.  Dental practices still charge upwards of $600 to bleach a patient’s teeth.  This is in spite of the fact that in many states people can go to the local mall and get the same procedure around $99.

Cruise ships began offering whitening services as well.  Through it all dental practices kept charging the higher fee as a “profit center.”

Well things are changing faster than going from A3 to A1.

In my book The Art of the Examination I wrote about the forces in dentistry that have made our services into commodities.  The forces I wrote about were dental insurance and advertising.  Today we have the new social e-commerce sites like Living Social and Groupon that are offering services, especially tooth whitening for as low as $79.

I wrote about this in my last couple of posts.

I always wondered where we would be if no dentists accepted dental insurance…obviously that’s a dream.  So many of our colleagues have used dental insurance as a competitive advantage.

Well the same thing is happening with the Living Social and Groupon fascination.  I mean really…who doesn’t want a great deal?

Dentists all over the country are jumping on the bandwagon.  Patients everywhere are waking up to e-mails offering bleaching for $99 or less.  I know it’s a matter of time before we see Invisalign and veneer deals.

Dentistry’s founding fathers could not have seen this Darwinian competitiveness coming.  The phrase “all’s fair in love and war,”  doesn’t work for industries that are held to a higher standard…industries that are public trusts.

My feeling is that creating price wars through bitter competition can help the individual practice at the expense of the collective profession.

What’s your take?  The way I see it I wouldn’t be investing in a lot of bleaching supplies in the future.


TAO the Book Installment 10 – What patients are looking for

August 15, 2010

Filed under: TAO - The Book — Tags: , , , , — Barry @ 10:28 PM


I am a baby boomer. I am part of the generation that was born between 1946 and 1964.  Baby boomers have the reputation for being quite independent.  There are 77 million baby boomers in this country, and they have driven the marketplace since they were born.  My practice has seen this over the years.

I began practicing in the early seventies when dental insurance became popular. I have seen insurance become a major force in the dental community, and I have witnessed its relative irrelevancy.  I have seen the coming and goings of closed panels, department store clinics and DMOs.  I have been part of the cosmetic revolution.

I feel that the key to success in today’s marketplace will be to pay attention to the “longevity” factor. The most important thing (more…)

One Thing that Will Give Your Exam Process a Quantum Leap

April 28, 2010

Filed under: Art of the Examination — Tags: , , — Barry @ 2:12 PM

I have done a lot of examinations in my career.  Readers who are familiar with my book, The Art of the Examination, know how much stock I place in the examination process.  As the years go by I only become more firm in my admonition about the importance of a comprehensive examination.  I know what it has done for my practice and career, and I know what it can do to practices when it is not included in the daily management.
As the owner of Niche Dental Studio, I get to (more…)