Economic Factors in the Management of a Dental Office*

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T h e Journal of the Am erican D en ta l Association

o f the cro w n itself sufficiently to p erm it its rem ov a l. A rap id cut w ith the bu r part w a y to the pulp on the su perior su rfa ce o f the cro w n w ill perm it a thin bla ded ele v a to r to fractu re the tooth, the sections b e in g easily rem ov ed and the roots slip p in g fo r w a r d w ith ­ out extensive sa crificin g o f the bu ccal plate. T h e com plete rem ov al o f a third m o la r in the case o f a cro w n to root im paction w ith ­ out the rem ov al o f a p ortion o f the cro w n seems to be a physical im possibility unless there is needless traum a at som e point, either

at the ap ex o f the su perior root w h ere the close p rox im ity o f the m a n d ib u la r canal p re ­ sents g reat p ossibilities o f harm , or at the distal bu ccal corn er o f the second m olar, w h e re exten sive d estru ction o f the bu ccal p late w ill result in a reten tive depression fo r débris. T h e r e is no qu estion ing the fa ct that a great m any o f the second m olars are ruined at this p oint b y both bu r and chisel, but w e are speakin g o f p rop er con sid eration fo r the bu r w h en it is used in a correct m an ­ ner and to a m in or d eg ree.

ECONOMIC FACTORS IN TH E MANAGEMENT OF A DENTAL OFFICE* By CHARLES R. LAWRENCE, D .D .S., Enid, Okla.

H E subject, “ Econom ic Factors in the Management of a Dental O f ­ fice,” is one of wide range, and to attempt to deal with any of its many phases in a detailed manner w ould re­ quire more time than is available. T here­ fore, my efforts w ill be confined largely to trying to arouse a greater interest in and to lead to a closer study o f this im­ portant subject by the individual dentist. T h a t there is a great need for this is evidenced by the fact that far too great a number of dentists reach their declin­ ing days in somewhat strained or needy financial circumstances. 1 fully realize the significance and importance of the professional duty of the dentist. Under no circumstances should he allow the economic phase to overshadow the professional side o f the question. I make this statement in the

beginning because, in the past, whenever the word dollar has been mentioned be­ fore our dental organizations, a large number of listeners expected the speaker to put on the “ soft pedal” and whisper it softly.1 M a n y men in our profession and other professions have been so out­ spoken as to say that it was the wrong thing for a true professional man to con­ sider such a sordid thing as money, that all his energies and efforts should be centered on the scientific and service side of his calling.

*R ea d b e fo re the Section on O p e ra tiv e D entistry, M a te ria M e d ic a and T h e ra p e u tics at the Seventieth A n n u al Session o f the A m erica n D en tal A sso cia tio n , M in n e a p o lis, M inn., A u g . 23, 1928.

ter fate, and it should serve as a warning

T

Jour. A . D .A ., February, IQ2Q

T his, to my mind, is an unfortunate attitude. It has been responsible for many men in our profession who have worked hard and rendered good service reaching the brink of life suffering hu­ miliation, deprivation and want. This has been the lot o f far too many o f our fellow practitioners who deserved a bet­

1. Johnson, C. N . : T h e E con om ic P r o b ­ lem — H o w Shall Dentists M e e t I t ? J. A . D . A ., 11:307 (A p r il) 1924.

Lawrence-— E conom ic Factors in a D en ta l Office

to those w ho wish to avoid such experi­ ences. There is a sane, common sense and humanitarian way for the average den­ tist— and it is the average dentist with whom w e are dealing— to avoid such experiences. T here are various reasons for the present economic status o f the rank and file of the dental profession and one of the foremost of these is that we have not come to a realization of the fact that the practice o f dentistry is a business as well as a profession. Every profession is a business, but not every business is a profession; hence, if dentists expect or hope to improve their economic status, we must consider the practice o f dentistry from a business, as well as a professional, standpoint. Pos­ sibly one of the principal reasons why presentations of this kind have been frowned on is the fact that far too many of the papers presented before our organizations have been written by com­ mercial men, who have ignored the pro­ fessional side of the question. A ny appeal to the financial side only that makes the dentist believe that he is justly entitled to a wonderful income, irrespective of whether he is rendering service, is absolutely wrong. O n the other hand, it is equally w rong to render service without some consideration of the financial side. It is a noble thing to serve humanity and, while pure idealism is one of the finer things of life, to be too idealistic not only may cause impoverishment of our own lives, but also, in many cases, the devastation may become more com­ plete and extend to persons near and dear to us. T here are tw o principal types of den­ tists : not the ethical and the unethical, but the honest and the dishonest. T h e dishonest dentist’s sole object seems to

335

be to extract a few more dollars from the unsuspecting patient without any consideration o f services rendered. T h e honest dentist puts service above all, and, far too often, forgets everything else. T h e records on the two pages are about equally divided; in other words, 50 per cent of the dentists are in the “ leech class” and are already receiving more than their just share of compensation for services rendered, and many on the other page are, for various reasons, not balancing accounts. It is to the latter class that we will turn our attention at this time. W H A T

IS

SUCCESS?

Success in any endeavor consists of something more than making money, but as viewed by many people nowadays, since it no longer is considered a virtue to be poor, this is a part o f success. T he dental profession has no monopoly on high ideals: this is a quality that is found in many men in all walks of life, even those who are financially successful. D r. Kells, in his splendid book,2 which every dentist who is interested in office management should read, says: “ Real success in dentistry means, as I take it, that after a life spent in honest endeavor and consistent and constant application, one has been able to make some pro­ vision for that fateful ‘ rainy day,’ has gained the respect and confidence o f all those with whom he has come in con­ tact, and, best o f all, has won and still holds amongst his fellow members o f the profession the reputation for fair dealing and honesty o f purpose.” T his is a splendid definition for suc­ cess in dentistry. M an y dentists attain partial success, but few attain complete success as defined above. T h e greatest stumbling block in our way in attaining 2. K ells, C. E .: T h e Dentist’ s O w n B ook, St. L o u is : T h e C. V . M o sb y C om pany.

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The Journal of the American D en tal Association

complete success is in being able to make some provision for that fateful “ rainy day.” “ T h ere’s a reason,” a reason that can be corrected, but it requires the same diligent study and application that im­ proved technic or any other advancement requires. W ish ing fo r it w ill not bring it about as there is no place in dentistry for the easy life. To my mind there are many qualities necessary for success in dentistry, such as ability, industry, judgment, honesty, cleanliness, personality and business acu­ men or skill in office management. A dentist may have great ability and never attain success. H e may have abil­ ity plus industry and not attain success; H e may have great ability, industry and judgment and not be rated as a success­ ful dentist. W e may grant him ability, industry and judgment plus cleanliness, honesty and personality, and still he may fall short o f being a financial success because of his poor office management or business ability. It is unfortunate that this is the state of affairs confronting the dental profes­ sion in the United States, the most pros­ perous country on earth and the w orld ­ wide leader in dentistry. Possibly, we can more fully realize this fact by a study of T a b le 1. First, it might be well to state what we mean by “ office management.” Office manage­ ment may be defined, in a general way, as all those factors that enter directly or indirectly into the production and distribution of our services not connected with our actual ability. Some of the things that may be specifi­ cally mentioned a re: P la n n in g the office. E q u ip p in g the office. T h e boo k -k e e p in g system. C ollection s. T h e r e co rd s and case histories.

T r a in in g the assistant in her num erous duties and resp onsibilities in a w a y that w ill h a rm on ize w ith ou r efforts. D e te rm in in g the question o f fees. P u rch a sin g m aterials. P la n n in g the w ork. M a n a g em en t o f patients. S ellin g o u r services. E lim in a tin g lost m otion. B a la n cin g the p rod u ctiv e and u n prod u ctiv e w ork . W h e n an d w h en not to extend credit. A p p o in tm en t cards. B rok en appointm ents. T e le p h o n e calls. E xam inations. C on serv ation o f time. Investm ents.

T o attempt a complete analysis o f T able 1 w ould require considerable time. T h e main object in presenting it here is T able

A b ility Ind ustry Ju dgm ent C leanliness H on esty P erson ality Office M g t.

1 100 100 100 100 100 100 100

1.— S e l f A n a l y s i s

2 75 80 65 75 90 60 85

3 65 85 75 85 90 75 50

4 50 100 70 100 40 100 70

5 95 100 50 50 85 45 25

6 40 70 30 50 60 40 35

7 30 50 40 75 30 100 0

to show that office management is a great factor in the financial success o f the average dentist and to refute the idea that if a man possesses ability, the finan­ cial rewards w ill take care o f themselves. A ny dentist of a few years of experi­ ence w ill readily recognize that each of the things mentioned in this table is an important factor in his success. Possibly the least understood of these are ju d g ­ ment and office management. Judgment is necessary if the highest purpose o f professional success is to be reached, the lack o f which causes many o f us to fall by the wayside. Colum n 1 is for comparative purposes only. In columns 2 and 3, the rank and file o f the dental profession is represented by two different types o f dentists. Each

337

L aw rence— E conom ic Factors in a D en ta l Office

is fairly well balanced, and down to “ office management,” they w ill be about equally successful financially. T h ey have reached the same point economically speaking but have traveled different roads to arrive at this place. As to whether they have a good road to travel over from here on during the “ rainy day,” depends altogether on whether they take the 85 or the 50 per cent route in office management. Considered from an economic stand­ point, there is no question in my mind that the higher grades on industry, ju d g­ ment, cleanliness and personality of the man represented in column 3 w ill more than offset the difference o f the two men in their ability. But give the man in column 2 a grade of 85 per cent on office management and number 3, 50 per cent on office manage­ ment, and number 2 w ill come under the wire far ahead o f number 3 in the economic race. I f we choose to reverse these tw o figures, the results w ill be reversed. In columns 4 and 5, we have two ex­ treme types of dentists represented. Neither man is w ell balanced, both are hard workers, one has great ability, yet I dare say down to the point o f office management, number 4, from an eco­ nomic standpoint w ill be as successful as number 5. T hen, if we give number 4, 75 per cent on office management, and number 5, 25 per cent on office manage­ ment, number 4 w ill win the race. T h is is not only an unfortunate state of affairs for number 5, but it is also unfortunate for the people o f the com­ munity in which he lives; for I do not believe that any dentist w ill go along year after year rendering good service under poor economic circumstances. Number 5 is a discouraged man, and yet if some o f his industry were directed in

the right channels, he could put himself very much in the running and be a bene­ factor to the people o f his community. W e have another group o f dentists represented in numbers 6 and 7. These men do not expect much o f themselves; neither does any one else. T h e only rea­ son they can continue to prey on the people is because the law allows them to call themselves dentists ; hence, they, and not the people, are protected. T hey are in a race by themselves, and it mat­ ters little which one o f them wins. OUR

GREATEST

W EAKNESS

Undoubtedly the greatest weakness o f the rank and file o f the dental profes­ sion, in the foregoing analysis, is office management. I have proved this to my own satisfaction, in a number o f in­ stances, by having dentists o f different groups grade themselves according to T able 1, first requesting that they do not sign their name to the card, and that they be honest in their grading. T his was done after a detailed dis­ cussion o f the part each of the foregoing factors play in the success o f the dentist. In practically every case, the recorded figures show the general average on office management to be far below the com ­ bined general average o f the other things listed on this chart, and on many o f the individual cards, the grade on office man­ agement was the lowest recorded. I feel sure that if we could do the same thing in this audience, our findings would be duplicated. N ow , if this is a true state o f affairs, and to my mind it is absolutely correct, why should the dental profession con­ tinue in this way when it is a matter that can be corrected by the same in­ dividual and cooperative efforts that we employ in solving many o f our other problems ?

T h e Journal of the Am erican D en ta l Association

338

T h e team that usually wins is the one that is w ell balanced. T o have a general average of 75 and to be well balanced is far better than to have a general average o f 75 and have too many weak spots. O f course, occasionally, a dentist may make a “ touchdown” with weak office management in his lineup, but that may come a long way from winning the game. TH E

CAU SE

OF

OUR

W EAKN ESS

I f a good business man has some weak departments in his business, he proceeds to find out the cause and then corrects these faults. N ot so with most dentists. T here is a lot of lost motion, energy and effort in many dental offices, and the confusion that prevails in the manage­ ment of these offices results in continual playing at cross purposes. Disorder is incompatible with any attempt to put into execution many of the things that mean greater success. Far too many dentists fail to realize this fact. T h ey go along from year to year blindly, self-satisfied ; let the office run itself, and allow the little details which might be made powerful aids to be neglected or fall into disuse. “ Systematic men are always in closer touch with every detail than slip-shod individuals who know little o f their busi­ ness, and it matters not how great may be the practice, a complete cognizance of the minor details is essential.” W e are inclined to wait until we are struck by lightning on some “ rainy day” before we become aroused to the im­ portance of these things. It is true that

O ne o f the principal causes o f this weakness is the failure o f dentists to keep books as they should be kept. I once heard G overnor Lowden make this re­ mark, “ Years ago, while an attorney in Chicago, I found that many o f my clients who went to the wall did so because they could not bolster up sufficient courage to look their balance sheet in the face. Tender souls o f this type shrink from things that shock them, failing to realize that the only way to overcome unjust conditions is to seek first to understand them.” A nd so it is with us: if we are to over­ come our unjust conditions, we must seek first to understand them. T h e very first step toward seeking to understand these conditions is through the book­ keeping system. Dentists are notoriously poor book­ keepers. A great majority of us keep books on a “ scratch-pad basis.” I doubt that 10 per cent of us know what it is costing to produce our services as a whole, and when it comes to the differ­ ent departments of our work, we know little or nothing. I once had an income tax man tell me that o f all the men who are supposed to keep books, the dentist is about the poor­ est bookkeeper o f the lot. Dental sup­ ply houses inform me that a surprising number o f their customers write to them about the first of each year to find out how much their account amounted to the previous year. H o w far would the business man get without a good bookkeeping system? N ot

much of our weakness along this line is

very far: it is his sheet anchor.

due to lack of training by our dental colleges, but I am pleased to note that

after we get and use the bookkeeping system, what must we d o? Have the

the colleges are seeing the need of this

courage to look the whole story in the

thing

face and not be so tender hearted as to shrink from the things we find, even

and

are

making

strengthen this weakness.

an

effort

to

Then

L aw rence— E conom ic Factors in a D en ta l Office

though we may be shocked for the time being. W h at are some of the things many o f us w ill find? Cost o f conducting the practice far above what we thought it to be. A long list of unproductive work. Collections below what they should or could be. T h e actual productive hours cut down to about one-half the working hours in the office. The w ron g propor­ tion o f living expenses to net income. T o o long a list of poor investments. TH E

Q U E S T IO N

OF

FEES

I hardly need say to you that the popular impression that dental fees are exorbitant and dentistry is a highly profitable profession is wrong. O n the other hand, the most reliable inform a­ tion that we have been able to obtain shows the average income o f dentists to be small for the necessary training and investment. T h e fee question is an individual and a community problem. Every dentist of every community should have a minimum fee schedule. W e should know where the danger line is and never get beyond it, and every dentist must figure this out for him self; not by the time-worn guessing-contest system but on the basis of common-sense bookkeeping. Fees are usually based on whatever is customary in the community. These customs are quite often foolish ones of long standing and were never founded on a sound economic basis. W e need only to cite foolish custom number one, which has been so prevalent all over the country, of extracting from one to thirty-two teeth free o f charge for the privilege of making a patient some plates or dentures. N o w the exodontist, who is usually a better business man than the general practitioner, receives about as much for

339

his services as we have been receiving for both services. These foolish customs have brought into dentistry what we term productive and unproductive work. I f there is any sane, common sense, humanitarian or business reason why the honest dentist should have to con­ tinue to w ork many, many days each year for about what it costs him, or even less than it costs him, to render conscien­ tious service, I do not know what it is. One o f the greatest needs of office management at this time is to get the dentist to know and understand more about the productive and the unpro­ ductive work. T his is the place where we are w oefully weak and are using poor judgm ent in not maintaining a better balance in the different departments of our services. T h e unproductive w ork varies in dif­ ferent practices and different communi­ ties. Some of the most common and almost universal things found in this list are : T rea tm en ts and root canal fillings. Free exam inations. C h ild ren ’ s dentistry. P ro p h y la ctic w ork . T r e a tin g p yorrh ea . C ollections. B roken appointm ents. C em ent fillings. N igh t calls. T h e sh opper. F ree services. Stopping toothache. F ree consu ltations. Com e back and w ork ov er. Snap ju d gm en t. D iagn osis. Lost m otion and tim e h a n d lin g patients.

G ood business demands that there not be too many unproductive departments to sap the vitality of the productive de­ partments. Ninety per cent o f the den­ tal practices are burdened with too much unproductive work, and it is poor

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T h e Journal of the Am erican D en ta l Association

business for any one to continue this state o f affairs. So if we move all or even a part of the unproductive w ork over into the productive column, we w ill be more successful and render a better service. Gilpin has said, “ I hate a thing done by halves. If it be right, do it boldly, but if it be wrong, leave it undone.” It is undoubtedly right that we move the unproductive w ork over into the produc­ tive column, so why not do it boldly? S T O P P IN G

TH E

LEAKS

T h e economic problem is not so much a matter of increased or large fees as it is one of correcting the evils or plugging the leaks already existing. T h e first step in this direction should be in getting rid of the unreasonable or unjust things. M ost people are fair minded, and if we can get them to see our point of view, we w ill not have so many leaks to con­ tend with. It seems unreasonable that the busy dentist who spends at least 2,000 hours in his office each year should find that he has had something like from 1,000 to 1,200 productive hours, which is about the average. Let us analyze the matter o f broken and late appointments. Broken appoint­ ments are a bugbear in every dental office and a big drain on our finances. It is safe to say that 75 per cent of the serv­ ices rendered by dentists are by appoint­ ment, and much o f this time is lost by patients failing to keep these appoint­ ments promptly if at all. T h is is a very unjust situation and one that the profession as a whole is doing little or nothing to correct. M y obser­ vation leads me to believe that not to exceed 25 per cent of the dentists are using any form of appointment cards, and many of the cards in use fail to

stress the importance of keeping appoint­ ments promptly. M u ch can be done by the individual dentist and still greater results accom­ plished by the dentists o f any community adopting and making use of a uniform educational appointment card. Some­ thing along this line is effective. A fter the usual blank spaces, name and loca­ tion o f the dentist, add under the head “ Important” : T h e time in d ica ted on this ca r d is reserved esp ecia lly f o r you, reg a rd less o f the num ber o f persons w h o m ay d esire ou r services at that tim e. T h e r e fo r e , you w ill be expected to keep this appointm en t prom ptly. I f fo r som e reason you are unable to keep the appointm ent, please n otify this office at the earliest p ossible m om ent so the time m ay be allotted to others. F ailu re to do so causes g rea t inconven ience and loss o f v a lu a b le tim e to the dentist, fo r w h ich ch arg es w ill be m ade, unless you com ­ p ly w ith this request. T h is office is on a cash basis, and you w ill be expected to p a y f o r y ou r w o rk at or b e fo re com p letion . Patients w h o d o not desire to co n fo rm to the fo r e g o in g rules should m ake it kn ow n b e fo re the w o r k is begun.

These should be printed on flexible paper (not card paper) on one side only. T h e assistant should fill in the blank spaces and give every patient an appoint­ ment card. W h en appointments are made over the telephone, a card should be mailed that patient. T his is simply another link in the economic chain, and one that is appre­ ciated by the patient and produces good results. The big and important problem of chil­ dren’s dentistry never w ill be solved until the economic problem along with it is solved. T h e barber who cuts the child’s hair receives more for his services than most dentists receive for services ren­ dered the same child. T h e superintendent of dental activities in our state depart­ ment of health informs me that one of

L aw rence— E conom ic Factors in a D en ta l Office

the most discouraging things she has to contend with is the fact that dentists w ill not take care o f the children after she has urged the parents to take them to the dentist. T h e root canal problem is just as much an economic problem as it is a scientific problem. T h e dental profes­ sion has been economically burdened with this thing for years, and it is little wonder that they are avoiding dealing with it on the slightest pretext. A t times, w e like to compare ourselves with the medical profession, and here is an economic comparison. I have asked hundreds o f dentists this question: H o w many o f you men receive as much for a night call as the physicians in your com­ munity? T h e answers show less than 3 per cent. T h e dentist is certainly en­ titled to just as much as the physician for this service, yet very few of us get it, owing, I suppose, to another foolish custom among dentists. Another big leak is free examination and free consultation. Free examina­ tion is one of the big farces o f dentistry, and it is little wonder that this is one o f the poor services rendered by dentists. T h e extra ten to thirty minutes which we give to people without consideration in the fee charged, is the thief which robs us o f the leisure and freedom from w orry to which we are justly entitled. T h e long-standing custom of cleaning teeth, regardless of the condition o f the mouth, for an insignificant set fee should be discontinued. W e should at least re­ ceive a manicurist’s price for such work. Another growing and unjust situation confronting us arises when we have people come into our offices and ask us to look over roentgenograms. T h e roentgenographer has received a good fee for his services: the dentist usually receives

341

nothing. H o w long are w e going to let this leak continue? Another tremendous leak is to be found in our collections. It would be a fine thing for us and for the people whom w e serve if we did not have to worry about, and spend time making collec­ tions ; but we may as well face the situa­ tion as we actually find it. T h e install­ ment plan o f buying is getting to be more and more of a menace to the pro­ fessional man, and w oe unto the dentist who fails to throw aside some o f his professional dignity and put his collec­ tions on a sound business basis. T h e average dentist who loses from 5 to 10 per cent o f his gross charges through poor collections is swamped eco­ nom ically; for that is just about what his net savings w ill amount to. M ost practices that are conducted on a busi­ ness basis w ill show collections amount­ ing to nearly 99 per cent plus. T h e best collecting agency in the w orld is a clear and distinct understand­ ing with most patients as to just about how much the services w ill cost and the method o f payment, before beginning the work. D o your part o f charity work, but make the people who can pay fulfil their part of the obligation. T h e practice o f dentistry, at the most, is not an easy task. “ T h e exactions of daily practice with their constant phy­ sical and nervous tension take a toll which should be cheerfully paid fo r in adequate coin of the realm and they w ill be so paid for as soon as w e and then the people become convinced that it is right to do so.” T h e dental society has an important duty to perform in educating its mem­ bers along this line, and when this is done, instead o f many o f our members doing the w ron g thing, more o f them w ill be doing the right thing.

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T h e Journal o f the Am erican D en ta l Association

There is seemingly so much to be done that most men say it cannot be done. W e cannot keep the birds from flying over our heads, but we can prevent them from building nests in our hair. T h e accompanying chart and T a b le 2 show additional reasons why some den­ tists fail to provide for the “ rainy day.” T h e chart shows the financial rise and decline of the average dentist, physician and lawyer as based upon their profes­ sional earnings. If we take three young men, one in each o f these professions, and give them

Physical infirmities are likely to ac­ count for the difference; for when the eyes of the dentist become dimmed and his hands begin to shake, he starts on the down-grade, while these handicaps do not affect the lawyer or the physician to so great an extent as they affect the dentist. T h e average lawyer or physician can reasonably expect to maintain his normal professional usefulness from 45 to 65 or even lo n g e r; while the dentist, at not later than 55, can reasonably expect the line to take a sharp turn downward.

Y e a r s o f greatest e a rn in g ca p a city fo r the dentist as com p a red w ith the la w y e r and the p hysician.

equal degrees of success in their respec­ tive professions, we w ill find their finan­ cial rise from 25 to 50 to be constant and about on an equal plane. T his does not mean that they w ill make an equal amount o f m oney; for if this were the comparison, the dentist w ould probably be in third place. It means rather that the length o f time over which the dentist can maintain his normal professional usefulness is much shorter than that of the lawyer or the physician.

T his is something that few dentists ever take into consideration in their fee basis, and it is a cogent reason why it should be one o f the aims of every den­ tist to so shape his affairs in the early days o f his professional life that ample provision w ill be made for his declining days. T h e dentist who fails to establish him­ self well financially before he reaches the danger line at 55 does not have much chance to make the grade. It is pathetic to see a dentist struggling under great

L aw ren ce— E con om ic Factors in a D en ta l Offict

handicaps in an effort to come back financially after the age of 55. T able 2 suggests some of the reasons why a great many dentists are playing a losing game. O n this chart, we have some figures put out by the United States Treasury Department. T h e stingy man, the spendthrift, the thrifty man, which class are we in? I have never come across many stingy dentists; in fact, most dentists spend freely and gladly without any judgment as to what their limit should be except when it comes to paying their dental society dues. I f this is true, it puts many of us in the spendthrift class, and here it might be well for us to “ stop, look T

able

2.— H o w S o m e M

en

D

iv ide

T

h e ir

I ncom es

T h r ift y Stingy M an M a n S p end th rift P er Cent P er C ent P er Cent L iv in g expenses E ducation G iv in g R ecrea tion S avings

37 1 1 X 60

58 1 1 40 0

50 10 10 10 20

and listen,” and turn toward the thrifty man’s road. It takes a tremendous effort to slow the spendthrift down to the point where you can show him that he is in danger; that old age and poverty are an ill mated pair; that every dentist must look to the time when he can w ork no m ore; that only a gnat plans to live but one day, and only a grasshopper makes no pro­ vision for the cold and dark just ahead. H e mistakes motion for progress. H e is very much like a squirrel in a cage, the faster he runs, the harder he has to go. Possibly, he would get along faster, if he would go slower. A dentist earning $300 a month can­ not travel a $400 a month gait and ac­ cumulate anything. Likewise, a person

343

making $600 a month cannot keep up with the $10,000 a year crow d and have an easy chair to sit in at quitting time. A competency is not made under that plan. Ijn the course o f twenty-five years, one dentist w ill have about as much of the unexpected, for example, in the way of illness in the family, as another. So, in the long run, most of us have an equal chance to lay up something for the eve­ ning of life, especially if we get into the thrifty man’s class. N o one has much respect for the stingy man or the spend­ thrift, so why not get into the thrifty man’s class? T h r ift does not mean that we should stop spending, but it does mean the abil­ ity to manage our money carefully or judiciously, spending less than we earn or saving systematically. T o cultivate thrift, we must learn to designate be­ tween luxuries and necessities and not let our judgm ent be swayed by the seem­ ing pleasures of the hour. M a n y dentists have been working hard for twenty years and are not any farther ahead financially than when they started out. T ake the case of the young dentist who is hopeful against poverty in old age. T h e amount o f money or property he has next year doesn’t mean much. W h at he w ill have five years from now means little more. It is what he w ill have thirty years from now that counts. Therefore, he must look thirty years ahead and strive to arrive by that time. T h e man who looks ahead gets ahead and stays ahead, and the dentist who does not heed the warning signals is likely to get behind and stay behind. SU M M ARY

1. Every dentist owes it to himself and the people whom he serves to render the very best service of which he is capable, and the degree of this service

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T h e Journal of the Am erican D en ta l Association

will depend on his ability, industry, ju d g ­ ment, honesty, cleanliness and office equipment. 2. The rewards we receive for serv­ ices rendered, in most cases, come in the form of a monetary consideration. T h ere­ fore, the practice o f dentistry should be considered from a business as w ell as from a professional standpoint. 3. W e should and do have at least as much respect for a man who has some money honestly gained as for the man who has no money at all. In other words, it is no longer a virtue to be poor. 4. Ninety per cent o f the dental offices are inefficiently managed; hence, a large number of dentists can increase their income very materially by better office management. 5. It is far better to stand out in your community as a man with a good credit rating than to possess a worn out auto­ mobile. 6. It is not necessary to sell dentistry at sensational fees. It is only necessary to put the nonproductive w ork at the same price as the productive work. 7. Remember, we cannot receive just “ fees” through the time worn guessing contest system. 8. A long list of unproductive w ork w ill keep any practice down to a low financial basis. 9. It is very easy to make ourselves think that w e w ill not have to face some o f the problems of life that are almost sure to come to us, and whether some of the “ rainy days” are to be follow ed by sunshine w ill depend on whether we heed the warning signals. 10. Far too many o f us are inclined to put off until tom orrow what we can and ought to do today. Therefore, let us ( 1 ) render fu ll and fair value to our patients in the shape of our very best services; ( 2 ) know and

put into execution every detail of proper office management; ( 3 ) have the cour­ age to ask a fair and honest fee and per­ sist until we get it. D IS C U S S IO N

John S. O w en s, C am d en , N . J .: It is a notable fa c t that the dental p rofession p os­ sesses only a fe w books that m ight be term ed standard textbooks on dental econom ics, a l­ though nu m erou s articles h a v e a p p eared, o v e r a lo n g term , in our dental p eriod ica ls c o v e r in g p ra ctica lly e v e ry phase o f the sub­ je ct. T h e p a p e r o f D r. L a w ren ce is a d is­ tinct contribution to this su bject, w ith the analysis and g ra p h ic p ortray al o f our short­ com in gs an d their correction in the m an a ge­ ment o f o u r dental offices. E m phasis must be g iv e n to the p rofession a l attitude on this su bject. T h e m easure o f a p ro fe ssio n a l m an ’s success w a s b ea u tifu lly stated in the q u ota ­ tion fro m ou r rev ered D r. K ells. T h e ques­ tion that w e should ask ou rselv es is “ W h a t sort o f success do w e d e s ire ? ” T h e m an w h ose sole aim in life is a b ig fee, a large incom e, a b ig bank accoun t is a m iserable fa ilu re in a p rofession d ev oted to the healing art. T h e p ra ctition er w h o cann ot take time to attend dental m eetings, take p art in the p ro ce e d in g s o f his local, state o r national society, assist his p rofession a l brother o r g iv e attention to research w ork or teaching, unless he sees fin ancial gain , w h o is w ra p p e d up in the scram ble and greed fo r his o w n a d v a n ce ­ ment, is an u n w orth y m em ber o f the p ro fe s ­ sion. T h e m an w h o takes no tim e to keep his b o d y healthy, his m ind b r o a d and his d is­ position sw eet is a flat fa ilu re, no m atter h ow m uch o f a m aterial success he m ay be. I w ish to lay p a rticu la r stress on the g r o w in g ten d ­ ency on the part o f som e dentists tow a rd the com m ercia l attitude. T h is must be re ­ pudiated by the p rofession b efore it u n d er­ m ines the true id eals o f ou r ca llin g . W h a t are these id e a ls ? T h e y are exem plified in the lives o f the outstanding ch aracters in our p rofession , m any o f w h om h a v e died in the harness, yet, shabby harness, but their m em ­ ory lin g e rs w ith us, in d elib ly w ritten on the p ag es o f history o f our p rofession . T h e y h ave giv e n unstintin gly of their accom plishm ents and substance fo r the betterm ent o f m ankind and h ave rea p ed the g lo r y o f service. W e , m ust not fo r g e t that w e b e lo n g to this group, d evoted

to the

art o f

h ea lin g .

Success is

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L aw rence— E conom ic Factors in a D en ta l Office w ith in the g ra sp o f e v e ry m an, even to the m ost m en ial o r hum ble o f us, but the p oint o f v ie w must not be w a r p e d by the d o lla r m ark. W it h the a p p a llin g lack o f in fo rm a tio n on the elem en tary p rin cip les o f this subject, on the p art o f the g e n e ra l p ra ctition er, it is ap p aren t that lo ca l dental societies should fo r m study classes f o r the p ro p e r d issem in a­ tion o f in fo rm a tio n , w ith due respect to the p ro fe ssio n a l aspect. I regret, w ith D r. L a w ­ rence, that m uch o f the so -ca lle d in form ation on this su b je ct o f dental econ om ics is co m in g fr o m co m m e rcia l sources an d not fr o m the p rofe ssio n . L et us c a r ry w ith us into the study o f this su bject w h at T h o m a s P. H in m an has ep itom ized in the w o r d s “ truth,” as in d i­ ca tin g the attitude to w a r d ourselves, and “ serv ice ” as the attitude to w a r d our patients. D r. L a w r e n c e ’s p ap er strikes the keynote “ k n o w th y se lf,” and h e g ra p h ica lly , in his analyses, brin g s to ou r attention the neces­ sa ry qu alities that constitute a successful p ra ctition er. In his definition o f office m an­ agem ent, I can n ot see h o w w e can d ivo rce ou r actual ab ility fr o m this departm en t, fo r our office m anagem ent is in tim a tely co n ­ n ected w ith our capacity, p o w e r to p e rfo rm or skill. C ertain ly, ou r ab ility enters into the tra in in g o f our assistant, d eterm in in g fe e s and p la n n in g w o rk . F o r the v a st m a ­ jo r it y o f us, the w eakest link in the chain o f our qu alities u n dou btedly an d the easiest o f correction is office m anagem ent. A ll one has to d o to b rin g this p oin t hom e, and w h at to m y w a y o f thinkin g constitutes a necessity fo r the m a jo r ity o f us, is to em ploy re g u la rly a certified accountant to check up ou r b ook ­ keep in g systems. W h ile m uch has been rightly stated u n d er the head o f u n p rod u ctiv e w o r k ­ in g hours an d tu rn in g these hours into the p rod u ction colum n, w e must not fo r g e t that a definite am ount o f tim e d a ily must be spent at the desk p la n n in g and m a n a g in g the p ra c ­ tice, w a tc h in g the office system, stu d y in g e f­ ficiency, cost o f p rod u ction and collection s and d eterm in in g the m a rg in o f profit. W h ile the hours spent this w a y are not righ tly classified as p ro d u ctiv e hours, they rem ain the key to the office m anagem ent, b y close ob serv a tio n o f w h ich any and all leaks are detected. N o m ention is m ade o f liability insurance. It is a w e ll kn ow n fa c t am on g

sue, he is co v e re d by insurance” and w o e unto the m an w h o has not stopped this leak if he e v e r gets caugh t, f o r a life ’s sav in gs m ay be lost in a sin gle slip. T h e r e rem ains an oth er leak, the d ra in on on e’ s physique, w h ich , if not stopped by its r ig h tfu l rem edy, recreation , w ill end y o u r c a llin g early in life, or w ill shorten y ou r days, lessen you r skill and enthusiasm , b e f o g y ou r m ind, w ill take the p leasu re out o f the serv ice an d make y o u r disposition such that y ou are neither fit to p ra ctice n o r to liv e w ith. O n ly those that h a v e g on e th rou gh this ex p erien ce know the w isd o m o f the truth that a sound m ind and a sound b o d y g o togeth er. U n d er the head o f s a v in g s : i f y ou jo in the th rifty m an class, h a v in g determ in ed the am ount, save it each m o n th ; f o r i f you w a it fo r a surplus to show on the r ig h t side o f the led ger, experien ce has taugh t that y ou w ill g o on w aitin g . T o quote E d H o w e . “ W e h ea rd a m an say to­ d a y : ‘I f a m an w ins success, he m ust fight f o r it.’ Is that a fa c t ? W e som etim es b e lie v e it is not— that success is easier than fa ilu re. I f a m an w ill be m odest and honest, and rea so n a b ly industrious and carefu l, he cannot v e r y w e ll a v oid b ein g su ccessful. T h e men w h o are successful sim ply w ork aw a y, take care o f w h a t they earn an d m ake n o bad breaks. F in ally , success com es— not a lw a y s in g reat m easure, but en ou g h to satisfy a reason able m an. M o s t m en w h o m ake a fa ilu r e o f life are not content to w a it ; they becom e im patient, an d m ake a ba d break, in w h ich there is an elem ent o f trickery, if not d o w n r ig h t dishonesty. T h e n p eop le lose co n ­ fidence in them, and they soon acqu ire the habit o f say in g that industrious and w orth y m en w h o h a v e succeed ed are thieves.”

that an e v e r -in c r e a sin g num ber o f suits are

C. C. S p a rrow , M in n e a p o lis , M in n .: I h ave been f o r som e tim e g r e a tly interested in the business side o f ou r d a ily w o rk and h ave been astonished at som e o f the findings. D r. L a w r e n c e h a lf a p olog izes fo r presentin g a p a p e r on this su bject b e fo re a Section o f the A m e r ic a n D en tal A ssocia tion . H e should be com m en d ed f o r his effort, fo r it is h igh time that w e should, as a p ro fession a l b od y, aw aken to the necessity o f g iv in g this qu es­ tion serious con sid era tion and thought. C hanges in business, social and econom ic con d ition s in the cou n try at la rg e m ake it im p erativ e that, w e g e t a w a y fr o m som e o f ou r old custom s that h a v e lo n g since becom e

b ein g

an tiquated.

p rofession a l p rotectiv e insurance com pan ies p re fe rr e d

against

p ro fe ssio n a l

m en.

T h e attitude o f the p u b lic is “ g o ah ead and

are

F or

co m p elled

by

ou r

self-p reserv a tion ,

the v e r y

chan ge

we

in the

T h e Journal of the Am erican D en ta l Association

346

ord er o f things to g iv e strict attention to this g rea t p rob lem . W e must so con d u ct our offices that w e m ay be able to live a life in keep ing w ith that o f a true p ro fe ssio n a l m an, and, at the sam e time, be able to save a com ­ petence fo r that p ro v e r b ia l rain y d ay. W e must h a v e h igh id eals in o r d e r to g et the v e r y best out o f ou r w ork, but I know o f no other one th in g that w ill kill that w o n d e r fu l spirit so qu ickly and su rely as lack o f m oney. N o m an w h o is fin ancially em barrassed and liv es in m ortal fe a r o f the b ill-co lle cto r can d o his best w o rk and ren d er his best service to his clientele. I cannot agree w ith the classification o f “ honest and dishonest d en ­ tists.” I can n ot belie v e that in this day and ag e even a dentist cou ld be so near-sighted as to think that dishonesty cou ld p ossibly b r in g him fin ancial returns f o r any length o f time. It is true that m any m en are re ce iv ­ in g m ore than their services ju stify , but this is due m ore likely to ig n o ra n ce or fe a r rather than to d o w n rig h t dishonesty. I w o u ld term the m an dishonest w h o is g iv in g a w o n ­ d e rfu l se rv ice to his patients fo r starv ation fees. T h is m an is dishonest to his fa m ily and h im self and is m altreatin g his fe llo w p ractition ers. D r . L a w re n ce d w ells, to quite an extent, on record s, book k eep in g systems, etc. T o m y m ind, w h ile they are necessary, they are n ot so im portant to success in d en ­ tistry as he b eliev es. Dentists fa il fo r m any reasons, an d one o f the greatest reasons is the fa ilu r e to keep in constant touch w ith patients. W e m ay com plete a case toda y fo r a p atien t in a m ost sa tisfa cto ry m anner, and the patient is loud in his p raises o f us as dentists. H e th orou g h ly appreciates the p ainstaking care w e g a v e his w ork and the lo n g hours w e spent on his case, in o r d e r to g iv e him the splendid result obtain ed, but unless w e keep in touch w ith this patient in the w eeks, m onths and years to fo llo w , he w ill v e ry lik ely d rift to another m an. T im e makes us fo r g e t m any things, and this is no exception w ith dentists and their patients. W e should h ave each p atien t report to us re g u la rly f o r p ro p h y la x is and exam ination. T h is w ill keep up that constant contact, a llo w us to w atch our w o rk ca re fu lly , to see that it is w o r k in g out as w e had plann ed, keep us constan tly b e fo re that patient and g iv e

sion al m en, and earn fo r us the r e w a r d it d eserves. T h is system is bein g c a r rie d out in a fe w offices toda y, but their num bers are fa r to o sm all. In m ost cases, w h en an exten­ sive recon stru ction case is com p leted , and it is w o rk in g w ell, the patient does not return fo r m onths and years, if at all, or until som e­ thing bothers him . T h is m ay be w h en som e­ th in g serious has h a pp en ed . T h is m ight have been easily a v o id e d had the patient reported re g u la rly f o r exam ination. W h e n som ething serious has happened, and it is necessary to rem ov e a la rg e b rid ge, o r w orse yet, a tooth to w h ich the b rid g e is attached, and the patient is a g a in ob lig e d to un d erg o c o n sid er­ able distress and at g reat expense, he loses fa ith in his dentist and dentistry. W h y not a v o id all o f this by reg u la r inspections, at w h ich tim e w e are p aid f o r a serv ice to keep in con d ition not on ly the m outh, but the w ork that 'w e h a v e p laced there, thereby exten din g the life o f ou r dental w ork and crea tin g a m uch m ore fa v o r a b le im pression o f our service and o f dentistry in g e n e r a l? B roken appointm ents should not, in my op in ion , be ch a rg e d fo r , except under the m ost unusual circum stan ces. A ch a rg e fo r a broken a p ­ p ointm ent p ra ctica lly alw a ys leaves a bad taste, and does not help one to cem ent the p rofession a l tie and create the fr ie n d ly fe e l­ ing so necessa ry fo r continued patron age. Im press on the patient, in the v ery beginn ing, the necessity o f b ein g p rom p t and the reasons w hy, and y ou w ill h ave no trou ble w ith the a v e ra g e patient. I f a patient has a repu ta­ tion o f a lw a ys bein g late and b rea k in g a p ­ pointm ents, take that into con sid eration w hen m aking the fe e and you w ill h ave m uch bet­ ter results. M ost m en lack v olu m e in their business. T h is volu m e w ill n ev er be in ­ crea sed by b ook k eep in g systems. F o r the m an w h o has m ore than he can d o and fa ils to m ake m oney, it w ill help, but fo r the man w ith ou t a volu m e o f w ork , it m eans little. W e must g et n ew patients and h old the old ones, and this, to m y m ind, is m ost im portant. E v e ry m an should h a v e a roen tg en -ray m achine in his ow n office. H e should learn to use it, and use it often . C h a rg in g fo r exam inations w ill ruin the a v era g e man, unless he does som eth ing definite fo r the patient. I f w e do our ow n roen tg en og ra p h ic

him a se rv ice w orth y o f the cause and in

w ork , w e ca n then in corp ora te this as part

k eep in g w ith

of

service.

T h is

a ju st rem uneration fo r w ill

help

that

cem ent the tie o f

fr ien d sh ip and respect fo r us as true p r o fe s ­

our

routine

exam ination,

and

get

paid

w ell fo r ou r time. T o ch arg e fo r an ex a m i­ nation alon e is ruinous to any p ra ctice.

Pa­

M a v e s — Inlays tients do not like it and w ill a v o id it, as w e w ou ld , sh ould the con d ition s be reversed . T o be successful, one must be w illin g to w o rk and w o rk h a rd . H e m ust be honest and g iv e the best that is in him . H e must k n ow the kind o f se rv ice that he is g iv in g , and i f it is not up to standard, he must learn to b r in g it up. H e m ust be a m an. H e must learn to handle p eop le w ell, and sell his p rofession a l service at a figure that w ill be fa ir to his patient, fa ir to him self and fa ir to those d e­ p en d in g upon him . In closin g, I w an t to

347

quote to you a little creed w h ich I think w o u ld help us all to be m ore su ccessfu l: “ I take no thought o f m y n e ig h b o r’ s birth, N or the w a y he m akes his p ra yer. I am w illin g to g ra n t each human a place on earth I f his g a m e be on the square. I f he play straight, I w ill call him mate, I f he cheats, I w ill d rop him fla t; F or all rank but this is a w orn -ou t lie, A nd each clean m an is as g o o d as I, A n d a k in g is no m ore than that.”

INLAYS* By HERMAN A. MAVES, D. D. S., F. A. C. D„ Minneapolis, Minn.

H E answer to Herbert Spencer’s question, “ W h a t knowledge seems of most w orth ?” is surely “ T h a t which conserves the health,” and the teeth play a fundamental part in this conservation. Since our study, teaching and research, up to the present time, have been un­ able through preventive measures to check caries, it undoubtedly is obvious to all of us that we, as a profession, must continue our efforts to perfect our me­ chanical technic, for we are called on to deal with existing conditions, the ravages of decay. Therefore, an exposition on casting and a practical demonstration carry with them a deep significance and a keen re­ sponsibility, stimulating all o f one’s efforts. T o me, these opportunities, made possible through the splendid or­ ganization of the American Dental

T

*R ea d b e fo re the Section on O p era tive Dentistry, M a te ria M e d ic a and T h e ra p e u tics at the Seventieth A n n u a l Session o f the A m e rica n D en tal A ssocia tion , M in n ea polis, M in n ., A u g . 23, 1928.

Jour. A . D . A ., February, JQ2Q

Association, are a distinct privilege, and viewed in the nature o f a privilege, they necessarily entail a strict obligation. T o o often, in the past, metallurgy shrinkage and expansion of waxes, investments and golds, has been largely ignored, and our castings fit fairly w ell in spite o f us, rather than because o f us. W e are all keenly aware of the out­ standing fact that any new procedures which tend to depart from the old, how ­ ever inadequate the old may be, are not usually met with much enthusiasm. On the contrary, it is the rule that they are accepted slowly. It is not easy for the men who have been doing things in a certain way— teaching and advocating certain methods — to renounce them, much less to admit the fallacy in the things that they have been teaching and executing. W e are all prone to meet progress reluctantly, especially if it demands that we cease doing things in the manner in which we have been doing them; and, as we grow older, we are likewise reluc­ tant to take up the new, even though we