The Five Pillars of a Dental Practice
Bill Brown, DDS
The new scientific information and the shift of dental practice from a series of techniques to a process that involves the dental patient and dental team in a human setting required new systems. What evolved was Comprehensive Oral Health Care (COHC). Because of the transformation of dental practice from authoritarian, where patients presented for dental cures to one of collaboration, in which the patients were responsible for their oral health, it was necessary to engage them in a different manner.
Working with Dr. Bob Barkley and Dr. Nathan Kohn, Jr. provided a view of practice that was like opening a window to a fresh spring breeze. Dr. Kohn, a psychologist who had studied dentistry and dentists for two decades, believed dentists should understand themselves as a foundation to understanding others. I realized that I needed to understand the person before I could understand each of them as a patient. Knowledge Was Empowering The new scientific information and the shift of dental practice from a series of techniques to a process that involves the dental patient and dental team in a human setting required new systems. What evolved was Comprehensive Oral Health Care (COHC).
 This blog will discuss Humanistic and the other four components subsequently. 
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The Five Pillars of a COHC Practice: Humanistic
Biologic
Diagnostic
Therapeutic
Philosophy
These are TENETS, not TACTICS. This blog will discuss Humanistic and the other four components subsequently. The First Pillar? Humanistic.
Humanistic consideration is not secular humanism. It is the realization that dentistry is about people, not just teeth. A Humanistic dentist is concerned with the interests and welfare of humans, their patients. The Humanistic dentist sees the whole person as more that the sum of the parts. In this regard, Humanism is based on the premise the ultimate success of the other components of Comprehensive Oral Health Care is dependent on involving the patient as a person; a total being. Not a procedure, a tooth, or a technique. Because of the transformation of dental practice from authoritarian, where patients presented for dental cures to one of collaboration, in which the patients were responsible for their oral health, it was necessary to engage them in a different manner. This radical shift compelled dentists to become teachers and for the first time the profession engaged behavioral scientists. My first experience with behavioral science was with Dr. Nathan Kohn, Jr. I was introduced Dr. Kohn by Dr. Barkley and I had an immediate affinity for him. He was a large man in his late 40's. He had spent the previous two decades studying dentists, working with the dental profession, and part-time teaching at Washington University Dental School in St. Louis, Missouri. After listening to his presentation in Monmouth, Illinois with my staff, and in Chicago, Illinois, I engaged Dr. Kohn and he spent two years coming to my office in Des Moines, Iowa. What did he do for me? Working with Dr. Kohn was like drinking from a fire hose. It was so completely different from my dental school education of the "advantages and disadvantages" of technical procedures. Dr. Kohn helped me understand that the dental office should be primarily a place of education. In that connection, I needed to think seriously about my philosophy of practice.
The first element was my Self-Discovery. By articulating my core beliefs they became guideposts for my practice. The serious thought revealed how my beliefs would direct and determine my practice. It was apparent that a written, shared philosophy empowered my staff and patients to come together for a common purpose. The refinement of my beliefs into a written philosophy resulted in my practice becoming what I wanted it to be, not just following the paths of those who went before me. My philosophy had to be based on my beliefs. Any practice philosophy is greatly influenced by your technical abilities. For example, if you can't perform a procedure that you say is important for the welfare of your patients, you must either learn it or refer it. Your philosophy is shaped by your self-understanding and your expectations must be communicated to your staff so they can support, expand, facilitate, and communicate your beliefs. This becomes the roadmap for your practice, your life, and living. The philosophy will be dynamic-it will change over time.
Dr. Kohn had me begin the process with self-understanding. Knowing myself provided a foundation to understanding other people and was fundamental to the rest. The process of self-understanding was the basis for uncovering blind-spots and understanding what type of people were suitable to work with. Dr. Kohn started with a careful, in-depth study of myself. My attitudes and feelings. My prejudices and desires and other personality attributes. Dr. Kohn helped me understand that dental practices are highly complex and as a dentist I was cast in new roles not envisaged in dental training. Nate showed me how a dentist can feel trapped in playing roles they have no training, experience, or inclination for. He also felt that every professional person could benefit from a visit with a skilled counselor in behavioral sciences to seek advice with respect to their won personality traits. Dr. Kohn thought a few brief session in discussion of traits, goals and ambitions could be very beneficial for better service to the patient, better return for the dentist, with less strain. I followed his advice and found it to be extremely helpful professionally and personally. In my office we started with me and my staff completing a Practice Analysis and Understanding Yourself workbook. This helped us develop goals, redefine our organization, establish new procedures, develop a process of continuous evaluation, and institute a new level of inter-staff communication. After completing the initial profiles, Dr. Kohn suggested that my wife and I come to his office in St. Louis for more in-depth testing. We had established a very good relationship with Nate and felt comfortable working with him. In his office he and his staff administered to my wife and me MaxQuarrie test for eye-hand dexterity, WAIS test of intelligence, Diagnostic Reading Test, Miller Analogies Test, Strong Vocational Interest Test, Sex Knowledge Inventory, Mooney Problem Checklist, Minnesota Multiphasic Personality Inventory, and Rorshach Thematic Apperception Test. It was three days of testing. Dr. Kohn discussed the results in private consultations. After self-appraisal I was better able to define my practice. It gave me the basis to determine what was required to attain my goals. The appraisal defined my organization. It became a workable strategic plan. Who were the responsible parties and the timetables for implementation. Dr. Kohn introduced us to Management By Objectives and the teachings of Dr. Peter Drucker. It became apparent that I couldn't just be a dentist. Because of the complex task of running a dental practice I was required to learn the basic art of management. Like other dentists, I had no training in management. I found the development of a philosophy was an important exercise and it must be written. It was apparent that if it weren't well enough defined to articulate in writing it would be ineffective. In a written form it was shared with my spouse, certain colleagues and staff for discussion and feed back. Following the philosophy allowed us to offer all patients the same level of care. I found that if the philosophy wasn't followed it was very apparent to the staff and patients. By involving the staff in the process a sense of ownership, community, and a shared vision and purpose were established. I found that the staff must be able to speak freely without retribution and by listening to their suggestions created positive and powerful results on many levels. Their perception of my behavior and practice were sometimes different than my concept, which gave me an important perspective. How does this exercise translate into a warm, welcoming, and engaged staff instead of people who are detached, uncaring, and aloof? For example, my staff was indoctrinated with the philosophy of the office, i.e. that our office adopts a patient-centered philosophy. This functions primarily by utilizing basic principles of caring for and thinking about the patient's welfare. The education of the patient, the caring for the patient, the serving of the patient are all functions of this approach. We incorporated the fundamental principles of open communication, mutual respect, and an emotional connection between my staff, the patients and me. Dr. Kohn introduced the power of Gestalt so that we as a dental team viewed the patient as the whole person rather than the sum of the parts. By incorporating these principles for learners, it becomes easier to remember a whole rather than a part. Another way of looking at the concept is an athletic team. A team illustrates the principle of unified wholes. A well-coordinated team that shifts its emphasis as the pitcher changes his delivery is more effective than the sum of the individual players. This underlines the importance of the philosophy of practice as the critical element to having an effective dental team. Instead of trying to teach auxiliaries individual parts of a practice, we want to see the wholes, which are much easier to remember and apply to patient care. The philosophy of practice is the glue that holds the other components of the practice together and it is used as a communication and management tool for staff and patients. The discipline in self-appraisal and writing a philosophy of practice was the first step in the process of establishing COHC. Next time I will discuss the Biologic component. Footnotes: Selection, Hiring, and Training of Dental Auxiliaries, E. Green, N. Kohn, 1970, W.B.Saunders Nathan Kohn, Jr. Personal Communication
The Second Pillar? BIOLOGIC « Dental Intelligence The Third Pillar? DIAGNOSTIC « Dental Intelligence The Fourth Pillar? THERAPUTIC « Dental Intelligence The Fifth Pillar? PHILOSOPHY « Dental Intelligence
To read more about Bill Brown, go to: Bill Brown, DDS To read his blog, go to Dental Intelligence
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Speaking from the patient side, I'm impressed as always with Dr. Brown's appreciation for the humanistic side of dentistry and with this articulation of it.
It's particularly the new ones fresh out of dental school who could benefit from this. Understandably, they're on fire to share their technical knowledge with patients, but many of us sitting in the chair don't make it a priority to know the details about CEREC or root canal procedures. Our priorities are much more like the ones Bill lists here: first, humanity--simple, gracious empathy. Everything else comes in a distant second.
I'd take small issue with differentiating between tactics and tenets here. Whatever the motive of the dentist, whether it's to be a better human being or just to make more money in a busy practice, the outcomes for the patient are what matters more than the motives of the dentist. Put another way, tactics become tenets. The dentist who adopts a more caring approach for purely practical business reasons is, to my thinking, likely to discover unexpected satisfaction and success, and quickly evolve as a person into someone truly caring. The journey doesn't have to start with sincere caring, but either way, it takes you there.
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