45 Days of Practice Ownership

I alluded to it in my last post, but I have officially purchased a dental practice in Greeley, CO.

The name is NorthStar Dental, and you can find me on the web in these locations:

Website: NorthStarDentalGreeley.com

Twitter: @NSDGreeley

Instagram: @NSDGreeley

Facebook: Click here

I've learned a few things in my first 45 days, but I mainly want to discuss the differences between military dentistry and civilian dentistry here.

1. Treatment planning

Military treatment planning is very conservative. This stems from the fact that we are often so booked out, that it's easier to push off that tooth with some visible fracture lines to next year, or do a big filling and hope it doesn't break in the meantime, rather than stuffing the schedule full of crowns.

In civilian practice, you can pitch the option of a crown as soon as you know a filling is a poor long term solution which means your crowns are going to be far more predictable and often not require a core buildup for the patient (which saves them $) if the existing filling is small.

2. Problem solving

The military has a multitude of issues but most of them are small. However, this constant small background annoyance is akin to a constant static slowly invading your work life. There's a lot of problems that you can't fix at all, or that take so long to fix that you just start to ignore them.

In civilian practice, problems get solved very quickly. There's a host of helpful people waiting to service your practice via equipment purchases, financing, supplies, etc. 

Example: It took 8 months to get new curing lights in the military. In my new practice? 4 days.

3. Administrative tasks

One big benefit of the military is that you have a lot of enlisted personnel to help with admin duties. But wait a minute, you also have your own! Writing notes, running programs, the list goes on and on. None of them are that hard, but again, it's like the constant static in the background.

In civilian practice, you have far less that you are "required" to do yourself (treatment notes are an obvious example here). Not to mention you can run your "programs" (referrals, etc) however you want! My admin burden is probably 10% of what it was in the military. My staff is small and efficient and takes most of this load away. Now, I do have a host of new issues to deal with, but with the right leadership background, I have had no problems at all with these new items and I have more down time (yep) than I did in the military.

My overall thoughts after 45 days:

I have been totally surprised at how easy the transition to civilian practice has been. The everyday joy of treating patients that actually chose to come see you cannot be understated. Having a very small team of highly motivated individuals makes you far more productive than having large military teams (ironically) bogged down with red tape and hours of extra non-dental work. The nearly total lack of administrative tasks in the civilian world is a dream. Solving problems instantly means that there's no buildup of stress "static". Being able to actually lead a clinic and have ultimate autonomy is wonderful.

I've loved it so far. If I had to put a number to it, I would say it's about 20% as stressful as I expected, and 2x as fun.

My big caveat: 

If you're thinking of getting out just to associate forever, think twice. The military has such a great end goal for those that can stay for 20 years, and many private offices hire associates too early which means you won't be busy enough. Working for a corporate office might work because they typically have a better pulse on their needs, but you may burn out quickly because you'll definitely be seeing more patients.

So let me encourage those that are considering getting out. Do it!

If... you want to own a practice :)

P.S. If you decide to get out, you *must* use an intraoral camera for *every* exam finding. Showing the patient what you are seeing is far and away the best tool for gaining trust and building rapport. 

The End of the Beginning -- And An Offer for Readers

I started this blog in February 2010 with the intention of chronicling my journey as an Air Force dentist and being a resource to help out people who had questions.

I was "scratching my own itch", if you will. I didn't see anything on the internet like what I wanted to read. So I made it myself.

500 emails, 250,000 page views, and a few phone calls later, I'd say it was quite a success.

After a long 10 years, I am finally in the process of leaving the military and acquiring a dental practice for myself. I can't say really anything more than that, but now you know. I've already learned a ton along the way, and I'm hoping to help military dentists get over the fear of transitioning into practice.

If you're a dentist (military or otherwise) considering transitioning to ownership, please contact me (my email is on the right side of the page)!

I would love to help you better understand if this is the right step for you and even do some help you look at different practice offers, associate contracts, or just brainstorm your next steps.



As for the future of this blog...

I've struggled recently trying to decide what direction to take it, if any, given the facts that:

1. I'm leaving the military (so the title doesn't work super well)
2. It makes me no money (so I can't sell it)
3. It's a very narrowly focused/designed blog (so there's not much else to explore)

However, I think it may be beneficial to continue my story in some way and I haven't quite decided if that will happen here at this domain or on some other blog that is tailored more towards my next phase in life. Stay tuned.

I've received literally hundreds of emails over the last decade and this blog has been a central location for those looking for information about military dentistry, the Air Force HPSP, dental school, and life in the military.

My email is still live, so keep the questions coming! Like I said at the top of the page, I'm welcoming any and all questions from those looking to transition to ownership.

It's been an honor and a pleasure, and I'm excited for the next step in my journey and helping you with yours.

Nuts and Bolts - Part 3/3 of Organizing a Military Dental Clinic

Nuts and Bolts - Part 3/3 of Organizing a Military Dental Clinic

Practical tips for making your clinic more efficient. These are actual, real world things you can do to help improve different areas of your clinic.

Post contents:
-Supplies
-Patient Records and Forms
-Meetings

Supplies:

1. Everything has a home

Make sure every single supply has a "home". Some bases have storage areas that can accommodate everything, but some don't. That's ok! Everything should still belong somewhere. NEVER order a supply and deliver it straight to the treatment rooms only and don't just throw the box on a shelf somewhere. You MUST have an area that the rooms are restocked from that itself is a holding area for the clinic. An assistant should never ever ever ever run out of an item and not know where to look for more. The process CANNOT be "tell me when you're low". The item must have a home!

With that being said, this "home" should have standardized labels! NEVER place a box on a shelf by itself unless it's a large box and the shelf itself has a label for that item. Always place the box, or the items in the box, into a standardized container with a label on the front that will allow ANYONE to find that item again later. See #2 for how to do this.


2. How to label item containers in supply areas

Every item must be labeled on a standard container with at least the following information:

-Item Name
-Manufacturer
-Manufacturer Number

These 3 pieces of information are all you need to reorder the correct item. Do NOT just rely on the name alone. Too many products sound similar to trust the name alone! We moved to this system at my previous base and one had 1 item ordered incorrectly in 2 years. At my new base? We accidentally ordered an extremely similar, but extremely wrong, version of the "right" product last month that has wasted money and time, not to mention we have to start over and order the right thing (which we are now out of).

We are working on it :)

3. Have a doctor supply huddle

Every time you get new doctors in the clinic, sit down and go over the supplies. There's no reason that the doctors in the clinic can't compromise on 1 or 2 types of bond. Every single doctor should not have a special bond for themselves. This is ludicrous and adds unnecessary work and strain on the supply chain. Bond is just one example, but it goes for everything.


4. Develop a simple system for alerting the person who does the ordering

Here are some ideas that have worked well --

• Place a sticky note on the low supply container. The Logistics person sees the sticky note and orders more. When they order more, they write the date the item was ordered on the sticky note and the sticky note stays on the item until it comes in, at which point the sticky is removed and the item is restocked.
• Pros
• Eliminates verbal communication 
• Eliminates Logistics person being notified multiple times about the same item
• Eliminates the assistants and doctors wondering when an item was ordered
• Good for clinics with 1 supply area
• Cons
• Stickies sometimes fall off
• Required Logistics person to visually scan supply area
• Not ideal for clinics with multiple "main" supply area

• Create a re-order clipboard. The logistics person keeps this clipboard in their area and techs and docs come write down items they need.
• Pros
• Centralizes all ordering information
• Good for clinics that hold supplies in multiple areas
• Cons
• Same item might get logged multiple times
• Handwriting might be an issue
• Often still required Logistics person to go look for the low item to decide how much to order

• Create order sheet binders or forms that can go in special areas. Many clinics have supplies that are exclusively held in an Endo cart or Surgery room. Hang a printed and laminated Excel sheet with the applicable information (name, manufacturer, manufacturer number) in the room or on the actual cart itself. 
• Pros
• Makes reordering very simple, because the item is identified as being low and the reorder information is right there
• Cons
• Make sure the sheet stays updated with new items or item changes

• BONUS: Same as the "order sheet binder" idea, but just place the info in a relevantly placed Excel document on a shared computer drive. Post the location of the document in the relevant location. This is the same concept as the binder, but more accessible for the person who likes their information digitized. Plus, when you modify it, there's no need to print it off.

5. Consider pre-sterilized burs

I love these so much. Individual burs, sterile from the factory, at practically the same cost as whatever burs you are currently using. 

• Pros
• No more nasty looking bur blocks!
• No more burs running through sterilizers 20 times (or more) before they get used
• No more "is this rust or blood"?
• Eliminates entire process for your sterilizer workers
• Safer for everyone (assistant, doctor, sterilizer techs) due to fewer burs needing to be handled (ie: decreased needle sticks)
• Cons
• Takes up more physical space in the treatment room and in the supply area
• Packages must be opened when needed, stalling your work slightly during the appointment vs having an open bur block with several types of burs

Brasseler and SS White make tons of these. There are other companies as well that should be easy to find with a Google search. Email me if you want some catalogs. I also recommend some magnetic bur holders from Dux Dental to act as temporary bur blocks.

6. Standardized treatment rooms

This is easier if your clinic was built so that all the rooms are the same. This is far harder if you have various types of room layouts in your clinic. Consider at least making all the basics (barriers, suction, etc) standardized. At my previous assignment, we had literally every room standardized, with the exception of the 3rd drawer in a rolling cart, so the doctor could add special things they wanted into that specific drawer.

This made room checks unbelievably simple. Doctors could move to other rooms in a breeze. Assistants knew where everything was in every room. It's a dream come true.

My new clinic was built within the last couple of years, but was actually designed very poorly with little foresight. We have 3 different types of room configurations in the clinic among our 12 treatment rooms (in addition to a severely dwarfed main supply area). I'm still scratching my head trying to figure out how best to serve our patients with these bizarre construction limitations. If I had it my way, we would demo the place and start over! Whoever designed Buckley would have been wise to recall this famous quote: "Begin with the end in mind" -Steven R Covey.

I put this step last on purpose. You must have the previous 5 things accomplished or the standard room will be a nightmare to try to create and enforce.

Note: In order to make this stick, you must have the room photographed so that binders with these photos can be made of what a "perfect" room looks like so the standard you create isn't lost! The binders are used by the techs to standardize the rooms, and used by the docs and NCOs to enforce the standard. 

Patient Records and Forms:

1. Have a weekly record scan program

I wish I thought of this one, because it's so simple. Basically, you have someone in charge of reviewing a set of records weekly.

You have a form on the wall where that person can log the date, the record range they checked, and how many errors they fixed.

Common errors to look for:
Duplicate records
Poor handwriting (rewrite the record)
Misfiled records
Records with missing or incorrect colored tags and papers

This would be in addition to the monthly records review, because that program doesn't hit every record. This does!


2. Put all the forms in the same place on the network drive

Nothing drives me crazier than having a medical history in this folder, the initial charting in that folder, etc.

Put them all in one spot! Here's why:

Makes it simple to train new people (the forms are here)
Makes it easier to update forms (this is the only version of the form, let's update it)
Eliminates redundancies (no more having 3 versions of the same form floating around)


3. Develop a naming system for the files so they are printed correctly

This is how we name our files:

"(BW, Yl, Double sided) Fly Cover Sheet, updated 31 Oct 18"

This naming scheme answers 5 questions:
1. Black and white, or color?
2. What color paper do I print it on? (In this example, Yl stands for "Yellow")
3. Do I print double or single sided?
4. What form is this?
5. When was this form last updated?

No more misprinted forms! Yay!


4. Put the date the form was updated on the form itself

In the example in #3, we would also have "updated 31 Oct 18" printed somewhere on the Fly Cover Sheet itself. This helps us know if a form we are holding in our hands is the most recent version or not.


5. Put physical forms in as few locations as possible

No more forms in treatment rooms. Period. This is where forms go to die and get resurrected 2 years later in a chart out of nowhere.

Find a centralized location, or two, that all the forms can be stocked. This is much easier to replace forms and make sure everyone is using the same version now that they aren't scattered to the 4 corners of the Earth.

6. If the form is part of a program, type the directions ON the form itself

Class 3 forms are standard in the Air Force, but we added a couple things to ours. We minimized some fonts to make room for these instructions:

"Putting a patient in Class 3
1. Have patient sign this form
2. Write up treatment note
3. Assemble completed chart and place chart in Class 3 box in records room
4. Class 3 NCOIC will take chart and... etc...

Taking a patient out of Class 3
1. When treatment is completed, write treatment note
2. Take the blue chart tag out of the chart
3. Take this form out of the chart and place the form in the Class 3 box in records room
etc..."

Now, it's extremely obvious what to do with a Class 3 record! Again, this forces the doctor or tech to go through the proper steps, get the chart to the right person so that person can run their OWN checklist for the Class 3 program. This ensures that all Class 3 charts are handled identically, and HOW to handle them is clear and obvious.

How easy would it be to train a new person on what do to with Class 3 charts using the above instructions? If they can read, pretty darn easy.



Meetings:

1. The length of a meeting is a maximum time limit

Don't feel obligated to stretch the meeting to fill the time allotted. Consider that a "maximum time". If the goal of the meeting is accomplished sooner, leave!


2. Have an agenda for every meeting

This is why people hate meetings. They turn into a circus of confusion and pointlessness. If the goal of the meeting is "let's brainstorm XYZ" then that's great! But set aside time for that type of work, don't make it the default. For everything else, plan it out in order and get to it. A powerpoint on the wall that helps guide the meeting is a great way to keep everyone on task.


3. Don't hate the meeting, hate the chaos

This sort of goes back to #2, but don't hate the meeting itself. If you are prepared with an agenda for the meeting, then implement it use this time to work ON the business/clinic. This is the time to build a better machine! If absolutely no one wants to attend the meeting, you should think very hard about why it exists at all, or how you can make it more efficient (or how you can convince the team that the meeting will result in better outcomes). To gauge interest in the meeting, don't ask a large group. Ask individuals one-on-one.

Don't eliminate the meeting just because you as the meeting leader don't see the purpose. There could be other people looking forward to that meeting for a variety of reasons and they deserve the chance to speak in that setting if they were expecting it.

Most meetings need to happen, but simply don't have an aim and end up running into chaos problems.


4. Be prepared and be decisive

Meeting chaos stems from a variety of places I've already mentioned, but the big one is indecisiveness. Make the decision and move on. "Let's talk about this later" is still a decision. Don't let a group of people spin on a topic forever unless the purpose is to get everyone to brainstorm ideas.

Actually, most decisions are made before the meeting beings (most meetings are a time to disseminate information), unless there is designated decision-making or brainstorming time. If you are prepared for the meeting, a lot of it should be delivering clear and concise decisions to the relevant group, or soliciting feedback from a group to finalize a decision. Once you get the feedback, finalize it. Start moving on it. You can adjust later.

Also, it shouldn't take an entire meeting to decide the theme for the summer picnic so don't let it. Most people won't care anyway, so have a separate conversation later with the group that cares... which brings me to point #5.


5. Don't waste everyone's time

If the decisions in the meeting, or outcomes of the meeting, are only relevant to 1 or 2 people there, consider having a discussion with those people only. The entire clinic doesn't need to hear a discussion about which bonding agent 3 doctors like the best.

Principles for Thinking - Part 2/3 of Organizing a Military Dental Clinic

Principles for Thinking - Part 2/3 of Organizing a Military Dental Clinic

Below is a list of concepts, ideas, thinking principles, thought experiments, mental models, or whatever else you want to call them. I do not claim to be the originator of any of these concepts, but all of the following are some synthesis of the many ideas I've gleaned from the books I've read and the experiences I've had.

They are "how to think" about certain types of problems, without delving into any specific issues. Hopefully these can be useful ways for you to think about problems as you work to come up with solutions.




Would they choose to come here? (for military clinics)

If your patients had a choice, would they choose your clinic? In the military, they don't have a choice! This question is the best way to think about the entire patient experience, and will ultimately lead to a more streamlined and efficient clinic all around.

Build it for the new person

You should do your best to *never* build a system just to accommodate a person. You build it to accommodate a position and fulfill the purpose of that role. Now, having said that, you may have to tweak it for a certain person but the resulting outcome should not change.

Example: some people prefer digital lists of supplies while others prefer written lists. The resulting outcome should still be identical.

When creating a system, imagine yourself as a new person walking into the clinic for the first time and as yourself the following question.

How quickly could we train a new person to be proficient enough to run this system alone?

This question is the measuring stick for every system you create. The quicker the training to sufficient proficiency such that you trust them by themselves, the better the system.

The poisoned river problem

Imagine a village living on the edge of a river. One day, the water in the river starts making people sick. What is the best way to solve this problem?

1. Build a water filter
2. Remove the contamination upstream

Most people will answer #2 but actually do #1 in their life, because #1 simpler. Don't give in. Solve the real problem! Stop building filters. Filters are for emergencies, they are not solutions.


Ask "why?" several times

I can't remember specifically where I learned this, but "why" is the most powerful tool you have to get to the root of any problem. It should be asked several times before settling for the answer.

This is a summary of a real conversation I had a few months ago.

Me: "Why are we out of XYZ forms?"
Person A: "Well, Person B isn't here"
Me: "Why does B need to be here?"
A: "She prints them" // *(MOST PEOPLE STOP HERE!)*
Me: "Why can't you print them?"
A: "I don't have access to the forms"
Me: "Why not?"
A: "I don't know, they tried to give me access but it didn't work"
Me: "Why didn't you follow up?"
A: "Person C was working on it but I haven't heard anything"
Me (talking to C): "Why doesn't A have access to the forms?"
C: "Person D is in charge of that, and I tried for a while to get A access but they couldn't do it"
Me: "What is D's email address?"
...

In 2 hours, person A had access to the forms via an email and phone call I had with person D. Most people would stop at the first question and just accept the problem. No more!


Pay attention to your shoulders

Shrugging your shoulders is admitting defeat. I do this too, usually without thinking. But don't let the shrug be the final response. You know you're making things more efficient and simpler when the shoulders of people around you are being shrugged less and less.

A shoulder shrug says "I don't know, I don't want to put in the effort to find out, and I give up".

It's ok to not know, but it's not ok to not know who DOES know or how to find out. A shrug is an indication that people are too far removed from the solution to take any action at all. A shoulder shrug is an indication to make things easier or more accessible!

When someone shrugs their shoulders, this is a silent request for a better system.


Remove redundancies

If there's 3 versions of the same thing, but only 1 is the real version, hunt the other 2 down and get rid of them. Bonding agent, rubber dams, paper forms, whatever.

Having more than 1 version of something, especially if it's no longer used, adds confusion to the supply chain and your clinic at every level.


Organize relentlessly

This sort of plays off the previous comment, but be relentless in your pursuit of organization. Do not accept clutter. A cluttered work space (unless a project is in progress, obviously) means the mind is cluttered. Our mind is a powerful tool, don't waste its energy on clutter.


Don't let other people dictate your programs

Put your foot down, standardize the process, write down how to implement it, enforce the rules you set, and watch the chaos subside. This often takes lots of up front work (although sometimes it just takes making a decision to stop tolerating something), but the ultimate result is a better process for everyone, and a happier work-life for you.


Don't ever rely on verbal transfer of information alone, except in emergency situations

Every important verbal exchange should be followed by an email or a note, and every interaction you have with those you work with that involve one-way exchange of information should involve as little verbal communication as possible because this is where things get either confused or forgotten. Exceptions are very routine items that require very short instructions, like "please check XYZ before you leave today". An email would defeat the purpose here.

Sometimes conversations must be had in person, and they are more efficient that way, but summarize the conversation with a note or an email, especially if action will not be taken on that item immediately.

Example: If you're running logistics, don't let people come tell you an item is low. Have them mark the low item bin itself or write it down on an order form (more on that in part 3). Asking them to verbally tell you something is begging for trouble. Some day, you will forget or hear them wrong, or they will get used to telling you and filling up your brain instead of putting the information somewhere simple for you to access.


Think into the future

The clinic needs enough supplies to last through a shortage, and enough notice to get an item before it runs out. If you know that product X takes 30 days to come in from the day you order it, you better have some way to know when you are getting close to a 30 day supply. Stop waiting for the product to dwindle down and then panicking that it's low. This also touches on the previous point. If you run into this problem once, design a better way to communicate.

If the same problem happens again, that's on you. You're not thinking into the future. This is a key mistake I see people make very often.


Have projects ready for down time

Sometimes things break. Sometimes patients cancel. Have some projects ready that can be handed off and worked on during this down time. Stop just working "in" the clinic and start working "on" the clinic.

Everything can be simpler, better, or faster. Everything. Make it so.


Your clinic is a machine. Build a better machine.

Could you imagine the hilarity of watching a family push a Flintstones-style car down the highway? It would be absurd.

But we do this ALL THE TIME! How often have you watched a coworker (you and I aren't exempt here) complain about a process but fail to actually do anything about it? They keep pushing their Flintstones car down the highway, complaining about how slow it is, and never really thinking it might be time for a new car.

The car is a symbol of the system you've created. If you're not getting the result you want, build a better system!


Put instructions at the point of contact

If you want someone to do something when they encounter an particular object, make it obvious.

Example: If you want people to know where they can print new forms, post an address to the computer drive on the wall above the paper forms! Tada!


The good system you'll actually do is better than the perfect system you won't

I don't care how good a system is. If it's too complicated or burdensome to actually use, it's no good. Make something that's good enough but simple enough that people will actually follow it. Then you can gradually improve the system from there.


Start now, but make things editable

There's two problems that occur when you make a system too hard to modify:

1. You have your ego tied up into the time it took to make it perfect
2. You're more reluctant to change it because it will take a lot of effort

Example: At my first base, I typed labels for all our supplies. It looked nice, but it took forever and was a pain to change. At my new base, I made blank cards that we can just handwrite. It doesn't look as nice, but it's been much easier to make changes and it works functionally just as well as the typed versions. Besides, once we are stable for a while, I can always go back and type the labels.

Get started, but be prepared to change course. It doesn't have to be perfect before you begin. In fact, it shouldn't be.


Be thankful

Give people specific thanks and praise for what they do. Every. Single. Day.

People are far more motivated to continue doing good things than being constantly told to fix bad things.


Write it down, and take a picture

If you want something TO GET DONE a certain way, write it down. Checklists, how-to guides, easily accessible Powerpoint presentations... it doesn't matter. Don't rely on mouth-to-ear transfer of knowledge.

If you want something to LOOK a certain way (a standardized room, for example) then you MUST take photographs and make them easily accessible. Photos are the gold standard for standardizing anything visual.

Bonus: Add pictures or computer screenshots, where applicable, to whatever written process you want people to follow for added clarity.


If you want it to fail, fix it and walk away

This sort of piggybacks off of the previous point, but you must have a process for duplicating your solutions.

Here's the progression, applied to treatment rooms:

1. Create the standard (develop a standard treatment room) *(MOST PEOPLE STOP HERE)*
2. Make the standard reproducible (take photos of a perfect room setup)
3. Give people time to hold the standard, and then enforce the standard (the photographs, not a person's opinion, is the ultimate authority, so use them to enforce the standard)
4. Develop repercussions the failing the standard (what happens if the standard is not met?)


A car uses more energy than a spaceship (how to create a system)

Ok, sort of. A spaceship uses WAY more energy to get off the ground and into space. But once it's in space, it's aided around the Earth by the force of gravity and does very little work to propel itself in orbit. Eventually, it travels farther than a car could ever go.

A car is under the same gravitational influences, but it must have constant energy input because it deals with FRICTION. It takes way less work to move a car on a road than a spaceship from a launchpad, but the car takes the same amount of work every single day, and ultimately, the car can't go that far.

Look for friction in your clinic. Where are people complaining? Where are people bumping up against the same problem over an over? Where are things harder than they need to be? Where are things taking 5 steps when they could take 3? Where are efforts being duplicated for no reason?

Can you be a spaceship and put in a lot of energy up front right now to make the friction go away forever?

This is how you create a good system.

(Amazon's "One-click ordering" is an example of reducing friction)


A system is a 3-part answer to "how do we... ?"

The answer to this question must be:

1. Obvious ("here's an obvious location to find clear, documented directions on how to handle certain patients")
2. Clear ("here it is, documented in easy-to-understand and follow language")
3. Documented ("here it is, documented completely, so that you could do what I do if I'm not here")

If you don't have these three components, you don't have a complete system. People plug the holes of incomplete systems. An incomplete system is going to collapse when the person (or people) that is running it eventually leaves.

If you have someone just manhandling the Class 3 program, answering all the questions, doing all the work, but none of what they do is obvious, clear, and documented for someone else, you are asking for problems.

Tip: ask people to document their own jobs! Most are happy to do so.


Create decision ladders

For my Class 3 program, I have a file on the computer that is basically a "how-to" guide called "Class 3 Operations Manual".

Open that document and you'll find only 3 main points. What do do daily, what to do weekly, and what to do monthly.

Each section has references to other places on the network drive where there are directions on how to create certain forms, how to log our patients, and where the log is located.

In fact, once you navigate to the patient log, the log itself has instructions on how to use it!

Do you see what I've done? I hand over the starting point (the "Class 3 Operations Manual") and it points the reader--

Where go to
When to go there
What to do when they get there

Boom. All they have to do is open that first document and "climb the decision ladder" to each step. Every rung is built for them. There's only one way to do it.

Systems fail when there is a gap in the ladder so wide that the climber has to find another path to keep climbing. That's where mistakes are made.


Don't let old problems disguise themselves as new problems

Sometimes we fix a process, but something that was created under the old process pops up and causes discouragement.

If you created a new process on 1 October, 2018, then give it some time! If a problem pops up that was created before 1 October, 2018, no sweat. That problem says absolutely nothing about your new system!

Now, if the problem popped up in November, then you may need to do some tweaking. But old problems will bubble up, just have your head wrapped around when the problem started and don't nuke your new system or add a bunch of new steps just because old problems are still out there.

The goal of the new system is to prevent new problems from arising.

Side note: It might also be good, when creating a new process, to have a sister-process that can go try to hunt down old problems that might exist. The sister-process can be shut down when everything is corrected. (Example: you have a new chart color system, so new charts get the new colors as the patients come in for treatment, but for a while, someone needs to go through the old charts and proactively update their colors, too.)


Don't enforce a standard that doesn't exist

"Have your rooms cleaned and looking nice by the end of the day" is 100% unfair.

Your definition of that statement may be different than the person who has to clean the room.

Who is right? You both are. And by default, neither of you are.

Have a checklist or photographs of every standard you wish to enforce. If the standard is unclear, make it clear and then update the checklist/photos. You cannot rely on someone's opinion as a "standard". This allows the standard to change on the whim of the person enforcing it. Not good.


Ask "what's the most annoying thing you deal with?" and fix it ASAP

Learned helpless will drag someone down slowly over time, to the point that they may fail to realize that their situation is solvable or avoidable.

People typically either:

1. Fail to see the "real" underlying problem as something small and easily solvable
2. See the problem, but lack the experience or critical thinking skills to come up with a sustainable solution

Solving someones most annoying problem will accomplish and demonstrate a few things:

1. Helps them realize their problems are really not that big, usually just an accumulation of small issues
2. You're on their side, you are a team, and you want them to win
3. Being "busy" and "stressed out" does not have to be the default operating mode
4. Paying attention to the little things and fixing those can lead to a spiral of success, instead of a spiral of destruction
5. Most of the things they don't like about their job are the accumulation of small loses, not just a few big problems

Automate your brain

With calendar alarms, reminders, and digital to-do lists, you should never ever forget a task or an event.

If you are, you're relying on your brain to be a calendar or a to-do list. This is secretary work for your brain, something it's notoriously bad at doing.

Write it down, make a calendar alert, whatever you have to do. There is no excuse for "forgetting" these things, because they should never try to be "remembered" in the first place.


Big goals, little steps

You can't complete big audacious goals in 1 day. Many will take months or years to fully realize. This can be hard in the military, but you can do it if you focus on the smaller pieces!

Set an intention to accomplish big things, but break the individual steps into small and manageable pieces that you can accomplish.

I even like to have daily goals that are very small (example: research 1 new item each day).

Here's why:

On your "off" days, when you're just too busy to really get anything done, you can still find time to do your one small step.

On days when a patient cancels or you have a ton of unexpected free time or energy, you can slay a weeks worth of work!


Double the time, halve the results

Anticipate that any change you want to make will take twice the time and be only half as effective as you hope it will be.

This isn't to discourage you from trying to make changes, but to keep in mind that difficulties are often impossible to see, especially when the perfect end result is to clear in our minds.

Be prepared to work hard, long hours to get things done. Keep moving forward, and you will accomplish them.

10 Books that Have Helped - Part 1/3 of Organizing a Military Dental Clinic

Organizing a Military Dental Clinic - 3 part series

This is part 1 of a 3 part blog series called "Organizing a Military Dental Clinic"

I'm going to talk about what I've learned from running logistics at 2 bases over the last several years, and hopefully it will help some military (and even civilian) dental clinics! I was fortunate enough to be part of some awesome teams that have won MAJCOM and Air Force level awards, but those victories were a testament to the systems and habits we created, not the will of the people in the clinics. I don't claim to have all the answers, but I have tried a lot of different things and I'm a relentless experimenter so hopefully these posts can help spark some new ideas for you and your clinic.

Ordinary people can do extraordinary things with the right habits and systems. 

You don't need "superstars"; leaning on them may work in the moment, but things will crash when they are gone.

Let me say that one more time: this is not about the PEOPLE, it's about the SYSTEMS and HABITS you create and enforce over time.

There is a basic level of competency required, obviously, but I'm betting that most of the things your clinic does could be simplified significantly, making everyones job and life much more enjoyable.

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10 Books that Have Helped- Part 1/3 of Organizing a Military Dental Clinic

Books are the #1 way I've learned (with podcasts coming in at a close #2) what you're about to read in this 3 part blog series. Obviously, the knowledge must be applied, but I firmly believe that you can only imagine combinations of that which is already in your mind, and the best way to add new things to your mind is to digest knowledge from the great thinkers via books and podcasts.

Here's my list of 10 books, in no particular order, that can help you become a better thinker when it comes to organizing your clinic.

1. The Power of Habit - Charles Duhigg

A modern classic on "how" to think about what we do every day. We are our habits. Instead of trying to change people, change the structure and incentives to drive them to the result they want. We aren't trying to change people, we are changing their habits. This is not a "quick fix" book, but it can lead to permanently new habits, which is the ultimate goal.

2. Extreme Ownership - Jocko Willink

Stop blaming other people for failings that happen on your watch. If you're in charge, own it. This extends to your personal life as well, but is relevant here for your work, too. Discipline = Freedom. 

3. The Goal - Eliyahu Goldratt

This is a business book disguised as a novel (or maybe the other way around). It's a fun read that makes you think about how you can pull what you're learning into some real life actions for your business or clinic. This book gave me an actual idea for our supply chain at my first base that we ended up implementing and utilizing. For that reason, it had to make the list.

4. The E-Myth Revisited - Michael Gerber

I wish this was mandatory reading for all Air Force officers. This is the bible for how to think about any organization, even in a 1-person shop. The basic premise is to imagine your business/clinic as a prototype model for thousands more (even if you never plan to build a thousand more). The reason? This will force you to simplify things so aggressively that your business/clinic will start to run well almost regardless of who you plug into those spots. People will need less and less training and expertise to run your ever simpler clinic as you trim waste and make things better. This is a vital concept for military leaders when we don't know who will come and go. 

5. Principles - Ray Dalio

Another modern classic. This will be a book that will go down in history as one of the most dense and actionable books ever written. I can't say enough about it. It's a big book, but it gives so many unbelievable mental models to think about your life and business/clinic. I wanted to dip the whole thing in highlighter. My favorite concept? Imagine yourself as 2 people (because you ARE 2 people -- reptilian brain and neocortex). Most people run life on autopilot (reptilian brain) without stepping back and imagining themselves from the outside. 

If you've ever played a video game, this concept comes easily. You are the person playing the game and you are the character participating. Most don't realize this and just behave like the character, reacting to everything in life, without stepping back and making intentional choices. It's very akin to the concept of working "on" the business and not just "in" the business, as laid out in Michael Gerber's The E-Myth Revisited. 

6. The Life Changing Magic of Tidying Up - Marie Kondo

Nope, not a joke. This book was written to help people organize their homes, but I can tell you, it is much more than that. This book helps you re-think about how you see "stuff" in general. This is an essential read for those wanting to organize anything in their life, and I'm dead serious. This will change your relationship with "things" forever, and by extension, dental supplies. You'll be much more decisive at ridding waste from your life, leaving room for the things that really matter. What could be more critical when trying to organize a dental clinic? Trust me on this one.

7. The Checklist Manifesto - Atul Gawande

Ugh, not another checklist. Ok, look. I hate being told what to do with those silly things, too. But dammit, they work. I love it when a patient can get a consistent experience and ultimately, checklists are the best way to focus new hires, establish consistent protocols, and enforce processes. Checklists save brain power, they put everyone on the same page, and they eliminate confusion. This book will make you smile every time you see a well designed checklist, and it will make you much better at making them yourself to systematize your clinic. I love sneaking checklists onto all sorts of things without people even realizing what it is. More on that in part 2/3.

8. Essentialism - Greg McKeown

This book is all kinds of awesome from every angle. The big takeaway here is to help your mind focus on what's really important. Too many of us treat our entire to-do list as an emergency and we end up freezing or just getting the wrong stuff done. It will help you think more about first-order problems instead of fixing the surface-level issue (you know, like the problems you "solve", only to watch them pop up again in a month?).

9. Switch - Chip and Dan Health

I love this book so much. It was one of the first books I read on the subject, and I've gone over it several times since then. It will help you think more deliberately about how changing the environment itself can help drive the behavior you want. It's not just about changing the people, which often doesn't work, but changing the way they work to eliminate ways they could get off course. This book has been pivotal in my work over the last few years. Another book I wish was a mandatory read for Air Force officers. Shape the path!

10. Ego is the Enemy - Ryan Holiday

You're not that special. Seriously. Once you can separate your ego from what you're trying to do or create, the sky is the limit. The harder you hold onto what people think of you, the lower opinion they will hold of you. Strip your ego away, be definitive, make the hard decisions, and own the results. Apologize when you screw up, be transparent, and don't skirt responsibility. Those with inflated egos are typically the kinds of people that don't build systems, because they don't trust other people to run them or they are too insecure about what other people will think if it fails. Get over yourself ;)


Bonus! The Power of Consistency - Weldon Long

This was the book that convinced me I had to read more books. It's the best. I'll leave it at that.

I have a lot more books, so if you want more recommendations, don't hesitate to email me (see the right side of my blog for my email address).

8 Year Recap Post, FAQ, and My Future

This is an ambitious post. My goal is to make this post a very concise summary of my experiences over the last 8 years and answer some of the most common questions I receive via email, as well as an update on my future plans.

Before dental school

Recruiters
If you have even the slightest inclination that you might want to pursue the Air Force HPSP (Health Professions Scholarship Program) for dental school, contact a recruiter. There is a link on the right side of my blog, or you can find it HERE and select "Healthcare Student or Professional".

Unfortunately, the recruiting system gets a bad rap for being unresponsive and often unhelpful, so if you're having trouble getting in contact with a recruiter in your area, start looking outside your area and contact one of those instead. They can probably help you get in touch with your actual recruiter who isn't returning your calls and emails.

Application process
Everything flows through the recruiter. You need to be in decent shape, have excellent grades and DAT, and nail your interview.

For the interview, focus on all the generic questions (strengths, weaknesses, etc), but be prepared for additional questions like: Why do you want to be in the Air Force? Why do you think you would make a good Air Force officer? What leadership experience do you have?

You're an officer candidate, not just a potential Air Force dentist.

Choosing a school
Go to the school in the area with the cheapest cost of living! Your stipend does not change based on where you live, and you'll devour the stipend if you're living in Los Angeles vs living in Oklahoma. I spoke about this on the Choose FI podcast, episode 99R at minute 57:40.

During dental school

Money!
You get paid about $2,000/month during school, and the Air Force will pay all your other required bills directly. Some things (scrubs, loupes, books) will be on you to buy, and then you will submit some reimbursement paperwork to the Air Force. You should have some information of some contacts at AFIT that can help you out.

Military obligations
You don't have any! Yay!

After dental school/AEGD-1

COT
The timing of COT depends on your school summer schedule and when you commission, but most dentists go after dental school. You may find the COT Survival Guide helpful, but keep in mind that it was written in 2014. Also, check out the newest Air Force PT Test Score Charts to get an idea of where you'll land and start training for this test during dental school! Here's a good pushup and situp video to help you out, but remember, the official Air Force guidance on fitness is found here at A5.3 and A5.4.

AEGD-1
Unfortunately, my AEGD-1 experience was not all that great, but most students love their experience. Having said that, despite my misgivings about the training I received, the year itself was very formative for me personally and the experience was one that I count as one of the most pivotal in my life. I certainly must recommend the AEGD-1 for the sheer fact that it's going to be difficult to operate as an Air Force dentist without this advanced training, since the Air Force has their own system to "allow" you to do certain procedures (called "credentialing"). Even if you did a procedure in dental school, a residency may be required to do it in the Air Force (restoring implants, for example).

You are required to apply for, and accept, an AEGD-1 now. Not everyone will be accepted by the Air Force, but there's enough spots for most applicants. Plan on going.

As far as what base you get, you'll fill out a preference sheet just before your 4th year of dental school, but they could send you to any of the 12 or so AEGD bases. I don't really have any insight as to why they send people where they do.

Specializing
I get asked this question a lot, and it's a bit of a moving target. Some specialties do allow you to apply right out of dental school, while others want you to have a few years of experience (or an AEGD-1) under your belt first. Your AFIT contacts should have this information.

After residency/Being a dentist in the Air Force

Where will they send me?
Assuming you do an AEGD-1 like most Air Force dentists, you'll get a list of bases (in February-ish of your AEGD year) that need dentists and you'll get to rank them based on where you want to go. Unfortunately, while you do get a say, you're not guaranteed a top choice. I got my 16th choice, but it ended up being the best thing for me and my career.

I got to go to a small and remote base that was in dire need of organization and streamlining, as we were updating and planning for the arrival of a new F-35 squadron in the coming years. Previous officers hadn't systematized the clinic functions, but instead just relied on the people to run the place. When those people left, so did their ideas and processes, and the clinic was constantly starting over on processes when people would leave! I stepped into some roles that most young Captains don't get to experience, and got to hone my organizational and systematizing skills that would ultimately prove very valuable for my life and career.

What's a normal day like?
It depends on what base you go to, but a fresh Captain out of residency will usually be doing dentistry about 80% of the week. The rest of the time is set aside for training, PT time, or lunch. Expect to do a lot of restorative, with some single unit crowns sprinkled in as the mission permits and requires, and exams. If you did an AEGD and have the training, you'll probably be doing some IV sedation and restoring implants as well! Elective procedures (anterior crowns, veneers) will depend a lot on what the mission of your base is, and how well staffed the clinic is to suit your desires. I did almost no esthetic work at my first assignment, but a dentist at my new base is doing lots of anterior crowns and veneers because the mission is much less strenuous here.

What's the best part about being an Air Force dentist?
This depends on how you look at it. The normal answer is that you get to do dentistry without being pressured to produce a certain level of $, while having a nice slow pace to the day and getting lots of vacation time (as compared to a typical civilian corporate job). I think the "bad" things are actually good, and I detailed them a bit more in this post.

As far as vacation days go, you get 30 days per year that accumulate at a rate of 2.5 per month. It depends on the base's specific rules, but this 30 days usually does count the weekend.

If you leave on a Friday and come back Monday, that's 4 days you have to take off. Monday-Thursday would also be 4 days. Your "leave" days start and end in your local area. The definition of "local area" depends on your base's rules.

What's the worst part about being an Air Force dentist?
Again, this is going to be very personal, but I think the worst part is the slow pace and the lack of incentive to produce. However, there are lots of dentists that love this part of the job and would consider this a benefit, since they can take their time on their dental work and typically don't have to work any harder than they want to. You just need to know what Air Force dentistry is like and weigh your personality against it.

(If you didn't notice, I cheated here by using the same answer -- no pressure to produce -- for best and worst part, which leads me to...)

How is Air Force dentistry difference than civilian/private practice?
*These are my opinions from having worked in 2 civilian practices during my time as an Air Force dentist*

-Quality of work - I believe the Air Force tends to have higher work quality than most civilian providers. We don't have time pressures or too many cost pressures, so we typically get to spend as much time as we need to get things done the right way. Also, most of our dentists are a few years removed from a 1 year AEGD, which lends to even higher quality knowledge and care.

-Patient experience - I'll give the edge to private practice. I think most Air Force bases do not put enough emphasis on customer service, and our outdated charting system results in far too many records errors. However, there's a host of different ways this is managed on the civilian side, but at least on the civilian side, a dissatisfied patient can choose to take their business elsewhere. This is where the Air Force slips behind: our patients don't have options so we aren't incentivized to give them a good experience and we too frequently miss the mark.

-Clinic organizational structure - Unbelievably, I give the edge to private practice here, and it's not even close. One of the most surprising things to me about Air Force dentistry is how disorganized the organizational and accountability structure is at the clinic level. There's usually some holes in accountability and organization at some level that lets a litany of small problems leak through constantly. There's very little focus on creating good systems. Instead, most clinics rely on strong-willed individuals to run large portions of the clinic that end up suffering mightily when they depart for a new base. It seems there's no real training on "systems thinking" that would alleviate so much of the constant stress and little mistakes that occur daily in military dentistry. Everything I've learned about how to lead people, implement systems, and build/design a clinic has come almost exclusively from books I've chosen to read on my own. The military doesn't teach you this.

The biggest problem here is that, contrary to popular belief, there's just no incentive to be organized in the military because our patients are walking through the door and our appointment books are filled no matter what we do. Most are content to do "enough" and never really get to the point of optimizing and organizing things so they actually run as smoothly as possible. Things run satisfactorily, and that's all that matters to most.

For example, both bases I've been at didn't even have a consistent system to ensure the same items were reordered properly each time something ran out! There aren't even consistent locations for some items to be stored, so if they're out, it's impossible to know what was there without consulting someone who had the room memorized. (This is one area I've worked on at both of my bases to eliminate waste and confusion. It's usually just as simple as placing the order number and item name on standard containers and ensuring that 100% of items coming into the clinic have a permanent location, that everyone agrees on 1 method for altering the Logistics person that an item is low, and items don't just get tossed on a shelf or into a room.) If a certain person out for the week, good luck.

Often, an item would run out and there would be no accountability until the clinic was in an "emergency shortage" and had to rush order the item to the clinic. Fortunately, we have all the time in the world to do dentistry so typically these errors just result in rescheduling the patient or doing some less efficient procedure to get the job done. The minimal consequences of being disorganized tend to perpetuate the "good enough" mindset.

*Caveat: Most military clinics are far larger than civilian clinics, and the disorganization is far more obvious the bigger you get. Small civilian clinics can often survive (and typically do) just on the personality of the lead dentist, with little regard for attempting to imagine the business as a prototype model for a franchise (a la "The E-Myth"), but this fails in a military setting because there's always more than 1 dentist. Large civilian clinics that are poorly organized simply can't maintain their business structure and end up closing or restructuring. Large military clinics, on the other hand, stay open no matter what. In my experience, the larger the civilian clinic (if it's been open for a few years), the more organized it is vs a smaller 1-doctor civilian clinic.

-Employees - This is a touchy subject, so I'll tread lightly. I'm calling this one a tie. Here's why.

In the military, we sometimes get people that just flat out don't want to be in the dental field. Some have personalities and skillsets that are more well suited for some non-medical field. These kinds of people probably wouldn't last long in private dentistry (but to be fair, they would have never wanted to work there in the first place!). But, in the civilian world, you have an outrageous 60% (or more) of dentists that will be subject to embezzlement at some point in their career. That sucks! Civilian employees are no more saints than the military employees that don't care about their job but at least the military ones aren't stealing money from you.

Here's a huge positive with the military side: sometimes you get outstanding coworkers that have big dreams and aspirations and they understand that their performance in whatever job they have is an important stepping stone to the life they want. These are true gems and a total win for the military. Many civilians aren't thinking about the next thing, but in the military, some are constantly focused on learning and growing and getting to the next step, and it makes them valuable assets to your clinic.

In the end, people are people, including dentists. If you don't want to worry about hiring and firing, but also can't cultivate the team you want, the military is the way to go. If you're able to have those hard conversations, listen to your employees, facilitate their personal growth, and have studied and practice leadership and management, private practice is the way to go because you can create the office culture you want with the people you hire vs using the people you're given that may not want to be there. It's up to YOU as the dentist (and the officer) to create the culture you want and use the strong ones as your pillars while you build a new culture (military) or team (civilian).


Are you going to stay in the military? Why/why not?

I'm not staying in. I have a lot of personal reasons for this, but here are the top 3:

1. I believe that my experiences and skills can better serve humanity in a civilian setting

The Air Force is great, but it has its limitations. I can't run a clinic how I want to, I can't hire and fire, and I can't do the dentistry I want to do. Promotions happen in a stepwise manner, and your leadership skills don't really have any bearing on how quickly you can get into a command position. It has to do with your rank, which has to do with your time in service. I'm not a huge fan of the "wait and get promoted" style that the military uses to choose their leaders. Even if I could get into a command position, I don't get to choose who works at the clinic, and that can be a big hindrance to the development and progression of a clinical mission.

At the end of the day, I have a strong will and lots of leadership experience that is just going to take me far too long to manifest in the military setting. The limitations of the military also come with a lot of safety nets that suit many dentists very well, but not me. If they would make me commander of a clinic and double my pay, I'd think about it ;)

2. More time freedom

Notice how I did not say "more money". That's not a typo. I don't necessarily want more money, but what I want is more choices.

One "benefit" of the military is getting 30 days paid vacation every year plus a lot of federal holidays. But you know what? I still have to come to work 5 days per week, do a lot of non-dental stuff, and generally spend a lot of time doing dental work at a slow pace that I could accomplish in half the time. Lots of dentists in the military do less dentistry than me (and many do more), but we all still have the same schedule.

I could walk out right now and work 3 days a week and easily make the same amount of money. Or, I could work 5 days/week and make 2x as much as I'm making now. So what's the big deal about all these "days off" in the military? It's a logical fallacy in my opinion.

Which one is better -- making more money or working less? It's personal. It's about having the options.

Right now, my plan is to leave, buy a practice, implement my vision and systems, maximize productivity and systematize an outstanding patient experience using new technology and beautiful office esthetics, serve my community well, and have the freedom to work far less than I do right now.

Time is the currency of life. Don't let someone in the military use the "days off" argument as a way to convince you that you have more time freedom as a military dentist, because it's not true. Your skills have an extremely high value in the civilian world that, when leveraged properly, is far more valuable than what the military can offer you.

It takes more work to be a leader in the civilian sector than the military sector, but it's worth it. Read some leadership books, work on your management and leadership skills, and build a practice that lets you build a life of your choosing and take off half the year if you want to. We can't get our time back.

3. Self-actualization

I've read about 100 books in the last 2 years. I firmly believe that knowledge without action is worthless, so I've put a lot of action behind what I've learned. I've completely changed my diet, my workout routine, my morning routine, my habits, my beliefs about myself, and the way I handle stress (among many other things). I've also come to the realization that the life I envision for myself is not possible in the military.

Despite my emphatic shouts of "you must do the military for dental school", I firmly believe that a 3-4 year commitment, when utilized properly, is plenty of time to wrap your head around what it is you want for your life, your family, and your legacy on this planet.

This is getting a bit philosophical, but I mean it wholeheartedly. I have big plans and visions for my life, and I personally feel I would be doing a disservice to myself and those around me if I stayed in the military at this point. What I want for my life can't be accomplished in a military setting, and I feel it's time to break free and start to build that new life.

I must admit, when I graduated from my AEGD-1 residency, I was lost. I hadn't read more than a couple books that year, I was not confident in my dental or leadership skills, I had failed part of a PT test (and had it wiped from my record on a technicality), and I was generally confused about my future and what I had to offer.

But, over the course of the last 2-3 years, I started following and listening to leaders from all walks of life and came across a common theme: leaders are readers. So I started reading again.

It became an obsession that has continued to this day. I don't recognize the lost, confused, and complacent version of myself from 2014 and 2015. I'm a new person and I have books to thank for it. Those that know me from back then would be shocked at this statement, because I've always been driven, but I had lost my personal identity on what, exactly, I was driving towards.

I can't unread what I've read, or unthink the thoughts these authors have given me. I have a new confidence in my life and in my future, and I'm excited for the next step of my journey.

It is with no bitterness or resentment that I will wave goodbye to the Air Force, but instead, give it a warm farewell for a phase of life that broke me down, reshaped me, and sent me on my way with the confidence to design a life well lived.


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As always, feel free to email me with any questions!

50 Days, and 3 Lessons Learned

*50*

That's (roughly) how many more days I will be here in Alaska.

It's been a wild journey. I still have, at minimum, just over a year left on my military commitment. If I choose to separate in 2019, my wife and I will likely settle somewhere in Colorado. Fortunately, my next base is also in Colorado, so that would be an excellent way to transition.

I also wanted to quickly touch on three things about the military to give prospective dentists a heads up about this world:

1. Flexibility vs stability

One of the tough things about military dentistry is that it doesn't afford you the flexibility that private practice can afford you. However, this is certainly a double edged sword. What it lacks in flexibility, it gives back in supreme stability. A steady and predictable paycheck, a pre-set number of days off per year, working 5 days per week with federal holidays off, 7-4 every day with a 1 hour lunch. You can pretty much plan out your whole life, but you can't magically have more time off or more money (and that's just fine for many). Many people see control of these two things, time and money, as the pinnacle of self-actualization, and you're just not going to have that in the military. Some people even enjoy the unpredictability of where they'll live next, something that is nearly impossible to emulate as a dentist in the private sector. Don't get me wrong, the time off is better than most jobs and the pay is certainly good, but it's an incremental and perpetual carrot at the end of a pre-cut stick. On the flip side, others are willing and able to forfeit the stability of the military for a chance at more flexibility and freedom with their time, life, and finances.

2. Inefficiency

The military is quite inefficient, and we don't do nearly as much dentistry as our civilian counterparts. I would argue that, by in large, it is of equal or greater quality, but there's virtually no incentive to learn new techniques and procedures or even do more dentistry per hour or per appointment. This can lull many people (in all military jobs) into a pattern of trying to work less and less for the same financial benefits. In the military, more productive work does not equal more freedom or more money; it's the dark side of having that job stability and it can be very demotivating to a person over a long period of time. There are other factors as well that make military dentistry inefficient: limited physical building space, limited support staff, lack of standardization, administrative burdens placed on the dentist rather than support staff, etc. I strive for efficiency, but that's under the pretense that I may not stay in the military long term and getting a higher volume of experiences is necessary, and fulfilling, for me. For those civilian dentists out there, it would surprise you to see how little dentistry we actually accomplish with vast number of days we are in the clinic. It's not unusual for a young military dentist to "produce" 1/4-1/2 of what a civilian would on about 200 working days/year. It's possible to push yourself to do much more than that, but be prepared to be met with resistance from those around you that don't see the value in the push to be faster, better, and more efficient.

3. Long term thinking

Ironically, there is very little long term thinking in the military, at least on a local level. While I would certainly argue that this is also a problem on the civilian side, it's surprising that a military force would lack this focus and direction. This one thing alone could help so much to alleviate the problems associated with point #2 above, since people tend to be more efficient and productive when presented with clear and meaningful goals. Because of this constant pull to see the military as a job, rather than a higher calling and working towards a tangible and meaningful goal, people tend to get in a rut very easily and quickly and decide not to improve or change the systems that operate within the military. The other reason that people get into a rut is that individuals are constantly moving in and out of different places and it's hard to even establish those long-term local goals. This means that people get burned out quickly if they try, since the team is always changing around them. So people usually move in and out of places with the idea they they will just do their job, collect their paycheck, and go home. People certainly do their jobs, but people rarely do more than that because there's 1. no long term goal/thinking and 2. no real incentive to step outside of their day-to-day tasks. This can be a drain on the team and its members. People promote to higher ranks in a relatively step-wise manner, so staying the course will still set you on a nice career trajectory.

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These are not necessarily universal negative things, but three important things to think about and they all come with their counter-points. I think they are all natural outcomes of a "salary without bonus" payment structure and a "move every 3-4 year" system. Honestly, I don't have any good solutions for the downsides, so you'll have to decide for yourself if you want to live inside these structures for a long term career. There are certainly exceptions to the rule, but the fact that we can call people that deviate from point #2 and #3 above "exceptions" help prove that, by in large, the rules exist.

I hope these musing give you some insight into military dentistry and whether its right for you. I had a vague idea that these were tradeoffs of the military system, but I now believe they are so powerful that few can truly muster the strength to rise above them regularly without ultimately deciding their vision for the life is better articulated outside this structure. If you try to beat down the walls of these structures long enough you'll ultimately give up (and work your way up the ranks for your career) or get out. More power to those that can endure, or ignore, it for a whole career. And even more power to those that see this calling as the purpose for the life and truly do make a difference.

Like I've said before, I would absolutely do this again, but I'm leaning a little more toward the "flexibility" end of the spectrum now and starting to see the unbreakable ceiling above my head in terms of what I want my life to look like in the long run.

As always, email me with any questions you may have!

3 Benefits of Being a Military Dentist You've Never Heard Before (Companion Post to Dentistry Uncensored Interview)

[A couple of days ago, I was fortunate enough to record an episode of Dentistry Uncensored with Howard Farran (#888), a popular podcast where Howard interviews all sorts of interesting people from the wide world of dentistry (and beyond!). My interview should be up in about two months. Be sure to check it out!]

Coming into my decision to pursue dentistry with the Air Force, I had heard all the typical lines about why I should (or shouldn't) do the HPSP to pay for dental school.  I made the decision to join the Air Force prior to even starting dental school, so basically I had to hope that the benefits outweighed the risks like I imagined.

This post explores three themes from the book Uncomplicate Business, by Howard Farran. He mentions people, time, and money as three pivotal factors in controlling your destiny as a dentist.  Don't miss how much you can learn about these 3 things while serving in the military! They are often forgotten points of learning by new and seasoned Air Force dentists alike.

These three benefits of being a military dentist are:


1. Not Enough People

If you have any desire to leave the Air Force after your commitment is over, this one point is huge.  I've heard Air Force dentists complain extensively about the difficulty in managing and dealing with co-workers, many of whom either did not want to be in dentistry at all or did not want to be stationed where they are stationed.  They blow this off as one of the downsides of being in the military.  WRONG!  This is, in my mind, one of the overwhelming benefits!

When in your career would you be able to work to motivate and collaborate with a group of people from all areas of life, from all over the country, who may or may not even want to be doing what they're doing?  Working through this problem, rather than blowing it off, allows you to hone your leadership and people management skills in ways that your civilian dentist counterparts will likely never experience.

The other factor is that you cannot simply re-hire to fill vacancies. Staffing decisions are made at a higher level than your local clinic level, so clinics are frequently understaffed for all the needed positions.  The biggest area I see this is in how many dental assistants there are.  In a typical private practice, you usually have more dental assistants than dentists.  In the Air Force, it's typically a 1 to 1 ratio, meaning there are several 10-15 min breaks during the day where the assistant is breaking down a room or setting up a room and you're in your office working on notes or other things.  Realizing you have the capacity to work 2 or 3 times as much as you are can be discouraging, but just use that opportunity to get treatment done quickly so you can have free time to do other things.


2. Not Enough Time

I ended the previous section talking about how much free time you have in a given day, so you're right to be skeptical for a moment.  The problem (or as I'll argue, the benefit) is that on a larger scale, your time is not under your control.

You should always be striving to do more, and time is our most valuable currency.  In the military, or any government job, the concept of working overtime isn't really feasible from a dentist's perspective.  Being in a non-commander role, it's not really up to me to rally the herd and stay open an extra hour each week, or shut down on a Friday and fly everyone to Anchorage for a teamwork seminar.

Time is always against you, but in the military, this is especially pronounced.  Like I said in the previous paragraph, your time flexibility on a scale from 0 to 10 is somewhere closer to that 0.  Having to squeeze 10 unexpected patients into an afternoon that was set aside for military training so that the base can send those people to Guam by next week, are the kinds of time constraint issues you run into.  You exist to keep the Air Force running smoothly.  Your time is the military's time.  And if you can figure out ways to creatively control your schedule to continue improving your skills in this environment, you'll see huge benefits when you step out and finally get to control your own time.

Fortunately on a day to day basis, you do have control over the lengths of procedures, just not on the actual work week or overall schedule itself.


3. Not Enough Money

Imagine you're out and about on a Saturday when suddenly the craving for hamburger hits.  You and your spouse drive to a nice place to have lunch and then come home.  Does this seem like a money-intensive process?  Probably not.  Why not?  It costs money to put fuel in your car, it costs money for the wear and tear on the car, you need to have purchased car insurance and have a license to drive the car, not to mention the cost of the meal when you arrive. Did you consider all that?

Ok, now imagine you're 16 years old again and you want to have lunch with some friends.  You don't own a car and you don't have gas money because you rely on your parents for an allowance and you spent it all on a video game last week.  So your friend (who is 17 and has a job) decides to help you out.  They come pick you up and buy your meal for you.  It's a little annoying but they don't mind.

Being in the military is like being 16 years old again.  You have almost no control over the amount of your "allowance" that comes in each month and you foot the bill for your own dental license and often for your own CE courses.  You hope the "allowance" comes into the clinic on time so you can buy what you need and if it doesn't, you're going to have to choose between gas and food.

This sounds a little extreme, but it does happen.  The government has situations where they can't promise money to a medical clinic or dental clinic, and so your clinic may be forced to operate on a drastically reduced budget.  So what's the benefit in that?

Learning how to operate a clinic for 5 months on a budget roughly 35% of its normal size when you're in charge of ordering supplies for the clinic, forces you into all kinds of new and uncharted territories.  Finding out which items are crucial to not only keep the clinic open, but to maximize the potential to meet the specific mission of your base, is no easy task.  Saying "no" when people ask if you can buy this or that, or completely reorganizing every treatment room to streamline your supplies so that absolutely nothing goes to waste, are two delicate but vital strategies.  Some day you'll leave the Air Force and be a grown up dentist, not reliant on the Air Force's "allowance" anymore.  But those important financial pivot points will already be part of your natural decision making process.  Lucky you!

Not having money obviously means not having what you want.  But often times the standardization of the clinic will trump your preferences.  The benefit here is flexibility.  You'll need to learn to work with other doctors (and even your assistants) to come up with supplies you can all agree on.  It may not be your favorite bonding agent, for example, but it's cheaper and more efficient and the expiration dates are 2 years out, so it fits well within your clinic's goals.

These are the type of weird supply decisions that have to be made when there are people moving in and out of your clinic every few months.  We are fortunate enough to have such a tight-nit group of doctors at Eielson that agreeing on standardized supplies is rarely a problem.  Again, knowing the clinic's main mission helps clarify and point us in the right direction.

Here are questions we have had to ask ourselves at Eielson when considering changes in supplies:

Should we focus on getting every doctor exactly what they want, or take into consideration that assistants will get confused if every treatment room is set up differently?

Do we buy burs for $0.98/each and put the sterilization burden on someone to package all of these burs for us, or do we order burs that come sterilized from the factory for $1.01/each?

If diamond burs are not consistently cleaned properly, or sometimes get dull without the next doctor knowing, is it worth it to re-process these or should we move to single-use diamonds?

The list goes on and on.  The supply game is a hard one to play, especially in light of the money game!  But learning how to make compromises and think of the clinic mission every time you make a supply decision will lead to huge benefits in how you eventually think about your own practice some day.



I hope this post was helpful.  My goal here was to pick out 3 topics (people, time, and money) that are most often cited as downsides to military dentistry and show you how, when looked at from a different angle, are actually 3 of the biggest benefits. As always, email me (see right side of blog) if you ever have any questions!

HPSP Laptop Rental

My blog tends to be about me.  Stories about what I'm doing or what I'm going through.  I tie that in together with details about the Air Force (as much as I am allowed to divulge) and particularly the HPSP scholarship.

However, as a "regular" practicing Air Force dentist now, I don't have much more to say along the way other than updates about how things are going in clinic and information that can help you along your HPSP path, whether that means talking you into or out of the scholarship (which I've done many times both directions!) or giving you tips along the way.  My 5 year track record of being one of the only active HPSP student bloggers online and the many hundreds of emails I've received since this all began, gives me some unique insight into what HPSP students are doing and thinking about.  So what's my point?

One unknown aspect about the HPSP scholarship is this weird option in there to rent a laptop and have the military totally cover the rental.  These days, people aren't usually thinking about renting a laptop (vs buying) and the logistics of renting electronics is less and less appealing.  On the other hand, it would be nice to take advantage of this free offer from the military and be able to rent a high quality laptop for the few years you're in school.  This would prevent wear and tear on your own machine and your dollar would go further to buy your own laptop for yourself once school is over.

I think I've only heard of a few people actually utilizing the laptop rental reimbursement but that may change very soon.  A company called Laptops for Military Docs is getting straight to the point.  This company will give you step by step instructions on how to rent a high quality laptop from them hastle-fee.

Now I must admit, this company is very new and I have no personal or financial stake in this whatsoever.  Obviously with them being so new, I did not personally rent a laptop through them (or anyone, actually).  But every once in a while something comes along that I feel compelled to let my readers know about.  This is one of those times!  This company is clearly set up for specifically this reason and I have to believe that by focusing solely on HPSP students, they will be able to help you, too.

Technology is changing rapidly so consider a rental reimbursement during dental school to save yourself some money!  It's an option that's free to you as long as you're willing to do the legwork and Laptops for Military Docs is there to make it easy.

I'd love for some of you all to give this service a try and let me know how the process was for you!

Overseas

We got Alaska.

So it's been a while since my last post and I wanted to let the dust settle, per se, before I posted again.  My residency is over and we have been at Eielson AFB for almost 2 months now.  I started seeing patients a few weeks ago.  Eielson is considered overseas for somethings and not others, so it's a weird mix of both!  My assignment is only 3 years like an OCONUS assignment, not 4, but I'm not actually overseas in a foreign country (for example).

First off, I'll talk about the AEGD now that I have some perspective.

Not a lot more I have to say that I haven't already, to be honest.  I will say that the personnel at your location can make or break the experience in a given specialty and you really have no way to know what each base is going to offer.  People are moving all the time!  Having said that, I don't see how you could survive as a brand new Air Force dentist without doing a residency.  There so much "Air Force" stuff to learn that it would be really hard to learn on the job if you came straight out of dental school. With that being said, if you absolutely do not want to do a residency then think twice about the HPSP at all!  You are now required to not only apply for, but also accept, a spot in an AEGD residency.  That's right, no longer optional!

My AEGD was good, and the location was incredible.  The Academy was a beautiful place to be!  However, there were aspects of the residency that were less than ideal while other aspects were very well executed.  It certainly wasn't a traditional educational environment like dental school but more of a "learn by doing" situation but the faculty all see their own patients most of the time.  It had a tendency to feel somewhat disorganized at times with lectures being fit in where they could be and not a real over arching theme or long terms goals, except when outlined by each specialist as they saw fit.  Syllabuses for different specialties either didn't exist or were usually incomplete, and there was a tendency for contradiction in lectures or between faculty that made things frustrating at times as someone trying to learn.  It's something you have to embrace as part of the unavoidable nature of the constant movement of parts and pieces in a very large Air Force system.  As someone who really likes to make their own way and be as proactive as possible, I encountered a surprising amount of opposition to that style and found it more beneficial to "go with the flow" most of the time.

On a positive note, I got to do quite a few IV sedations and 3rd molar surgeries as well as perio surgeries.  I got to do far more root canals than I did in dental school, and I got fairly proficient in whats known as a "cuspal coverage amalgam", something you have to see to believe!  I felt like I was adequately exposed to all the specialties enough to help me decide if they were something worth exploring further as a specialty. The general feel of the residency all seemed geared towards serving the Air Force population, and many of the skills I learned will serve me very well at my new base, even though I won't use many of them if I choose to leave the Air Force some day.


Second, Alaska!

Being on my own is really nice.  It was weird at first, and still very much is, but you'll be amazed how much faster you can work when you're doing 1 or 2 fillings and there's an hour set aside to do it without faculty looking over your shoulder.  You just sit down and crank it out.  For me, it hasn't been all that difficult of a transition for me.  I've always worked pretty fast so this doesn't seem that bad!  I do feel a little rushed sometimes but considering this is my first experience out of an educational setting, I'm really pleased with it so far.  This is a small clinic and was designed for a couple more dentists, so we have a lot of room.  Having an office is nice too!  I'm not sure what to put in it quite yet other than trail mix and extra paper.  Very official.

Eielson AFB is not a very desirable location but to be honest, I really like it here so far.  The people are very nice and for being a smaller city, they have a lot!  Amazon still delivers here so I think we'll survive after all.  We had to get our cars "winterized" but so far, we've only had 2 snow storms!  It was actually quite nice out today and my wife and I went on a walk with our dog.



That's all for now!  I'd love for some comments or emails with some ideas about what I should start posting about now!  This is kind of the end of the road in terms of my journey from the end of dental school when I started this blog.  I'm here, I'm done with dental school, done with my residency, and now a full blown real life Air Force dentist!

So let me know what YOU want to hear about and I will gladly, within the limitations of what I'm allowed to talk about, let you know!