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.

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.


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

Dental Tips from a Newbie

I've been at this dentist thing for a few years now, but I'm constantly running across different tips and tricks that make my life easier as a dentist.  I wanted to share them with you guys, because sometimes in the military, we have to be creative with the supplies we have at hand!

Hemorrhage control in restorative dentistry:

This is tough sometimes.  You've got a patient that has less than ideal hygiene and when you drop the box for your prep below the gingival margin, inevitably you get some bleeding right into where you're working.  Here are some tips to help you out.

1. Viscostat Clear on a cotton ball - Viscostat Clear is an excellent product that is comprised of 25% Aluminum Chloride to help control minor hemorrhage.  Emphasis on "minor".  It will not stop the gushers from gushing but it will keep minor hemorrhage at bay.  However... if you saturate a small cotton ball with it and use pressure against the hemorrhaging area for about 3 minutes, you will be able to push the tissue back and control bleeding at the same time.  Excellent for working that tissue distal to mandibular 2nd molars on crown preps or deep restorations.  This saved my bacon on a CAD/CAM crown 2 days ago!  You could use another hemostatic agent, but Viscostat Clear is what we use at Eielson.

2. Injecting surrounding gingiva with anesthetic - This was a trick I learned in my AEGD residency and it's saved me more than once.  Here's how it works.  Anesthetic has epinephrine in it to constrict the blood vessels so that the anesthesia stays in the areas we want it to stay.  But this effect of epinephrine can also be utilized to control localized hemorrhaging. Let's say you are prepping a crown on #14 and the mesial marginal area is sub gingival and none of your hemorrhage control methods have worked.  Take some anesthetic and insert the needle directly into the facial side of the papilla between #13 and #14 and inject 1/4 to 1/2 of the carpule with a fair amount of pressure.  This forces epinephrine into the tissue and can keep hemorrhage at bay long enough for you to refine the prep and get a good impression.  The best is to use a high concentration of epinephrine (1:50,000) but traditional anesthetic works well, too (1:100,000).

Note: Do NOT inject straight into the area that is hemorrhaging.  The fact that you're stabbing pissed off gingival tissue will sometimes make it worse.


Prepping crowns:

This is a very stressful procedure for dental students and new dentists.  You're taking away a lot of tooth in hopes that you can reduce a tooth enough for clearance of your material but not so much that compromise resistance and retention.  Here are some tips to help you out!

1. Pick a more aggressive bur - If you pick a moderately coarse or medium grit bur, you're going to notice quickly that you sometimes want to push the bur faster than it will cut.  I've found that using a very aggressive bur allows me to push at a constant rate and get into a "flow", if you will, of prepping instead of constantly feathering off the prep to let the bur speed up again.  If you have an electric handpiece, you may notice that this isn't as relevant, as you can maintain pressure and not worry about stalling out the bur.  However, I like to move quickly but smoothly. I never prep out of control.

2. Prep a wider margin - Another tip from my AEGD.  I don't think I've ever had a case that I said "crap, my margin is about 0.2mm too wide on this one".  A wider margin helps you out in several ways: 1) Easier for you to tell that you actually have adequate margin everywhere 2) easier for lab to discern between gingiva and margin and give you a good product 3) a wider margin gives you some "play" room in case the impression is less than perfect or there's some sort of issue in building the crown all the way out to the margin.  If for some reason you'd need to enameloplasty the margin back after crown cementation, a wide margin gives you room to do this.  Crowns don't fail from having adequate axial thickness. :)

3. Reduce occlusion a little more - In my opinion, you're better off reducing that extra 0.3mm than fighting for the wall height if you can avoid it.  Not to mention, the area we tend to under-reduce is right in the middle of the prep which has no bearing on how tall the surrounding axial walls are.  Get a #330 bur and carve depth grooves into the occlusal table and go down to them.  Then smooth everything up!  Now, this is not a blanket statement condoning negligent over-reduction, but if you're on the fence and are unsure, reduce a little more. This is especially true when prepping for CAD/CAM crowns that will be bonded into place.

4. Change burs only three times/don't prep the same area twice - This is how I prep, and it results in very fast and efficient crown preps without me having to waste my bur trimming tooth structure from two angles.  Here's what I mean.

If you do your occlusal reduction first, you are inevitably reducing the occlusion on areas that will eventually be prepped away when you go to do your axial reduction (example: you reduce the entire occlusion and then end up prepping off the circumferential areas for the axial prep that you just reduced the occlusion on!).  Don't do that!  The axial reduction is virtually independent of occlusal clearance so do your axial reduction first.  I always start "in the open", as I like to call it, on a nice wide area of the tooth that's easy to see. I prep the margin down to the most acceptably apical position depending on the material I'm using.

Let's take a #19 e.max for example (assuming it's ready to prep and doesn't need a core, etc.).  I would start with my aggressive flat ended tapered bur mid-facial ("in the open"... a nice wide area of the tooth) and work my way towards the mesial until I broke through all the way to the ML line angle, keeping the bur as deep into the tooth as necessary to make a complete axial reduction with 1 pass.  Notice how I never switched burs to pass through the inter proximal area?  This touches on two principals: 1) I'm going to prep the interproximal area away anyway so I don't step up with skinny burs, I just push through it with my regular bur 2) prep a wider margin.  So, I work through to the ML angle and then I come back to my starting point mid-facial.  Then I work the same pattern, this time towards the distal until I break through and get to the DL line angle. Then I connect the DL and ML line angles across the lingual.  Margin and axial reduction are done.

Occlusal reduction is next.  Switch burs (first change) to the #330, or a bur of your choice with reference points, and cut the depth groves I mentioned in tip #3.  Now switch back to the first bur again (second change) and level it all out to the depth of the grooves.  Now switch to a fine version of your first bur (third change) and smooth everything.  Done!

The problem with doing the occlusal reduction first is this: You are using false reference points on the outer edges of the occlusal table.  If you reduce the occlusion, you don't yet know exactly which areas you're going to end up prepping off when you do your axial reduction.  So do your axial reduction first so you have your smaller "true" occlusal table, and then reduce it.


Oral surgery:

Caveat: I am not an oral surgeon but I do routinely perform IV sedations and extract impacted wisdom teeth.  I don't do the crazy ones, but I've seen enough to help me become more proficient at taking out all kinds of teeth.

1. Remove more bone - Don't be scared to take some bone away!  Now, this is not a general rule, but it's true most of the time.  On anterior cases, patience is going to serve the patient better than reflecting a flap and buzzing away 4 mm of bone to get that root tip out.  But... for posterior teeth, you should recognize that if the tooth isn't moving now, it's not going to be moving much later.  Do yourself and the patient a favor and remove some more bone on the facial aspect of the tooth and try again.

2. Section the tooth - This can seem scary for a new doc, but sometimes it's what we have to do.  I was recently extracting a severely carious #30 and the tooth kept breaking into pieces while I was trying to get leverage from the mesial.  I had great visualization, so I took the handpiece and sectioned the tooth from F to L across the furcation, broke the tooth in half, and plucked both roots out in less than 20 seconds.

3. Use an endo file - Huh?  Ok, so I've seen this trick before and finally had a chance to try it a few months ago.  A patient had facial trauma and had fractured #7.  The problem is that there was a horizontal root fracture so the root tip was lying a good 3mm apical to the crestal bone.  I got a set of endo files and took the largest file that would engage the root tip at least 1 full clockwise rotation. I wrapped floss around the handle of the endo file and twisted the file to engage the canal of the root tip.  I pulled gently on the floss until, about 3 minutes later, the root tip popped right out. (Notice the clean and unused blade?)

Extracting #7 with an endo file

So that's it for today.  I'll try to catalog some more tips and do some more of these posts from time to time.  Are there any other topics you guys would like my to discuss or give input on?  Just another dentist trying to learn!