MARKETING THE ORAL AND MAXILLOFACIAL SURGERY PRACTICE

About 8 years ago, the author had the honor to author a chapter on marketing the oral and maxillofacial surgery (OMS) practice in Dr. Fonseca’s text series. He considers it a further honor to once again be asked to update this marketing chapter. Believe it or not, a lot has changed since the original writing of this chapter. Huge paradigm shifts have occurred in our profession.

  • At the time of the original writing, most oral and maxillofacial surgeons were slaves to referring dentists; now many referrals are a virtue of participating (or lack thereof) in insurance plans, HMOs, PPOs, etc.

  • Eight years ago, most oral and maxillofacial surgeons were involved in the considerable practice of orthognathic and temporomandibular joint (TMJ) surgery, and now (for various reasons) many of us shun these procedures.

  • Eight years ago, most oral and maxillofacial surgeons took on-call duties at local hospitals, and now (unfortunately) many oral and maxillofacial surgeons have abandoned this responsibility and privilege.

  • Eight years ago, dental implants were popular, but now they represent a virtual “new age” in our profession.

  • Eight years ago, this author practiced full-scope OMS, and now his practice is limited to cosmetic facial surgery.

  • Eight years ago, having a website was a cute means of having some identity. Today it is not only the main way that society communicates and seeks information, it is essential for marketing, patient education, and registration and is expected by the public.

  • Eight years ago, the Yellow Pages were the mainstay of marketing; today the Internet has displaced telephone book advertising. We have gone from “let your FINGERS do the walking” to “let your FINGER do the walking.”

  • Eight years ago, mailing panoramic radiographs to and from referring sources was the standard; today digital imaging and electronic transfer of images is replacing hard copy transfer.

  • Eight years ago, cellular telephones were an upper class luxury; today one must post “turn off your cell phone” signs in the office so as not to be continually interrupted.

  • Eight years ago, this chapter discussed mailing newsletters to referring sources, and today an e-mail blast is a more popular option.

Considering all of these changes, there is a new spin on some parts of marketing our wonderful profession. This chapter will have a lot of repeat from the previous chapter because some of this material is timeless. Other information has been updated, changed, or refuted to reflect the contemporary changes of oral and maxillofacial surgeons.

To devote a chapter to marketing in such a comprehensive oral and maxillofacial textbook is indicative of progress. This progression has been made on many fronts. First and foremost is the progress made within our profession.

Whether in the military or in sports, the first rule of competitive strategy is to know your adversary. In the consideration of marketing the OMS practice, we too must realize the adversarial barriers.

OMS occupies a realm in the public perception interposed somewhere between that of dentistry and medicine. This fact has shrouded our identity and services with an air of ambiguity from the onset of the recognition of OMS as a specialty. This ambiguity of services rendered and the public’s lack of awareness of our training and education presents a further marketing barrier. Finally the voracious and aggressive increase of our scope of practice and procedures has increased exponentially, leaving the consumer confused about what exactly we do or used to do.

The aforementioned situations cumulatively have held us back in the marketing and public awareness arena. Ask the man on the street what a plastic surgeon does and he will likely give you an accurate description. That same question posed to the same person about OMS will more than likely not be representative of the scope of services we perform. This public appreciation of scope has, in the author’s opinion, not increased proportionately, even though our national organization has made great strides to publicly convey our training.

Entering this discussion with these principles in mind facilitates and obviates the barriers we face and the direction we, as a specialty, must pursue.

WHAT IS IN A NAME?

The majority of dentists graduating today receive a DDS degree, which implies surgical expertise to the public. The more descriptive DMD degree is of progressive thinking and public understanding. The specialty of OMS was in line for a name change for a long time. As a result of the politics of teaching institutions, many reputable OMS residency-training programs were forced to pursue nondentoalveolar procedures in a surreptitious manner. As a result of our excellent training in general anesthesia, many programs were able to perform some of the advanced procedures within their own clinic because of fear that other competing surgical specialties may protest. This proved, and in some programs still proves, to be a double-edge sword. On one hand, we were being trained in trauma, cosmetics, etc., but on the other hand, this secretive approach breeds the mind-set that propagates anonymity. For years we would not mention the word cosmetic because of fear of noncoverage by third-party carriers or criticism from other surgical specialties.

Some very progressive leaders in our national organization foresaw the need to change these preconceived limitations and levied for a name change within our specialty. Unbelievably, they met with resistance; however, history led us into the new profession of OMS.

The good news of the name change was that it was certainly more descriptive of our scope and gave us pride in pursuing procedures and techniques that were sometimes done in the after-hours clinic. The bad news is that the term maxillofacial is not understood by the general public and, in the author’s opinion, has further masked what exactly it is that we do. The author predicts a name change by our specialty to “oral and facial surgery” within the next decade.

On top of this, our public perception is further hampered by the fact that much of what we do is painful, inconvenient, expensive, and without a tangible physical appreciation for the patient. Third molar surgery would be a perfect example of this concept.

ACADEMIC MARKETING

Marketing is a popular major for many college students, and in the first-year courses, they learn the basics of the profession. Because much confusion seems to exist among health care providers on what exactly is the difference between marketing, selling, and advertising, it is appropriate to review the textbook definitions in Marketing 101.

Selling is concerned with the plans and tactics of trying to get the customer to exchange what they have (money) for what you have (goods and services).

Marketing is primarily concerned with the much more sophisticated strategy of trying to have what the customer or patients want.

By these definitions, one can clearly see that selling focuses on the need of the seller, whereas marketing focuses on the need of the buyer. Selling is concerned with the seller’s need to convert their product or service to cash, whereas marketing is satisfying the needs of the customer.

A marketing-oriented office provides value-satisfying service that patients want. It also provides not only the generic product (in our case, surgery), but also important is how the service is made available. Extended hours, payment plans, patient insurance assistance, modern facility, state of the art procedures, and painless treatment are just a few of the ways this service is made better.

ACADEMIC MARKETING

Marketing is a popular major for many college students, and in the first-year courses, they learn the basics of the profession. Because much confusion seems to exist among health care providers on what exactly is the difference between marketing, selling, and advertising, it is appropriate to review the textbook definitions in Marketing 101.

Selling is concerned with the plans and tactics of trying to get the customer to exchange what they have (money) for what you have (goods and services).

Marketing is primarily concerned with the much more sophisticated strategy of trying to have what the customer or patients want.

By these definitions, one can clearly see that selling focuses on the need of the seller, whereas marketing focuses on the need of the buyer. Selling is concerned with the seller’s need to convert their product or service to cash, whereas marketing is satisfying the needs of the customer.

A marketing-oriented office provides value-satisfying service that patients want. It also provides not only the generic product (in our case, surgery), but also important is how the service is made available. Extended hours, payment plans, patient insurance assistance, modern facility, state of the art procedures, and painless treatment are just a few of the ways this service is made better.

LEARNING FROM BIG BUSINESS

In the nineteenth century, the United States became a production-oriented economy and, over the past century, has shifted to a consumption economy. The energy and thoughts of the business community were once devoted to developing and improving ways of manufacturing. We now take our ability to manufacture for granted; the emphasis has shifted to a marketing orientation, and the energy and thought start with the customer (or in our case, the patient).

After the end of World War II, the General Electric Co. pioneered the marketing concept in industry. The marketing concept is described as “a way of life in which all resources of an organization are mobilized to create, stimulate and satisfy the customer and profit for the owner.” If one truly understands this paragraph, they can begin to understand what marketing is really all about.

Corporations speak of the four Ps of marketing. They are product, price, promotion, and place. Product refers to making sure that the product is the right one and of superior quality. Price refers to establishing a price that makes the product as attractive as possible and still maintains a profit. Promotion is simply communicating with one’s clients or potential clients. Place refers to putting the product where it can be most effectively used.

The correct analysis and mix of the four Ps are important, and marketing experts further maintain that a marketing leader must:

  • 1.

    Determine the nature of changes in the market.

  • 2.

    Identify and cultivate customers for the company’s existing or potential services.

  • 3.

    Meet the needs and wants of customers or potential customers.

  • 4.

    Maintain a profitable position.

All of these factors are applicable to our profession. One merely needs to supplement the word patient for customer or client.

Number two in the above list is very often overlooked. Historically, there have been many changes in the fee-for-service practice in medicine and dentistry. Before insurance coverage, the patient understood their obligation for responsibility for health care costs. With the advent of health insurance plans, the burden of responsibility, at least in the mind of the patient, became the responsibility of the doctor. With the advent of exponentially increasing medical technology, the price of health care soared and became beyond the reach of most self-pay patients. Physician’s and hospital’s fees became obtrusive, and cost-cutting measures were instituted with shifts toward less hospital time and generalized cost containment. Managed care then entered the scene and has caused profound changes in our profession. There is now a shift to having primary care physicians triage patients, and surgeons are looking for ways to provide their services without the time and monetary expense of hospitals.

Physicians who had the ability to see these trend shifts were able to adjust their marketing and business strategies to meet the current need. Those who do not adapt may fail to thrive in this managed market.

Anyone who has read about corporate marketing is familiar with the concept of paradigm shifts. A paradigm is a model, and the paradigm for marketing OMS practices has been the same for years. Be a good physician, PR your referring sources, and one would prosper. We are now in the midst of a paradigm shift. With managed care, larger practices with multiple locations have positioned themselves to be attractive to the managed care plan of large companies. Now many patients are referred to a given surgeon, not because the general dentist wanted to send the patient, but rather because they had to use a participating specialist. Those surgeons who refuse to explore managed care options may be driven out of business because they have not anticipated this paradigm shift.

A commonly used example of the loss of business domination from paradigm shifts is the Swiss watch-making industry. For hundreds of years, the Swiss dominated the making of watches and timepieces throughout the world. The paradigm for success was a mechanical product that was made from complex mechanical manufacturing and assembly of labor-intense intricacy. The Rolex chronometer wristwatch is an example of the fine product produced under this paradigm. The Swiss prospered and literally controlled the world production of wristwatches. In 1968 the Swiss controlled 65% of the world market in timepieces. They reaped 80% of the profit in the timepiece industry and employed 65,000 employees.

Around 1968 a Swiss company invented the liquid crystal watch and set up a booth at the 1968 World Watch Congress in Switzerland and introduced their new technology. This concept was staggering. The watch had no moving parts, did not require movement or winding to function, and delivered accuracy 1000 times that of the finest Swiss timepieces. Although this timepiece technology was astounding, the major Swiss watchmakers were indifferent and did not even patent their own invention. Why? Because it did not fit their paradigm for what a wristwatch should be. Two companies, Seiko and Texas Instruments, did take notice, however, and saw the old paradigm for timepieces go out the door. They realized the potential of this new product and were able to move with this new paradigm. The rest is, of course, history. The Swiss workforce lost 50,000 employees and dropped from 80% of the market share to 10%. Today the Japanese dominate the world timepiece market; they had virtually no market share in 1968.

The point is that what works in marketing today may not be effective in the future, and the ability to predict and adapt is critical. Marketing is dynamic, not static.

Staying abreast of current technology is also important in the paradigm model. The bread and butter of our profession was once the extraction of carious teeth. It was only several decades ago that multiple full-mouth extractions were common on the office schedule of most oral and maxillofacial surgeons. Today because of fluoridation and education, full-mouth extractions have diminished rapidly to the point that some dental schools have trouble finding denture patients. Having four difficult impacted third molars removed simultaneously was not common 40 or 50 years ago. With the advent of high-speed drills, effective ambulatory anesthesia, and antibiotics, this procedure has become the mainstay of most OMS practices. Anytime a single procedure dominates the well-being of any business, its obsolescence could doom the business. The insurance coverage of third molars may fall into disfavor or be otherwise manipulated by insurance companies. We must, as a profession, be aware of this possible paradigm shift for what constitutes OMS.

Fortunately, our leaders have seen these caveats, and many of our ranks are entering the arenas of implant surgery, cosmetic surgery and other nontraditional OMS procedures.

All of the above underline the predictive thought for medical marketing. It is not uncommon to find physicians who are very averse to marketing in the form of advertising. These physicians say that they do not market. This is such a fallacy; we all present an image, and this is marketing. Some physicians are actually doing negative marketing by having poor staff and lack of policy while condemning an office committed to excellence.

MARKETING THE ORAL AND MAXILLOFACIAL SURGERY PRACTICE

The author enjoys a mix of private practice and academic environments. The phrase “Always be a teacher and always be a student” drives many of our ranks to excel in both venues. The author has written and lectured extensively on the subject of marketing the OMS practice, and regardless of the community, state, or country, many physicians are in search of the “secrets of marketing.” The delusion of these individuals confounds the author time and time again. Practitioners want to know “what to do to get referrals.” Sometimes, despite a well-prepared and well-presented course on marketing, participants will confront the author at the end of the lecture and say, “all of that is fine and well, but what is it that you really do to get patients? Do you give holiday presents? Do you do lunches? Do you need fancy imaging, etc.” These physicians have missed the entire point. The correct answer is all of these and none of these.

Marketing is not the act of giving something to receive a patient on a one-to-one basis. Marketing is more of a mind-set and a practice lifestyle. There are many successful practices that spend tens of thousands of dollars on marketing events and gifts, and there are just as many practices that thrive without spending a dime on parties, gifts, etc. The latter practice focuses on two things: superlative patient care and simply knowing how to say thank you.

In addition to the above examples, there are physicians that do all the correct marketing, even employing professional firms, yet have stagnant practices. These practices go through the motions, but have poor leadership principles and staffs that negate their marketing investment.

Successful marketing, as stated earlier, is a grass-roots level of excellence that starts before the patient ever gets a foot in the door. The bane of existence of any specialist in any discipline is the reliance upon others for referrals. It is rare that a patient sees a sign for OMS and drops in, whereas a Family and Cosmetic Dentistry sign may cause people to walk in and begin a relationship. If one follows a thriving practice, they will see a constant trend of patients referred from sources other than general dentists. If an OMS office provides a warm, loving, and caring environment, patients of record and reputation will bring in as many or more patients than do primary referral sources. It is usually at this point that a physician really begins to feel and enjoy independence.

Getting to this point usually takes a number of years, but can be greatly accelerated by attention to basic communication skills and common sense.

The grass-roots level, of which we spoke, must literally permeate every aspect of one’s practice, and it must be stressed that the staff is far more important in the spectrum of marketing than the physician. Most offices that are stressful and unprofitable suffer from poor leadership. Most physicians have no experience at human resource management and have accumulated what knowledge they have from hard knocks. It is shocking but correct to say that most employee problems are the fault of the employer and not the employee. Leadership is essential to make any team of individuals with a common goal cohesive and effective. In the author’s opinion, 98% of the problems that make practitioners dislike their jobs stem from poor hiring and firing practices and the lack of leadership. There can be only one leader in an office and that must be the physician. Leadership cannot be confused with management. One can delegate management and hire managers, but again there can only be one leader, and leadership cannot be delegated.

For the sake of comparison, let us envision two separate practices. One practice is a thriving, progressive, profitable practice that continues to grow. This office always seems to be on the forefront of the profession, and when you walk into this office, you are overcome with the energy of the staff. The environment is modern, clean, bright, and friendly and employs the latest technology. The physician and staff are aesthetically presentable, and smiles and warmth abound. When in the office for awhile, it becomes evident that the office represents the leader. It is if he or she is “working at home.” It is also evident that the physician has a passion for his or her profession, and practice is a joy and a privilege. The staff is cohesive; their careers seem enjoyable, and they work as if it is fun. This office presents an image, and that image is impressed upon the patients that are exposed to this environment. It seems to rub off on the patients, and they leave with an enthusiasm for this staff. They sense the energy and the warm, friendly treatment and are impressed enough to comment to their friends and neighbors. Although they do not look forward to surgery, they do not mind and may even enjoy visiting the office. They enjoy being part of the energy and enjoy the special attention that seems so rare in this fast-moving technological era. The referring physicians and their staffs have the same feelings about this office and are confident that when referring a patient they will be thanked for sending the patient to such a compassionate office. If a patient goes back to a referring dentist and says that the OMS was expensive and the surgery made them sore and the recovery was extended but thanks for sending them to such a warm, caring, and compassionate specialist, megamarketing has been accomplished. This is never a coincidence; it is the finality of great effort and attention and detail. It is a result of the pursuit of excellence, based on the principles of leadership and policy.

Let us now contrast this office with one of mediocrity. This office may be right next door to our previous example, but always seems to be “chasing its tail.” The office does not glow and is unkempt. The staff is stressed and bickering. The physician and the staff do not convey an aesthetic image and seem to have a goal of reaching 5:00 pm . Confusion and happenstance seem to rule, and there is an obvious lack of organization. The general atmosphere seems tense and rushed, and fun seems to be the last thing that anyone is having. The entire experience is reminiscent of old-fashioned dentistry. The staff turnover is high, and the future of health care seems pessimistic to these folks.

Although the above contrasting examples are fictitious, we all can probably relate to a real-life example of each scenario. We must ask ourselves what exactly it is that makes such a difference. Knowing the answer to this question illuminates the principles of successful marketing. These are again leadership and human resource skills.

WHAT IS YOUR VISION?

The very first principle to discuss is vision. There are very few successful people in any walk who achieved success by chance. Virtually everyone who has achieved success and professional contentment is a visionary. A person must have a clear idea of their goals and a plan for approaching them. Without this, chaos will rule. If asked, any oral and maxillofacial surgeon should be able to state their vision or guiding principles and their end point. This should also be second nature to the staff; after all if you as a leader do not have a vision, then how can you expect your staff to have clarity on where you are going as an office? This vision must be communicated with the staff and constantly reinforced. If this is not done, a cohesive team cannot be built. It sounds trivial, but it is the single most important factor in beginning a journey to excellence. It is said that excellence is a journey, not a destination. In other words, there is no finish line; improvement and superlative patient care and the love of what you do are the dividends. If while reading this text you cannot immediately stop and write down your particular vision, then you should stop reading (and start writing your vision) because it is the first rung of the ladder to excellence. By the same token, if you and your staff are not in the pursuit of excellence, then you should send your patients elsewhere so that they may receive the best care available. Obviously, this sounds drastic, but underlines the point.

A vision must be practical, ethical, and attainable; have a time frame; and be modifiable to bend with the curves of life. The vision of the author has been to: (1) build a large group practice that is enjoyable to both owners and staff and to serve patients with a warm, loving, and compassionate environment; (2) pursue technical excellence and to stay abreast of the forefront of our specialty; (3) become financially independent and serve those less fortunate with the ability to obtain our services through community work; (4) become a well-known entity for going out of the way to better provide for patients and referring offices; and (5) to have fun in the pursuit of excellence in OMS.

After one develops a clear vision, the next critical step is to assemble a team of individuals capable of carrying out this vision. In any major team sport, tryouts are given, and the leaders search for certain critical attributes to best serve the effort. The vision is clear; it is to win. Can you imagine a team that merely selected its players without tryouts? They would never win because the right person for the right position would be all too random. With this in mind, it becomes obvious why some practices fail to win; the selection process is random.

Selecting the proper employees is a skill and can evade even the largest of businesses. There are scientific statistical methods for selecting the proper person for a job; however, the real answers are simple when applied to real life. For the sake of comparison, we will call a perfect employee a 10 on a 1 to 10 scale. In most progressive practices, a 7 or less is unacceptable. If a physician can surround themselves with 9s and 10s, marketing can be as easy as showing up for work. Because the caliber of employee is paramount and usually directly proportional to the success and stress level of any practice, the importance is obvious.

HIRING AND FIRING

Anyone who thinks that this topic is inappropriate in a marketing chapter already has serious misconceptions. Inevitably, when one closely examines the details of a successful OMS practice, exemplary hiring and firing practices exist. The converse is true for poorly run or unsuccessful stress-ridden practices. For the sake of comparison, the author will continually compare the details of two practices. One practice is profitable, user friendly, energetic, and sets new standards for the community and has a physician and staff that enjoy their careers.

The other practice withers on profit, has a frustrated staff and physician, does not experience sufficient growth, has high staff turnover, and just is not fun to work for.

By contrasting the factors that differentiate these two practices, we can gain tremendous insight to some of the most common marketing problems. It is not going out on a limb to make two important statements. Most problems that are encountered in a practice concerning marketing and communication can in some way be directly attributable to the hiring and termination policies of the practice. Statement number two is the fact that the extent of the leadership of the physician will directly affect the policies or lack thereof in the office and will contribute to the employee relations problems. Most employee relation problems are the fault of the employer, not the employee.

One of the inherent problems that have, for a long time, affected professionals in all branches of health care is the dearth of business courses offered to the physician in his or her preprofessional training. One of the thrusts of today’s medical and dental school curricula is the inclusion of business and practice management courses. Even in the most progressive didactic environments, this topic is usually too little too late.

A compounding modifier to the above is the fact that medical and dental practices have traditionally evolved as independent, closed-circuited, small business models that have been resistant to outside consultation or change of structural and managerial paradigm. This has created a very inbred system of strong independence, but little thrust toward interdependence. Although there certainly are positive points associated with this structure, it fails to adapt to changing paradigms, and because of this, physician’s offices tend to be trapped in a whirlpool of poor management, communications, and lack of adaptability. Inflexibility in this arena, in the author’s mind, has led to our inability to predict the current managed care crisis. Cost containment and efficiency issues should have been predicted and dealt with a decade ago, instead of now. The ability to foresee and adapt to change is essential to succeed in any facet of business, including medicine.

The other component that has crippled the business of private practice surgery, in the author’s opinion, is the failure to pay attention to the trends of corporate America. We have been so steeped in autonomy that we simply have ignored the changing trends of big business. Corporate America approaches management strategies with the same statistical scientific scrutiny that we afford our surgical literature. There exists a wealth of knowledge on human resources and marketing that has basically been ignored by health care providers. It is usually only through consultants that we gain exposure to this information. Because of this, we are currently reinventing the wheel, which increases stress levels and decreases efficiency. It is a safe bet that the successful practices that we contrast already have an understanding of the above.

PROFESSIONAL CONSULTATION

The term consultant has been mentioned several times already, and this is an appropriate time to expound on this now. We all seek advice from outside sources, especially in situations where that person has a higher level of knowledge pursuant to what we are doing. Most oral and maxillofacial surgeons would not take apart their own engines if their car stops running nor would they consider taking the transistors out of their TV if it falls into disrepair. This example can be carried out ad nauseam, but underlines that our lives revolve around professional advice. Therefore, it is difficult to believe that so many physicians are resistant to obtaining outside consultation. Our autonomy sometimes gets in the way. Anyone that runs a practice has very strong emotions and opinions about the way the practice runs. When you add partners to the scheme, these emotions and opinions increase logistically. It is very difficult to make prudent decisions in the face of emotional issues. Anyone who has made decisions to institutionalize a parent, euthanize a pet, terminate a marital relationship, or deal with similar issues will testify that it is very hard to make these decisions because emotions cloud the clarity of the issue. In these instances, we usually turn to those we trust to separate the issue from the emotions.

This emotional attachment to our practices often causes warped perceptions of the way the practice runs. To make rational decisions, one must have the big picture. A good metaphor of this situation would be a person enjoying a scenic boat ride along a beautiful river. The person in the boat is overcome with the beauty of the trees, water, and wildlife. The boat ride is absolutely wonderful, except there is something very ominous happening. There is a person in an airplane that is flying over this boat, and they can see more of the picture. The person in the airplane can see that 10 miles downriver is a huge waterfall that will kill everyone currently enjoying the boat ride. The person in the boat is disadvantaged by not seeing the entire picture, and the person in the airplane can avert disaster by alerting the captain of the boat to the impending danger. This metaphor illustrates the role that a consultant can play in your practice. Given the level of quality that we all seek in everyday life, it is unfathomable that so many physicians are resistant to these ideas. The author has experienced, in numerous practices, the awakening of the entire office by qualified consultants. Adapting an old adage, a physician who refuses to seek business advice has a fool for an advisor. Another pitfall that the author experiences is “pseudoconsultation.” This involves taking advice from the wrong people. Frequently, surgeons turn to accountants or attorneys for this type of advice because these individuals are familiar with the practice. Most of these professionals have little practice management experience and often prove to be poor advisors. A frequent excuse for not seeking outside assistance is cost. Some physicians say that they quite simply cannot afford it. The author is on record as saying that you quite simply can afford it.

Successful general dental practices have multiple hygienists doing recall visits. The dentist may pay these hygienists $200 per day. This can be a significant expense. These physicians may make a clear profit of $1000 per day after paying the hygienist. Many dentists never hire a hygienist because they “can’t afford one.” Again how can they afford not to? A qualified practice management may cost up to $10,000 for several days of work. If these people can institute changes that increase your accounts receivable, billing, coding, and staff relations by several percentage points, the payoff in profit and stress reduction may be tenfold. Yet why are so many physicians resistant to this concept? If a physician is truly interested in excellence, he or she must take the first step. For many people, they cannot ever commit to take that step. As stated earlier, if someone is not about excellence, then they should send their patients to another oral and maxillofacial surgeon so they can have the best care.

EMPLOYEE RELATIONS

Because many new practitioners will be reading this chapter, the author will begin at an elementary level and progress. The basis of the chapter is paramount to all employers, regardless of the time in practice.

There exist universal situations that enhance or detract from any business, and choosing the correct employees is paramount, regardless of the type of business. This applies especially to all of the service-oriented businesses, of which health care happens to be one. Unfortunately, many physicians never grasp the concept that their business is based around service and therefore struggle and endure unnecessary stress, whereas their colleagues who do understand the concept have fulfilling and profitable practices.

In any service-related industry, it is usually the level of service that sets businesses apart. For instance, if you had to ship one of your most prized possessions somewhere overnight and were ultimately concerned about its safe and timely arrival, would you choose Federal Express or the U.S. Postal Service? Most people would choose Federal Express because of the perceived level of customer service on behalf of Federal Express and the lackadaisical attitude often attributed to government employees. Service of one’s customer or patient base is the key to success. A physician may be a genius and the best surgeon in a given area, but if the staff is abusing patients, the practice will not prosper. On the other hand, a very mediocre physician can be elevated to hero status by a staff that nurtures their patients. Most physicians are clueless on correct hiring and firing concepts, and the ones with experience have often earned their knowledge through hard knocks. When the author lectures to large groups of physicians in any locality, employee relations always occupies one of the top three enumerations of practice stress.

In the past, poor hiring and termination practices may have only meant increased employee turnover and physician stress. In today’s litigious environment, improper human resource skills frequently lead to lawsuits. Wrongful discharge, sexual harassment, discrimination, and other employment-related litigation is on the rise. For a suit-prone employee, the ability to win a hugely unreasonable settlement holds much better odds than a lottery ticket. Sexual harassment suits have been settled for millions of dollars for innocently intended gestures or actions. This is a frank reality of modern employment law and circumstances. This is the wrong arena in which to learn by mistake. Suits for sexual harassment are not covered by malpractice or umbrella insurance and are the responsibility of the defendant. Guilty or not, subsequent publicity can be very damaging to the morale and reputation and pocketbook of the physician. Because most OMS offices involve a male physician with a female staff, the author strongly advises all new practitioners to thoroughly gain information about local and local employment laws.

Initially a new oral and maxillofacial surgeon will more than likely require a staff of at least three employees. The American Association of Oral and Maxillofacial Surgeons (AAOMS) recommends that two employees assist at surgery, and someone needs to tend to the front desk and clerical duties. Some new physicians may economize by using two employees and placing the telephones on a recorder during surgery; however, availability to your referring physicians is compromised. There is no doubt that as soon as a physician can afford adequate staff, he or she will enjoy a safer and more efficient practice.

The easiest positions to fill are surgical assistants. There exists a strong pool of dental assistants, nurses, surgical techs, etc. As with any business, previous experience is preferable. A seasoned assistant can actually teach many things to a new physician. It is also preferable to hire an assistant who can also obtain hospital assisting privileges. As with all positions, a friendly, compassionate, presentable, mature assistant is optimal. One potential problem of hiring new employees is the age and experience levels of the applicant pool. This pay and experience level is filled with young, inexperienced females. Many of these people have little experience, and their reliability and maturity levels may be insufficient to suit one’s needs. In addition, this segment of potential employees is often transient as a result of schooling, relationships, and childbearing. The author has taken pride in hiring this type of employee and watching them grow into an excellent staff member. This, however, has been in the presence of superlative staff members who had the opportunity to mold the new employee into a polished employee. Hiring this type of person without nurturing can lead to many employee-employer difficulties.

The job of practice receptionist is a much more challenging situation. This employee is literally the ambassador of the practice and, more than any other employee, can add or detract from the practice. This person is usually the first person that gives an impression of the spirit of your practice. In many cases, perspective patients call the office and are confronted by many barriers. Pain, expense, inconvenience, apprehension, third parties, and lack of appreciation of services are just some of the common barriers between physicians and their patients. Many of these patients are “shopping around” to find a caring and reassuring environment or the ability to tailor finances. An exceptional receptionist will act like a magnet bringing these patients to fruition, whereas a rude or noncompassionate person may distance them even more. This position calls for multitasking, especially for the new physician with a small staff. Besides the receptionist’s duties, this employee must assist in coding, billing, insurance, accounts receivable, and collections. All of these functions are as vital to the success of the practice as the skill of the physician. This position begs for a mature, experienced individual and will command a higher salary. This is money well spent because this person can literally help shape the future of the practice.

WHERE TO FIND GOOD EMPLOYEES

This is a question posed by all businessmen and businesswomen. Experience is very important, and the optimal situation is to hire someone that has worked in an OMS practice. The author warns against hiring an employee from a colleague’s office, unless it is discussed upfront with the neighboring physician. A new physician can count on intimidating existing practitioners, and there is no need to start off in a deeper hole.

Local dental societies usually have newsletters with employment sections that can prove useful. The want ads in the local area are a traditional means of finding help. The author warns about placing anyone’s home telephone number in the ad for applicants. It is not unusual to have many, many calls at all hours of the day and night. The author, instead, suggests a neutral address or P.O. Box to which applicants can send résumés. If the new physician does not have hiring experience, it is suggested that a qualified party assist in the interview process. It is important to hire someone with the correct “fit,” who will augment the personality of the physician. Many employment situations are a roll of the dice, but the author cautions hiring someone that conveys feelings of suspicion. This is no place for a demure introvert. Hire someone with good eye contact, a good smile, and an enthusiastic attitude. An employee that “glows” is a keeper and will infect the other employees and patients with that glow.

As the practice prospers, additional employees will be added. It is not unusual for an OMS practice to have three to six employees per physician. As we will allude to later in this section, many offices believe that they are understaffed, when, in reality, they are actually overstaffed.

New physicians are frequently at a quandary about starting salaries. By surveying colleagues in the general dental community, one can establish a scale for given positions in a given community. Additionally, many of the “throwaway” dental periodicals offer yearly regional staff salaries and regional fees.

One of the major incentives to work for many people is to obtain insurance benefits. In health care professions, it is pretty much a given to offer health insurance as a benefit. Although there are many means of doing this, some of the most common are as follows:

Many companies offer group health plans at a substantial savings, whereas other employers give their staff a monetary sum for the employee to use for the plan of their choice. Because many employees may have coverage from spouses, they may not need all the benefits that another employee would. So-called “cafeteria plans” present a menu of options that employees may choose from and are a popular option. Other benefits include sick leave, holidays, uniform allowance, and retirement benefits. Most physicians have pension and profit sharing plans and therefore are required to match funds for employees. This is a tremendous benefit and is often overlooked. An employee with longevity can save thousands of dollars in 401(k) plans or similar vehicles. This benefit must be fully explained to be appreciated and extends the gift of ownership to one’s staff.

Let us now direct our attention to the actual art and science of hiring and firing. If there is one element of running a business for which most physicians are unprepared, it is finding, keeping, and terminating employees. Almost every seasoned practitioner bears some emotional scar from improper handling of employee issues. Many in our ranks have been parties to lawsuits for violating the most basic tenets of employment procedures. Enumerating several commandments of hiring, it is important to discuss some absolute basics. Many of these principles probably existed in the marketplaces of ancient Rome, yet millions of bosses make these mistakes 2000 years later.

The author strongly believes that it is an absolute infraction to hire spouses or family members as employees. Nepotism will at some time cause employee problems. The author has lectured all over the country on this subject and is often met with resentment for stating this opinion. It never fails that at the end of a lecture a physician or spouse will confront the author in stern disagreement. The author’s response is that there are always exceptions to the rule, but he is aware of countless problems involving family. This is especially difficult for partners or other employees because preferential treatment may be perceived. In addition, the spouse may have the “coach’s son syndrome” and apply stresses that are unnecessary. There is no doubt that it is difficult for a partner or manager to reprimand one’s spouse, and if push comes to shove, it is rarely the other person who must leave the practice. The author has observed many state of the art practices over the past 20 years, and it is rare to find an exceptional practice with family members as employees. Two exceptions that exist are having family help in the very inception of the practice as a cost-savings issue or casual summer employment for odd jobs.

On the subject of nepotism, it is also an unwise practice to hire relatives of current staff. The same pitfalls apply, and many embezzlement schemes have involved this type of situation.

Although it appears painfully obvious, professional physician-employee relationships should stay just that. In this era of sexual harassment, even the most benign of gestures can be grounds for a successful suit. The author is aware of multiple cases throughout the country, involving very expensive and embarrassing outcomes for a surgeon. The author is aware of suits brought for telling off-color jokes, inappropriate body contact that was a “back rub,” and commenting on an employee’s attire or physical traits.

Another common violation is the temptation to manipulate monetary funds. Some physicians may pocket cash that comes across the front desk and believe that it is untraceable. Always remember that if a staff member witnesses a physician evading taxes or doing anything illegal, he now has a partner. If the physician can steal cash and no one knows, then why should not the employee also steal?

A physician spends as much or more time with staff than they do with his or her family, and there exists a temptation to bare one’s soul. The author cannot stress enough the need to always keep some distance from the physician’s private life and what the employee knows or hears. The author is familiar with several exceptional surgeons who were dragged through the mud by a terminated and disgruntled employee. Never underestimate the diabolic nature of a scorned employee. Like a nasty divorce, they will use any weapon of destruction, so do not provide them with ammunition.

Let us get back to hiring and discuss the interview process. There is a true art in being a good interviewer. This involves the art of listening. Listening not only to what the employee says, but being able to read between the lines as to what the employee represents. We will elaborate on this later.

First of all, the dress and demeanor of an interviewee is important. Given the fact that most people are at their best in dress and behavior at an interview, it is usually safe to assume that what you see is the best you will ever see. If dress or demeanor is inappropriate at an interview, it will only go downhill.

The author believes strongly in hiring bubbly, enthusiastic employees, and if an applicant does not smile and show strong eye contact, they are usually a poor choice.

An additional caveat is an applicant that speaks negatively of previous employers. This should be a severe warning, especially for individuals who claim to be “victims.” There is little doubt that you will be the next bad guy on their list.

As stated earlier, experience should be high on the list of employment attributes. Training someone to do a job is okay, but for a new physician, it merely adds additional stresses. It is better to hire a “teacher” than a “student” for the new physician. Interviews need not be exhaustive and should be standardized. In short you have two people sizing each other up. Do not forget that the applicant is also interviewing you as a boss, and when an employee resigns, they are effectively firing you as a boss. It is a two-way street. One good question to ask is what the applicant liked or disliked about their previous job. This can extract key information about how they may interface in your office. It is important to know if they can meet your standards in terms of overtime and Saturdays, etc.

The next most important thing is to be able to relate your vision and the goals of your practice. You must actually present written documentation of who you are, where you are going, and how you plan to have this applicant assist your journey. Many physicians do not have these guiding principles in writing. How can an employee relate to goals that are nonexistent? Again you should provide this applicant with his or her job description and discuss it in detail. If you desire an exceptional practice, you need to employ exceptional people. If you do not have written job descriptions, you must settle for mediocrity. The author suggests that the physician make an audiotape or videotape containing the guiding principles and visions of the practice. This will standardize the interview process and simplify this task.

If you have properly defined your goals and visions, you can effectively ask the employee if they want to play on your team and follow your rules. If you have not defined the rules of the game, then how can you possibly expect the employee to play? The author has presented the rules of the game to applicants, and they stated that they could not comply with our expectations. This employee has done both of us a tremendous service because it may have been months of frustration before the employee quit or was terminated. The point is that if we did not have the job description and rules of the game defined, then we could not have gained this information.

Employee references can be very patronizing or very significant as to hiring. Unfortunately, legal precedents have been set, and it can be grounds for a suit. Many employers are very happy to get rid of a problematic employee and do not want to have any backlash from a bad reference, so their word may not be accurate. On the other hand, an employer may be afraid to give an accurate reference because of concern about legal recourse. It probably requires speaking to several individuals to actually obtain an accurate base. To simplify this process, it is important to ask the previous employer if he or she would hire that employee again. It is also prudent to ask them if the applicant possessed the attributes or lack thereof that we are about to discuss. This gives some standardization to the referral process and allows the new employer to find out the applicant’s ability to fit into their office. Any employer must be extremely careful about providing a negative reference. If an applicant can prove that you have prevented them from employment, you may be liable. Million dollar lawsuits have been awarded to employees who were able to prove defamation. The author severely cautions any employer against giving a verbal or written negative reference, especially to a stranger. Many large companies will only verify employment history, the date an employee was hired, and the period of time that the employee worked. These companies refuse to comment on subjective questions. If an employer wants to provide a negative reference without jeopardizing himself, the statement “I cannot comment on this employee under advice from my attorney” should make the point without creating liability.

There is no doubt that hiring the incorrect employee can cost thousands of dollars. The cost of training, the loss of efficiency, and the negative impact are immeasurable.

The author believes that there are eight attributes that make a perfect employee. For the sake of measurement, we will refer to a perfect employee as a “10.” What we desire is to be able to screen for employees that are a “7” or above. The following attributes will greatly assist this evaluation process ( Box 19-1 ). The author owes Howard Rochesti of the Mercer Corp. in Santa Barbara, CA, for his ability to distill this valuable information into simple categories.

  • 1.

    Competency and presentation

  • 2.

    Unconditionally committed

  • 3.

    Givers or takers

  • 4.

    Offensive or defensive

  • 5.

    Superstar or team player

  • 6.

    Joyous

  • 7.

    Self-managing

  • 8.

    Learner

  • 1.

    Competency and presentation

  • Competency is the foremost attribute required in the consideration. Again in any service-oriented business customers or patients expect and seek a certain level of care and service. When a person goes to a nice restaurant, they know in advance that it will be expensive. For that expense, they expect a high level of service (e.g., prompt seating, polite treatment, accurate ordering, fast service, and attention to detail). A waiter that cannot meet those expectations is incompetent. If you order a rare steak and salad with dressing on the side and get a well-done steak and a salad drenched in dressing, that is incompetence. This incompetence will, across the board, cause unhappy customers and invariably harm the reputation of the owner. What is frustrating here is that the restaurant owner may really have paid attention to detail. He may have a beautiful facility with ample parking. He may purchase only the finest ingredients, and he may have hired the best chef in the area. Despite all the attention to detail, a single incompetent employee may shatter his dream of having a fine restaurant by negating his attention to detail. There is a difference between inexperience and incompetence. If our waiter had a badge that said “waiter in training,” we may expect a lesser level of service. This employee may become an excellent waiter, but should not be turned loose on the public without someone supervising. Presentation is also a very important factor to consider in our business. The discipline of OMS involves cosmetics, aesthetics, and health. One of your most powerful marketing principles is the appearance of the physician and staff. Slovenly, out-of-shape staff with yellow teeth or fingers from smoking or excessive body piercings or tattoos is not the image that we are trying to convey. An obese employee that is bubbly and neat may be an asset, but someone with cellulite bulging from dingy polyester white scrubs does not assist your marketing efforts.

  • 2.

    Unconditional commitment

  • Unconditionally committed is defined as commitment with the lack of conditions. The closest example that the author can find is a resident in a training program. As residents, we could not allow anything to take precedence over our work. None of us would have dreamed of telling our respective program chairman that we could not meet a deadline because we ate lunch and did not have time. We were in an environment where lunch was not a priority, and our work took precedence. When we are called to the ER in the middle of the night, we cannot say, “it’s late, call me in the morning.” These are examples of unconditional commitment.

  • Owners of businesses have much more impetus to be unconditionally committed because they reap more of the benefits or failures than the employees. For this reason, it is rare to find this level of commitment in an employee. One thing about any society is that people identify and bond with cohesive organizational units that convey a common goal. Fraternities, sororities, social clubs, sports fans, bowling leagues, scouting, and church groups are examples of situations where people unite and develop sometimes extreme loyalties. There is usually little monetary incentive in these groups, and the point is that we are social animals and will extend great effort for “the cause.” This same socialism extends into office settings, and when employees bond and identify, they will put forth great effort for the good of the practice. When you have a good leader, clear-cut goals, and the correct employees, the ensuing business is a beautiful machine. Physicians that have exceptional and profitable practices probably are good leaders and have exceptional employees with a well-defined common goal.

  • An unconditionally committed employee will perform within reason to accomplish the task at hand. An applicant that will not work overtime or on Saturdays or follow your rules of the game is only conditionally committed and does not meet our criteria.

  • Finally an employee may be unconditionally committed to you and not your vision. If an employee is only committed to you and you come into work with a poor attitude, then they will take on your attitude. If the employee is, however, committed to your vision, then they will pull you aside and remind you of your commitment to excellence and point out that your attitude that particular day is not what our goals define.

  • 3.

    Givers vs. takers

  • Someone is either a giver or a taker. A giver is a loving, compassionate person who truly enjoys giving of themselves. These people understand the win-win concept and fully realize that the more they give the more they will receive in return. These people exude a generosity that is not measured in physical gifts, but more importantly in the subjective sense. These people give gifts of advice, time, compassion, empathy, and service. You should, by now, be getting a picture of what it is that we want in an employee.

  • A taker, on the other hand, operates in the win-lose environment in that for them to win, someone else must look bad or lose. This was the person that reminded the teacher that they did not collect the homework assignments in school. Their means were not to serve as a reminder, but rather to look good at the expense of others. This is a malignant personality trait and is manifested in all sections of culture. An oral and maxillofacial surgeon that refers to other ORL and maxillofacial surgeons as competitors instead of colleagues is another example of a taker. Any person that speaks negatively about anything to enhance their own identity is a taker. A giver would compliment the other person on their efforts and then focus on those of their own. Although it is impossible to screen for this attribute in an interview, this behavior must be identified and these people removed from your staff. One bad apple can spoil the whole bunch. If, as an employer, you ever come across the “what’s in it for me?” attitude, you must take action. If an employee must have someone lose for them to win, guess who will be losing? The losers are the boss, the other staff, and the patients.

  • 4.

    Offensive and defensive employees

  • By this categorization, we are referring to one’s ability to accept change. Change is the basis for all molecular structure and all of life. Everything from the subcellular level on up involves motion, change, and energy. If you examine successful people and successful practices, you will see that they thrive on change. Change should breed excitement, but for many people, it breeds fear and insecurity. If physicians are truly interested in approaching excellence, then they must continually change all aspects of their practice to increase efficiency and service. The author challenges and rewards his staff for changing. We look at our forms, our policies, our furnishings, and so on and brainstorm, as a group, on how to improve. Accepted employee suggestions are validated by monetary rewards.

  • Some employees are intimated by change and take the “if it ain’t broke, don’t fix it” attitude. This is poison in a motivated practice. Employees that encourage and accept change are termed offensive, whereas those employees that fear and resist change are termed defensive.

  • The author recently made significant changes to the current charting system in his office. These changes meant altering the status quo of everyone’s interaction to the structure and handling of the office charts. It was truly enlightening as an employer to witness the offensive staff immediately recognize the potential for increased efficiency and service, whereas the defensive staff members could only see problems. For these defensive staff, this meant doing things differently, and even though it was actually less work on their part, they resisted as a result of their personality trait.

  • It is appropriate for staff to challenge change. When the author proposed the charting system changes, he did not consider some shortcomings and was enlightened by challenge from the offensive staff. It was interesting that the pitfalls put forth by the defensive staff were less amenable to improving anything.

  • We all like change because it counters boredom. If we all wore the same clothes every day and ate the same food at every meal, life would not be as interesting. The same holds true in the workplace. A valid leader understands that all change may not be effective and must concede to their staff that a given plan was not working. It is alright to make mistakes and not dwell on them, but rather to move foreward and, by trial and error, enhance the service to your patients. Successful practices have offensive players.

  • 5.

    Superstars vs. team players

  • The term superstar is not a positive adjective in the sense we are using it. A superstar is that type of employee that can do it all. Although this might be appropriate or even desirable for your first employee, you will have problems when you begin adding staff. The superstar manipulates situations so that all the attention swirls around them. It is not about winning the game; it is about how many points they scored. The superstar believes that for their previous experience or superior intellect they can “do better.” They feel superior and are often overprotective of the physician and the practice. Their attitude is that they must “save” the practice from the incompetent hands of the other employees. These employees may take some time to recognize because they seem so dedicated on the surface. If one examines the attitudes of their co-workers, it will become evident if they are respected leaders and role models or self-servingly critical.

  • There are tricks to ferret out this personality type. They frequently place themselves in situations that “no one else can do.” For instance, they are the only ones that can back up the computer or the only ones that do the payroll, etc. They thrive on being needed for important functions. They frequently do this to become indispensable. They may cause many employee problems and realize that the other employee will be fired because the practice cannot run without the efforts of the superstar. You cannot fire these employees because no one else can perform the vital functions, such as backup or payroll. The key to neutralizing superstar status is cross-training. Give several staff responsibility for critical functions. This is good business sense and lessens the chance of fraud and embezzlement. Cross-training prevents superstardom.

  • The above examples do not mean that one person should not have responsibility. The difference is in the person. Although the superstar wanted other staff kept in the dark, the team player would have communicated the important responsibilities to the other staff so that the office would function in his or her absence. Look for, hire, and reward team players; they will make your life and practice less stressful.

  • Although OMS is not physically challenging, many physicians go home at night exhausted and stressed. They are not exhausted from doing surgery; they are exhausted from having to constantly manipulate staff members to keep peace. Superstars embezzle from the practice. They do not steal money; they steal energy. They are like sponges, and they steal the energy and excitement from the other staff or even patients. To counter this type of behavior in these “indispensable” staff, the physician must constantly be manipulating situations and environment. This is what becomes stressful and exhausting. Surround yourself with team players and you will be energized. Synergy occurs when the total is greater than the sum of the parts. Team players, offensive staff, and givers blend harmoniously to create synergy.

  • 6.

    Enthusiasm, joy, and energy

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on MARKETING THE ORAL AND MAXILLOFACIAL SURGERY PRACTICE
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