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How to Go Fee-For Service and Save Your Life

May 4, 2021

Filed under: Control,Philosophy,The Stoic Dentist — Tags: , — Barry Polansky @ 12:45 pm

I first attended The Pankey Institute in the late eighties. I was at the lowest point of my career. Admittedly times were a bit easier for a young dentist back then, but in many fundamental ways they were the same. The fundamentals never change but how best to use them are something you must always stay on top of. Over the past thirty years things have changed but the fundamental wisdom of dental practice has stayed the same.

For that reason I believe…hold on everyone…that the best and really the only way to have a fulfilling career in dentistry is through comprehensive relationship based fee-for-service practice. Let me explain.

On the first morning at the Institute I remember feeling overwhelmed. It was like the first time I sat down to write a book…I was focused on the herculean tasks of creating the practice of my dreams…an unbearable project. Every moment of that first week tested my competence and potential to succeed…and then there was the comparisons and contrasts I made with the other students. But I paid attention and took notes.

In a lecture late in the week, the instructor was discussing how to schedule this new type of practice. He told us to reserve just a morning to practice what we were learning. I returned home and secured every Thursday morning for practicing the Pankey way. That included a lot of new techniques for me and my staff. It was an easy way to introduce the new school of thought to my staff.

How do you eat an elephant? I used to ask myself…one bite at a time.

The lecturer that day, Dr. Irwin Becker who later became my mentor was more right than he even knew. Just about the same time, during the eighties, two psychologists, Edward Deci and Richard Ryan from the University of Rochester were beginning to formulate their now groundbreaking self determination theory of human motivation.

Let’s face it, writing a book or designing a fee for service dental practice takes a lot of energy and motivation. Back then and sadly today, the advice comes down to “Just Do It.” Deci and Ryan put some science behind human motivation for me…and then I backed into it…but years later, while studying positive psychology, I was gratified that I took Dr. Becker’s advice; otherwise I may not have had an accomplished and fulfilling career.

Let’s look at the science.

Deci and Ryan defined motivation as the “energy required for action.” How many times do we attempt to accomplish a worthy goal but run out of steam. We need drive. Many people never even try. It was the Stoic Seneca who said, “It is not because things are difficult that we do not dare; it is because we do not dare that things are difficult.” Installing a fee-for-service practice is difficult…if we dare to do it. It requires resources like drive and energy.

Deci and Ryan went on to further describe the elements of the drive and motivation they were describing. Firstly they noted the difference between extrinsic and intrinsic motivation. The extrinsic drives were the material rewards we are all familiar with, as well as status and recognition. The intrinsic drives included passion, curiosity and purpose. What they found was that intrinsic motivation was more effective in every tested situation, excluding when our basic needs haven’t been met (See Maslow’s Hierarchy of Needs. That’s a discussion for another post.)

Then something interesting occurred to them. They separated motivation again into controlled motivation, a form of extrinsic motivation and autonomous motivation, a form of intrinsic motivation. If it is work you have to do or are being forced to do, that’s controlled. Autonomous motivation is doing work you choose to do. Deci and Ryan found that, in every case, autonomous motivation destroys controlled motivation. Remember that the next time you are being coerced or seduced into work…I’ll leave the politics up to you dear reader.

The psychologists further explained autonomy by saying it occurs when we are doing what we are doing because of “interest and enjoyment” and because “it aligns with our core values and beliefs.” In other words, it is in alignment with the other intrinsic drives: curiosity, passion and purpose.

When we are the masters of our own destiny, we are also more focused, productive, optimistic, resilient, creative and healthy. In retrospect, this is what I found on those Thursday mornings.

In the years following the development of the Self Determination Theory, companies like Google and 3M found comparable results. Google allowed workers to spend 20% of their time pursuing projects of their own liking. The result was products like Gmail, Google Maps and Google Earth. 3M did the same years before–using autonomy as the driving force behind their 15 Percent Rule. That created products like the Post-It Note.

Autonomy as an intrinsic driver works—so starting slow to install fee-for-service just one morning per week is a sound idea.

And then there is the riddle of mastery. Mastery sits atop Pankey’s Ladder of Competency…the question is how does one achieve mastery? Once again it has been reduced to “Just do it.” But there is more science.

In a 1953 paper by Harvard psychologist, David McClelland, a leader in achievement and motivation theory wrote an original thesis titled The Achievement Motive. Deci and Ryan acknowledged that this thesis may have described an intrinsic driver even more important than autonomy. They called it competence, but it now is known as mastery.

The pursuit of mastery has been the subject of numerous scholars and authors from Theresa Amabile and Robert Greene to George Leonard. Most agree that mastery is the desire to get better at what we do. It is the need to continually get better, to improve and to make progress. It is the royal road to growth and flourishing…and the opposite of languishing and drudgery…the low rung on Pankey’s Ladder of Competency.

Working toward worthy goals is pleasurable. Making progress produces the neuro-chemical dopamine. According to Dan Pink, author of the popular book Drive, “the single biggest motivator by far, is making progress in meaningful work.” At my lowest point in dentistry I felt stuck. Hopeless. My work had lost its meaning. Today we call that burnout. Those Thursday mornings turned on the light…the light of hope.

We need the freedom to chase mastery. That freedom comes from autonomy. Without the intrinsic driver of autonomy it is difficult to sustain the drive necessary to achieve mastery…this is based on our biology, not just some story, fairy tale, or business myth.

So after installing the Pankey Thursday mornings where I could practice autonomously, applying the lessons I needed to learn, I slowly put the complex elements of comprehensive relationship dentistry together. I started with the comprehensive examination and built on that by learning all of the components from the mundane mounting of models to the nuances of advanced occlusion. It took time…but driven by dopamine and progress, slowly I was installing my model practice.

I realized that learning the softer behavioral skills were just as important as the technical, so in time I learned about case presentation. Through the years I learned new skills like digital photography and Power Point. This is the essence of mastery. I am retired now and looking back I see how that moment when Dr. Becker suggested the Pankey Morning changed my life.

Today things are different. There is pressure on young dentists to go right into corporate dentistry or practice in a way that seeks the extrinsic motivators only. Many of the newer models of practice are an assault on autonomy. This is a mistake, but the young dentist doesn’t realize it for years to come, and I hear rumblings on social media…about the drudgery and burnout and professional exits.

My new book, The Porch, is a fable about a dentists who is losing his autonomy and breaks down. By finding a mentor and keeping his eyes on the ultimate prize he goes from despair to hope.

There is a way to enjoy dentistry…start with one morning per week and you will see, as I did that fee-for-service comprehensive relationship based dentistry is the only way to practice that makes sense.


The Dental Warrior

April 26, 2021

Every morning I awaken to the Serenity Prayer downloaded onto the desktop of my computer. To many this has become a boring, humdrum banality that we take for granted…unless of course you have a problem with alcohol. During these very difficult days of the Covid-19 Pandemic I began to read it more closely and observed how much sound judgment it contains.

Many people associate it with Alcoholics Anonymous. When I was in dental school during the seventies I used to pass an AA Meeting Hall on the way home. I never had a drinking or drug problem…but I was curious and went in one night. They welcomed me in and served up some good coffee and donuts. I remember the meetings starting with a reading of the Serenity Prayer. Recently I looked up the origin.

The prayer was written by a protestant theologian, Reinhold Niebuhr in the mid-thirties. He needed a topic for discussion for an upcoming sermon. It was meant for everyone…not just alcoholics. Alcoholics Anonymous(AAadopted the prayer in 1941 when an AA member saw it in The New York Herald Tribune and asked the AA secretary at the time, Ruth Hock, to see if it could be printed in distributable cards. And so it has since become the mantra of AA.

When I read The Serenity Prayer these days I see ancient wisdom. I see Epictetus when I read it.

Who? You might ask. Epictetus was one of the most prominent Stoic philosophers…a slave and the teacher of Marcus Aurelius. He is known for his handbook The Enchiridion which is meant to keep the philosophy close at hand. For those literary types he was also the center of the main theme of one of my favorite books, Tom Wolfe’s mega-bestseller A Man in Full.

My new book, The Porch is a tribute to Epictetus and the Enchiridion. It’s a reminder for dentists about how to use and apply philosophy in dental practice. You can order a copy of The Porch right here and for just a short time get a free copy of my book The Art of Case Presentation.

Those two books helped me to realize that philosophy…specifically Stoicism, was more about practical application than about thought, meditation and reflection. Real philosophers are warriors not librarians. Philosophy can guide us …offer us help, but only if we make it accessible. Alcoholics needs actionable counsel…and so do we during these most difficult times.

Epictetus 101 tells us to “control what you can and ignore the rest.” Like the Serenity Prayer he was all about knowing what we can and can’t control. He advised his students to carry his handbook with them…so the counsel would always be at hand— accessible – hence I keep the Prayer on my desktop. It reminds me of what Socrates and Dan Goleman, the neurobiologist, consider the fundamental rule of “know yourself.”

Let’s break down the simplicity of the Serenity Prayer. It includes some very key words like, courage, acceptance, wisdom and serenity. The first three words remind me of Aristotle’s Four Cardinal Virtues. Notice that the virtues are verbs – they require some actions. Let’s examine the warrior nature of these virtues.

First courage. It takes courage to get through each day. It takes courage to act in the presence of fear…to do the right thing. Mostly, it’s harder to do what we know is right than to sit back and do nothing. Aristotle considered courage the chief virtue because without it the other virtues could not be practiced. The Jospeh Campbell, the mythologist, would tell us that we should “slay the dragon ‘thou shalt,’ as a sign of maturity and courage.

Second virtue: acceptance. That does sound fairly passive…but I would substitute the virtue of gratitude here. To understand acceptance we have to look at its opposite…denial. The word denial implies a world of “should.” When the world doesn’t behave as we think it should…we get upset, angry and frustrated. The answer is acceptance. Accept everything…take nothing for granted…only as granted. Accept as if we had actively chosen the outcome. For that mindset we must be grateful for everything.

My father taught me as I was growing up, that life is unfair. If it were fair…s**t wouldn’t happen. But, as you know…”s**t happens”. But through acceptance I never feel victimized. I deal, accept, move on and take positive action…of what is within my control. Acceptance and gratitude are liberating virtues.

Finally the virtue of wisdom. Wisdom gives the warrior clarity and perception. To know what is up to us and what is not up to us. Without clarity we don’t know how to act. Socrates considered wisdom the chief virtue.

This is a blog primarily for dentists who are trying to reconcile their work lives and their personal lives. I hope this helps…because it truly is about the universal reward for being a warrior philosopher, and that is the final word in the prayer…serenity. After some tumultuous years in practice I realized that serenity was what I was looking for.

The great Stoic philosopher Seneca said, “Our character is the only guarantee of carefree happiness.”

Bill W. the founder of AA used to say of the Serenity prayer, that it tells us “accepting the things we cannot change.” Acceptance must not be confused with apathy. Apathy fails to distinguish between what can and what cannot be helped. Apathy paralyzes and acceptance liberates. But acceptance, he used to say, required moral courage, to carry on when things look hopeless.

By becoming a philosophical dental warrior you will gain the most important thing in life: serenity and peace of mind.

Jeopardy! and Dentistry-The Ultimate Game of Life

April 12, 2021

Filed under: Philosophy,The Porch,The Stoic Dentist — Tags: , , — Barry Polansky @ 1:52 pm

The Pandemic, with the creation of new time schedules, has had most of us crying out to develop new habits. That is not an easy task, so I decided to entertain myself by reverting back to an old habit: watching Jeopardy! every night. I was always a big fan of the show and its iconic host Alex Trebek. I used to be a better player…my recall isn’t as good as it used to be. These days I watch with a different perspective…how the game of Jeopardy is like the game of life.

Recently I watched a smart young attorney competing. In order to prepare she admitted to doing the NY Times Crossword Puzzle for one thousand consecutive days. Now that’s gritty. Apparently it worked as she plowed through the questions and reached Final Jeopardy in a “no lose” situation. She was $3000 ahead of the second place contestant…but she had only accumulated $10,000…a paltry sum when you consider the amounts most formidable contestants earn.

I was impressed with the amount of knowledge she had accumulated…it just didn’t transfer over to dollars. Isn’t that the point of the game? To win as much as you can and return for another day. I made a note that her style of play would cause her to lose the next night when she would play, not necessarily a more knowledgeable opponent, but one who knew how to play the game…the ultimate game.

Through my years in dentistry I have met many talented professionals who did okay, like the attorney above, but never reached their full potential because they never realized the game they were playing. When you know your ultimate game…your entire game plan changes. Let me explain through the Jeopardy example.

Take a look at Jeopardy’s three most successful champions in the photo. The guy on the left, James Holzhauer, long before he racked up $1.69 million as a contestant on Jeopardy!, he made a living as a sports gambler in Las Vegas. Holzhauer also has a very high IQ…but a big part of his game was taking big risks.

I’m not suggesting that we have to be gamblers…but in life we all need to take appropriate risks. All three of the greatest Jeopardy players were risk takers…and do you know what they were betting on? They were always betting on themselves. Our attorney, even when she was confident rebuffed the idea of taking a risk. In that moment of truth…something interfered. She had what the cognitive psychologists call loss aversion. It’s very common. Everyone likes to win but some people are just afraid to lose.

This isn’t a good strategy for Jeopardy, and it isn’t a good strategy for life or for a career. We have to take risks. I remember my career…every course I took I lost a little sleep over how I would pay for it or how much I would lose by being out of the office. Every new technique I learned I worried about the outcome and considered staying with techniques I knew. Taking risks is what moves the ball downfield. Our attorney contestant was smarter than she believed.

The guy on the right in the photo, Brad Rutter is the highest money winner of all time across any television game show, with total “Jeopardy!” winnings of $4,688,436. He has never lost “Jeopardy!” to a human opponent. Watching him play was amazing. He never lost his cool. He would ring the buzzer mostly when he knew the answer. So many contestants on Jeopardy these days don’t seem to have the emotional stamina to compete. Every answer is an adventure. Maintaining emotional composure in life is no easy task…especially when we take risks.

Serenity, tranquility and steadiness are worthy goals in life. Yet…so many of us chase the external returns.

I have seen Brad Rutter go “all in” and lose. He shrugged his shoulders and actually crawled back to win the game. Too many contestants just “lose it” after a bad call, as if their complete identity were at stake. Once again, as in life, we have to play to come back another day…so peace of mind and tranquility at all costs is the objective of the ultimate game as well as the prize money.

And then there is the guy in the center. Everyone knows Ken Jennings.  He  holds the record for the longest winning streak on Jeopardy! with 74 consecutive wins. That was no accident. Jennings knows how to play the infinite game. This is a game where there are no winners and losers as author Simon Sinek tells us. Jennings watched other contestants like Holzhauer and learned how to take the proper risks…and he watched Rutter and learned to stay calm under pressure…but mostly he watched the host Alex Trebek…who he became.

Trebek died on November 8th, 2020 after a long-standing illness. He hosted Jeopardy! for 37 years. He was loved and respected by all. Ken Jennings has stepped in to be his “temporary” replacement. And what a job he has been doing. Jennings knew how to play the infinite game and he watched the exemplars in the game…until doors opened for him where he didn’t even know the doors existed.

Life has rules. Wisdom…the virtue that Socrates thought was the chief virtue in life, is the virtue that guides us in knowing the game we are playing…the ultimate game…the infinite game. Life is the essence of risk and struggle…all of us must master fear…even the attorney who lost her championship the next night.

My new book, The Porch, is a fable about a dentist who uses the wisdom of learning about the ultimate game of life. His lessons taught him about the necessary tools to succeed and live a life worth living. Check it out…and if you order now I have a special offer for you.

There Are Teachers and There Are Teachers

April 5, 2021

Filed under: Epictetus,Philosophy,The Porch,The Stoic Dentist — Tags: , , — Barry Polansky @ 10:00 am

These days everyone wants to skip the line. Everyone is looking for instant success rather than putting in the time. I’m for that as well. I mean who wants to put in 10,000 hours to become a master at anything like Malcolm Gladwell and Anders Ericsson suggest in their bestselling books. Who doesn’t want a good hack?

Even when I was in dental school, students were looking for the easy way. Most of us learned dentistry like chefs learn how to cook…very procedure oriented. There is a story told by Stoics of a student who approached the great teacher Epictetus and said, “Tell me what to do.” The wise sage responded,”It would be better to say, ‘Make my mind adaptable to any circumstances.'”

His advice was to learn how to learn. We shouldn’t pay attention to teachers and friends who are only interested in showing us the shortcuts and the hacks. We need to pay attention to the principles…every field has them.

Harrington Emerson once said: “As to methods, there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”

When we take the time to learn the principles and apply the principles we can solve most any problem that occurs…as Marie Forleo tells us in her best-selling book, Everything Is Figureoutable, yes—everything is figureoutable. This is one of the keys to mastery. Being able to figure out solutions no matter the circumstances.

I am a big fan of Jim Cramer…the Mad Money guy on CNBC. I watch him every morning. Sure, he gives out stock tips, but more importantly he discusses the principles of investing. Every day is a new day in the stock market and only those who adhere to the fundamentals of investing will make money in the long run.

Years ago, I used to go to the racetrack. There is an old horse racing adage that claims you “can beat a race but you can’t beat the races.” There’s a lot of wisdom in that quote, and it applies to just about any field. Some might say the same thing about the stock market. But we don’t want our profession to become a game of chance…that won’t happen if we learn and follow the principles…our “odds” of success will go up exponentially.

How does this apply to dentistry you ask?

Remember, our ultimate game is to win over patients to accept the care they need for optimal oral health and for us to competently provide that care…and in order to win, we need a process backed by principles based on perennial wisdom. Just like the best stock pickers don’t speculate on every stock and the best horseplayers do handicap their spots…the best dentists choose their big cases wisely.

When I go on social media (way too often), I see magnificent cases of stunning dentistry. Some are simple cases and others are intricately complex. Because I am retired, I am like the boxer that Paul Simon described in his classic song…“In the clearing stands a boxer, and a fighter by his trade…” but I do carry the reminders of every case that cut me down and I tell myself that “I am leaving, I am leaving…but the fighter still remains.”

So I look at these cases on social media and wonder. I wonder whether the dentist followed protocols…principles based on a philosophy. I spent fifty years in dentistry…the early years…with no real philosophy. Then after writing The Art of the Examination and clarifying my philosophy, I never broke protocol. And still…

Cases failed. I’m pretty good at picking stocks…and still I pick losers. And horses…I used to be a legend in my time at the track…but still losers.

So I wonder how these dentists do their cases. I wonder whether what I am seeing on social media is an illusion…and whether the cases will stand the test of time. I know from my experience that collective success over time on Wall Street, the racetrack, and work depends on having a guiding philosophy composed of principles we learn from the best teachers and mentors.

I say best because not all teachers are equal, and many will just give you some how-to tips without teaching you how to figure things out.

I have a couple of lifehacks for you…Can you guess what they are?

Clarify the philosophy by which you will approach your dentistry and life.

Ben Graham, Warren Buffett’s mentor and teacher taught him a philosophy for investing. It was pretty simple: 1). Develop a worldview–or a philosophy on how the world really works. 2). Create methods or systems and be consistent. 3). Be aware of your temperament –the world and the markets are very fickle.

Ben Graham was a Stoic.

My new book, The Porch, is a fable about a young dentist who changes his life and career based on philosophical principles…order you’re copy and begin to learn the secret sauce of success in life and dentistry through philosophy.

Use that philosophy to guide you in learning…in communicating…in leading…in solving diagnostic and treatment puzzles…in doing your hands-on work.

As the wise sage Epictetus said, you will make your mind adaptable to any circumstances.

Time Has Come Today

April 14, 2020

Filed under: Philosophy,The Stoic Dentist — Barry Polansky @ 10:01 pm

One of the more frequent conversations I hear during the recent pandemic is people not knowing what to do with all of the time in isolation. I hear people saying that with all of this time they can finally get things done – yet as each day goes by they spend more time watching more Netflix.

Readers of this blog know that I retired from clinical dentistry almost two years ago. As a retired dentist I feel a bit arrogant giving advice to the still working. I could never imagine what it must feel like to practice during these trying times. Certainly I practiced through some tough times like the HIV epidemic, but this is much worse. I hope I don’t offend anyone.

But this may be the best time to finally get some very important things done for the future of most dentists. One thing we know: things will not be the same, and I just can’t figure out the tele-dentistry thing. As dentists we are so used to the word “production.” The problem is that most dentists are finding this almost impossible. Having virtual Zoom meetings with staff can only go so far when it’s production we’re after.

As an observer of young dentists I have noticed how many have developed an overachieving mindset. How tough it must be to stay at home and develop new workout routines or cook new recipes while their practices are suspended in limbo. I don’t envy the young dentist who is devoted to self-optimization.

I thought back to my career and how I put my practice together forty years ago. I spent innumerable hours reading, taking notes and working on a practice philosophy. Writing policies and systems. It was something many dentists never found the time to do. Most just went to work everyday with one goal in mind: produce dentistry.

But it was these hours I put in up front that gave me the production capability that enabled me to build a successful practice. And now many young dentists have the time to sit and reflect on what’s most important in their lives, and to create that vehicle to get them there.

I am reminded of a story from author Steven Pressfield from his book Virtues of War. It is a great lesson of leadership and with all of this down time, one to think about.

Alexander the Great and his armies were finishing up after a battle when a young man ( future philosopher) approached the great warrior. One of the soldiers told the young man to kneel. He pointed to the lad and said, “This man has conquered the world! What have you done?”
The young philosopher replied without an instant’s hesitation, “I have conquered the need to conquer the world.”

And so the lesson is to get to “know ourselves.” This is philosophy – the first step in developing a strategy for our lives and practices. Most do not take the time to do this…now we have the time—I can think of nothing more productive.