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Once Upon a Time… in Dentistry

May 10, 2021

Filed under: Control,The Porch,The Stoic Dentist — Tags: , , — Barry Polansky @ 1:30 pm

Isn’t that how most fairy tales begin… with that stock phrase that implies how things used to be… and like most fairy tales, end with the other phrase… they lived happily ever after? If the dental profession could be told in the form of a fairy tale, I don’t see it ending as they all lived happily ever after. 

I started practicing dentistry in 1973. Some would call that The Golden Age of Dentistry. Looking back, I would say it was the end of a golden age. I have thought about the exact moment or moments that changed dentistry… like the day the earth stood still, or the day the music died, but I always come up empty. Things rarely change radically like a revolution, but rather unfold over time like Darwinian evolution. 

Let’s begin this tale in 1973… what I am calling the beginning of the end. When I graduated, most dentists just hung up their shingle and started what has come to be known as their fee-for service dental practice. This was how we did things back then. Sure, there were alternative ways of practicing, like group practices and specialty practices, but the economic framework was pretty much cash and carry or fee for service.

Things seemed to be working well. The private practitioners worked well with the free clinics and the welfare offices of the time. In 1954, labor unions sought to add dental coverage as a fringe benefit and consulted with state dental societies in Washington, Oregon, and California to develop a benefit where care would be delivered in the dentist’s office. 

I wasn’t practicing in 1954 but apparently the idea caught on. In 1966, Delta Dental was established and by that time dental insurance was on fire in the corporate and government arena. It was almost a political issue… but I don’t want to get ahead of myself. Most dentists even thought it was a good idea. I never complained in the early years. These days I am not a big fan of corporate entities getting involved in the marketplace… but that is a story for another day. In the early seventies, what did we know?

Let me diverge for a moment with another story… Plato’s Allegory of the Cave. An allegory is a story which acts as a metaphor for other points of view. Click on the link for a quick summary of the story. Imagine us sitting in the allegorical cave just watching the cave wall as images go by. In Ancient Greece, that may have truly been a cave but today I think more of a lecture hall or newsfeed, social media… or wherever we get our information. Facebook anyone? Plato used the term puppet master to represent the person who was controlling the images. 

As insurance entered into the marketplace, we were fed many stories from various special interest groups until the entire landscape of dentistry changed. In my day, we had the early development of closed panel groups which were the early versions of what legitimate insurance companies converted into PPOs. As years went by, insurance plans converted from total indemnification plans to PPO’s and the thankfully unpopular HMOs. 

But slowly people were losing their freedom of choice. Slowly… slowly… slowly… not only doctors but patients as well. If you were around back then, you would occasionally read messages sent from insurance companies that were meant to coerce patients to join their plans. (“You can keep your own doctor.” Really?)

The Stoics believed in free will. People wanted to decide for themselves free of coercion. But outside interests from labor unions, insurance companies and in some cases organized crime were coercing patients to join their plans – upsetting the marketplace… slowly, slowly, slowly. 

And it worked. We no longer have what Adam Smith called the invisible hand of the marketplace

I am probably preaching to the choir. Understanding this concept may be attacking someone’s personal view of the world or work, or life in general. I get that. It’s an uphill battle… steeper now than in the seventies. What concerns me most of all is the well-being of individuals. What is best for the good of all. Through the years I have watched the dental profession change from a highly desirable destination for young people to a battleground for the health-care marketplace. 

We need to look out for the good of all the players… doctors, patients, team members, lab technicians… all of the frontline workers.

So, I wonder what the future holds. Will we continue to devolve? Or will there be a movement of leadership that has not existed in the past. My new book, The Porch, tells the story of a young dentist who is struggling with burnout. He meets his mentor who tries to combat the forces in dentistry and dental education with his own brand of leadership—an authentic, virtues-based leadership that confronts dentistry’s gatekeepers in a subtle manner and begins to change the tide by calling out the puppet masters.

Don’t we all want this story to end happily ever after?


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.

Time to Rethink Dental Education

April 19, 2021

Filed under: The Porch,The Stoic Dentist — Tags: , , , , , — Barry Polansky @ 1:30 pm

Adam Grant, in his new bestselling book, Think Again, The Power of Knowing What You Don’t Know (highly recommended), describes a few character traits that set the great presidents apart. Experts found that of the best character strengths the great ones had, that intellectual curiosity and openness to experience distinguished them from the rest. Grant said, “They read widely and were eager to learn about developments in biology, philosophy, architecture and music…”

In other words these leaders had a different mindset…rather than a certain skillset. Maybe dental schools (and other professional schools) should consider focusing more on mindsets rather than skillsets.

For those of you who study philosophy, Stoicism or positive psychology, you will recognize intellectual curiosity, openness to experience and love of learning as character strengths that come under the heading of the core virtue…wisdom.

When I look at the current state of the development of dental education over the past 50 years I see not much has changed. The focus has remained on training dentists in technical skills (techniques, materials and equipment have changed), rather than on training dentists to think more critically and to become better leaders.

It’s time to rethink dental education.

Through my years I have witnessed the coming and going of trends and fads that promised dentists happiness, freedom and success if they mastered the associated skills. From business management and sales and marketing skills to technical skills in cosmetics (veneers, Botox), implants, sleep dentistry and splint therapy, all made the promise of success.

I agree that mastering technical and business skills are the key to mastering dentistry…anyone who thinks otherwise is crazy. It is the job of dental educators to produce competent dentists…first and foremost.

Yet…something is missing…and that is becoming more and more apparent every day. With the rising costs of dental education, the rising incidents of burnout and suicide and the decline in trust by the public…I have to look at the dental education as a way to improve the existing conditions.

Maybe…it’s time to rethink dental education.

A good method of finding insight is to use what the great investor Charlie Munger would do…he would use inversion. His philosophy was to “invert, always invert.” That is not unlike the philosopher Aristotle who would explain the virtues by describing his golden mean by looking at their opposites (see diagram above). So, if our job is to find the truth— then lets look at the inversions of the strengths of curiosity and the love of learning.

First let’s take a look at the opposite or absence of curiosity and learning. Words that come to mind are orthodoxy, complacency, laziness and dogma. Then there is the condition of an excess of a love for learning — know-it-all-ism. Know-it-all-ism can be just as bad as the lack or opposite of a love of learning because it can lead to over confidence and arrogance.

Sometimes it is hard to detect the laziness and complacency in dental education but the arrogance sticks out like a sore thumb. Adam Grant suggests that we look for three behaviors that are emblematic of complacency, orthodoxy and arrogance: preaching, prosecuting and politicking. They all defend their current position until the status quo is upheld.

Preachers love to tell us why their point of view is the right one. Prosecutors take on the role of an attorney defending their position, and politicians just do whatever is popular. Grant recommends that we look at all sides of an issue by becoming scientists.

One of the roles of any doctor or health professional is to be a teacher. The word doctor comes from the Latin word for “teacher,” itself from docēre, meaning “to teach.” Yet, dental schools spend very little time educating students how to become better teachers and leaders.

Never forget that another primary role is to be competent technicians.

By neglecting the role of teacher and leader…who suffers? The patients, the community but mostly the practitioners. And that is what we are seeing in dentistry today.

How can we fulfill our role if we are not trained to be teachers and leaders?

Something else I have noticed through the years is that the best students—the A students, don’t make the best dentists. Just asking ourselves why that is can reveal more about the system than about attaining mastery and excellence.

The late and very great Peter Dawson would talk about teaching dentists critical thinking. Too many dentists focus on the outcomes of treatment and then claim success without waiting long enough to observe that actual results. Critical thinking is about being process oriented so that many future failures can be avoided…this is not only about technical dentistry but behavioral dentistry as well. Maybe it’s time for dental education to heed Dr. Dawson’s advice.

My new book, The Porch, is a tale about a dentist who suffers through depression and burnout until he meets a mentor who teaches him the real tricks to the trade. He then goes on to clinical success and more. What more you ask? Find out by reading The Porch.

Courses in positive psychology and leadership development at the dental student level would go a long way to making the dental profession better. In the end the students will achieve all of the things they became dentists for: mastery, freedom, happiness and peace of mind.

Maybe—just maybe it’s time to rethink dental education.

If you have any thoughts or feelings about this important issue please leave comments below….just don’t preach, prosecute or politicize.

Louie—A Cautionary Tale

March 29, 2021

Filed under: The Porch — Tags: , , — Barry Polansky @ 1:40 pm

When I was just a small boy, growing up in a quiet suburb of Queens, in New York City, I used take the bus to school every day. Back then we had to walk a mile just to get to the bus stop. I don’t want to sound like Abe Lincoln, but we got used to it…rain or snow. Everyday. Walking along with us…but really all by himself, alone, was one of my neighbors...Louie.

Louie wasn’t going to school. He was starting his long commute into Manhattan which he repeated five days per week. Sometimes I would see him reversing his route later in the day. It was a long time ago and I can’t recall how old Louie was at the time. My only reference now is that he had two daughters who were some years younger than I was, and they went to a closer public school.

Louie, otherwise, was a pleasant chap, but my memory of him and his circumstances at the time was one of pity…like that old comic strip character, Sad Sack. Every day he would move along slowly, head down, with the weight of the world on his shoulders, slumped over and plodding along, there was never a smile on his face. I vowed, as a young kid…never become Louie.

I did my best to avoid that fate.

I followed a straighter path that would lead to a much happier place…I went to school and became a dentist. The phrase, “master of my own destiny” became words I tried to live by. I was fairly successful. I chose dentistry (at least I thought I made an active choice at the time), because it was a profession, and like medicine, law and accounting it would give me the opportunity to be the commander-in-chief of my own fate. At least that is what I believed.

I had no reason to suspect otherwise. I was raised by parents who taught me the meaning of self-direction and freedom. Everything I had learned was confirmed by my own experiences…except the riddle of Louie. So I followed the well worn path of college and then professional school.

After school I went into the U.S. Army Dental Corps for some much needed practice and experience. Then I jumped right into private practice. Things were different in those days…it was an easy transition. I never had to get a job, I made a living right away. But…about five years into practice, things took a turn, not financially but emotionally.

I had become Louie.

I wasn’t happy, and I blamed everyone else for my unhappiness…family, patients (oh, those damn patients), staff, the supply guy, even the waitress at my favorite luncheonette. I didn’t know what was wrong with me. I sought outside help but the courses I took just taught me that doing better dentistry was the answer. I would make more money and that would make me happier. NOT!

So, probably unlike Louie and so many others, I took the ball in my own hands. I started to read books on self-development and philosophy. I came across a quote which has become my mantra: “If it’s to be, it’s up to me.” This became my anti-Louie strategy. It wasn’t an easy fix…but persistence and resilience pays off.

In life there is no such thing as instant pudding.

After a few years I learned about a dentist in Florida…Dr. L.D. Pankey. I went to the Pankey Institute and for the first time I met people who spoke my language. I was introduced to a book which L.D. used as a resource for his philosophy: What Men Live By, by Richard Cabot. This wasn’t a book that a kid from the streets of Queens, who drove a cab to get through dental school, would naturally gravitate toward.

Early in the book (not a page turner), I came across a word that resonated with me...drudgery. Right then I began to have visions of Louie. I knew that whatever Louie had fought and lost, Dr. Pankey had fought and won. I knew that I had found the answer.

I also realized that drudgery wasn’t about dentistry and that it was common in the world of work. Early in my journey for answers I realized that blaming my feelings on dentistry was not the way…soon enough I learned the opposite, that dentistry was a great profession, but only if I crafted the way I worked.

“If it’s to be, it’s up to me.”

And so my journey began. I read books, I studied, I reflected, I found wonderful mentors. I failed, I fell down…got back up and persisted. I felt like quitting…but I kept going.

Today, I am retired. After close to fifty years I can look back and say it was worth it. I avoided becoming Louie…or anyone else who dreads going into work everyday.

If you identify with with Louie…there is hope. There is a brighter future…there are known pathways and everyone is capable of finding a way.

Meaningful work is very different than drudgery.

Mike Rowe’s show “Dirty Jobs,” on the Discovery Channel, was his attempt to “tell better stories of men and women who master a trade.” He demonstrated that meaningful work is very different than drudgery…and meaningful work comes in all shapes and sizes.

A doctorate does not guarantee happiness. There was a point in my life when I thought that I could have continued driving a taxi and been happier. I could have found more passion for interacting with people in my cab than I did in my dental operatory. But with so much invested in becoming a dentist, I just couldn’t give up. Thank God I found my meaningful purpose and began making meaningful strides on “the road to mastery.”

Any trade, even dentistry, can be dull and dreary, or it can be pursued on this amazing road, becoming joyful. It’s on the road to mastery that we find our passion and purpose, but first we need to recognize what is most meaningful to us and apply energy in pursuit of it. It’s not only about “doing better dentistry.”

These days I have a passion for telling stories to improve lives.

That’s why I continue writing for and about dentists. Creating a life of personal purpose and wellness in dentistry is the “better” story that I aimed to tell in my latest book THE PORCH, which is fresh off the press and available now in print and digital form on Amazon.com.

THE PORCH is the story of a dentist… I think of it as a fable. Others may think of it as a fairy tale. My co-author, Deb Bush, thinks of it as an allegory for 21st century dentists. But every reader of the preliminary manuscript found it compelling. It resonated with their own experience in dental school and dental practice.