122: Maximize Your DSO's Potential: Consider Integrating Specialties

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Hello, everyone, and welcome to another episode of DSO Secrets. I'm your fearless host, Emmett Scott, and today I'm going to take on a topic that I think a lot of people are trying to figure out, which is the integration of specialties. I have Dr. Tarek Ali here with us, co founder of Orthodent and modern smiles, and Dr. Dustin Roden Johnson, co founder of Orthodont and clinical director of Orthodontics. I'm going to start. Tarek, you and I were chatting about this, just how hard integrating specialties is. We sit down and we look and we go, man, the patient need is really high. The practice managers might be saying, we're referring these patients out. I really want to be able to, you know, to service them. The doctor might even be saying that, no, usually not. Usually it's the practice manager and the teams that are saying that they see this patient care and they go, man, it'd be great if we had an endodontist. It'd be great if we had a pediatric dentist. It'd be great if we had an orthodontist. It'd be great if we had an oral surgeon. Am I leaving any other good ones out? Periodontist. Right. So wouldn't this be awesome? And then maybe you go over to a spreadsheet, you look at the patients that are getting referred out. Maybe you have other sophisticated ways where you think, man, if just 5% of our patients were getting this care that they needed, how much better things would be? And it's just never that easy. Anyway, Tarek, is that a conversation you have often is trying to integrate specialties?

Yes. Well, first, good morning. Thank you, Emmett. I love your podcast. I learned a lot from it. I love it when you say fearless host, because you are fearless. I learned a lot from you and your guests, so I'm glad to be here to share the love and knowledge. Yes, it's a hot topic. Should we include Specialties in our practice or not. Think about it. People nowadays love convenience. They want a one stop shop. They want to be able to get service and everything they want, hey, they want their oil change while they're being worked on their teeth. Who doesn't want everything at the same time? So it is the natural progression to, to have all types of services in one. Everyone's busy. And think about it, you've already paid the overhead, the rents paid off, the electricity is paid off, the teams are already there. Why not maximize the real estate, maximize the potential, maximize the skills of your team and see more patients in service. This the all different aspects of dentistry to the patients you are. And plus you're giving away all this potential service to someone else where you can do it in house, provide the excellent quality of care that you. But of course provided that you can give the excellent quality of care that the patients deserve and not over promise and under deliver. So yeah, yeah.

I love the intersection though that you just laid out there. Does the customer want this?

Right?

Does the customer want more care provided at the same location? And the answer is the yeah, if they like you, you know, so they, they come in the door, they love what they're getting there. Why wouldn't they want you to continue to add services? So the customer, the patient side is demanding this. We all want simplicity. Heck, we want simplicity just so we don't have to put another Google map, you know, pin in our, in our phone, right? It's just like, okay, I know how to get to this location, I know the staff, I know how they work, I know how scheduling works, et cetera. And then on the other side of this, the business side of this, you've already paid all the marketing, you got the website that's so beautiful, you did the two way texting or the online scheduling. You've done all this investment in order to get them in the door. And then there's these production revenue opportunities that they want that you're saying, yeah, I know this guy down the street, good luck, I hope you find him, you know, and you're referring that out so you're right, it just makes so much sense when you look at the return on both sides. And then let's just talk about the compounding of that for a second. Tarek. When the person says I love going to this place because they get everything done right, they took care of my pain, endo side, right. They took care of straightening my teeth, orthodontic side like when they're able to tell their friends that Versus, like, I really like my dentist, but it feels like half the things he or she can't do. They're always referring me out to stuff. Like, this is something that we know in the marketplace drives patient referrals, too. So there's this compact compounding effect. Absolutely.

And if you like, if you think about it, people have these comfort zones. We all love our comfort zones. That's why coaches always tell you, get out of your comfort zone. Get out of your comfort zone, because your norm is to have a comfort zone. And if the patient already loves your practice, you are their comfort zone. They're used to Susie and Sally in the front. They used to be greeted with a big smile. They're used to this friendly dentist. Why not continue that surgery service instead of having to make another appointment at a different place and getting out of your comfort zone? So it's the natural progression. Absolutely.

All right, great. You convinced me. Let's integrate all five specialties or so in our practices on Monday, and we're off to the races. This is awesome. Thank you all so much for coming today. I'm excited. No, it doesn't happen that way. So that's why we have Dr. Roden Johnson on here. Dustin, you know you've done a lot of work along with Tarek in integrating pediatric and orthodontics, and specifically as an orthodontist and a clinical director over orthodontist, you know that it's not as easy as you just walk in and, hey, all this orthodontist just starts coming out of the practice. So can you talk to us a little bit about some of the challenges and maybe even some of the mistakes you've made and kind of oversimplifying it. And I'm happy to throw in all the mistakes we've made, too.

Sure. Thank you, Emmett. It's great to be here. Longtime listener, first time guest, as we know. I've learned a lot from you and we've shared a lot over the years. So orthodontics is unusual beast relative to even most other specialties. A lot of times with orthodontics, what ends up happening is that you try to introduce something. You say, hey, we're just going to use all the systems like you just mentioned, like you want to bring in oral surgery and things like that. A big mistake that we oftentimes make is that we sit back and say, hey, we're just going to try to put this orthodontic piece into our practice, and we're going to try to do it with all these Same tools. And then we realize later on that, oh, guess what? Orthodontics isn't like the rest. We're trying to put the square peg into a round hole, and it just doesn't work out the way we want to. And I think that Tarek and I can talk a lot about this because we sort of did it together, and we've done it with orthodont for many years. But as things go on, we're getting better and better at it. But each progression that we make, each step, each time we add a specialty to a practice, we understand and learn things that we didn't foresee.

Yeah, I mean, let's call some of this out for a second. It's really easy to say it's all dentistry, right? Kind of like what we do with law firms. Like, oh, you're an attorney, Great. Can you handle, you know, this, this, this, this and this? For me, like my lease, a transaction and my divorce or whatever, you know, it's like, actually different capabilities. And so it is with dentistry. And I think orthodontics, you're right, is probably the specialty that we really need to look at and say, okay, so over here on the general dentistry side, it's really transactional, right? It's like, hey, you come in, you get your service, et cetera, you pay your dollars, boom, it's taken care of, you walk out. Yeah, maybe you have to come back for a crown seating or something like that, but it's pretty transactional compared to, hey, for the next two years, you're going to pay us on an ongoing basis probably, right. And you're going to come into the office and we're going to make these tweaks along the way. It's just such a different relationship and different setup on scheduling, on payment plans and everything else compared to what we see on general dentistry. And when you start thinking about the facility, when you think about how the staff is set up, et cetera, I mean, you can get some conflict and just confusion so quickly, right?

That's right. You hit the nail on the head there. Meaning that most of what we do in dentistry is transactional. It's procedure based. Right? Where is. When we look at orthodontics, it's contractual based, Meaning that the. Like you said, we're going to have a relationship. It was not to say that we don't have relationships in all dentistry. We do, and it's very important. I mean, that's how we build our culture and build our culture of team members and patients. But in orthodontics, there's a little bit higher level of commitment that you have to have to the patient with orthodontics. It's like say, hey, if you open an orthopractice within your facility, you have to be committed for years and years and years, because it's a train and it has a lot of momentum. And once you get that momentum going, it's really hard to shut it off. And I don't know if there's many listeners out there who have tried orthodontics and then say, hey, yo, I'm trying to pull it out. I'm sure they can feel and understand the pain that I'm speaking of, but it's really easy to get into, and it's really hard to get out of it. Give up. So that's the reason why we spent a lot of time trying to focus on making whatever specialty it is you have, making it part of your culture and building it from the front desk, from the first phone call, how does that look versus dentistry or whatever else you're doing, to the first engagement with the patient, how does that look different to getting the patient into treatment? Because I always say that it takes a village to get an orthodontic patient to start because there's such a high level of commitment on the team's part to deliver this care over the course of several years. For us, we didn't really appreciate how different even the billing side things was, because, again, it's a contract. And when you try to explain, oh, you have a billing team that's really, really great at dentistry, and you say, oh, now we're going to do this orthodontic piece, they just kind of look at you dumbfounded because they try to do the things that they've always done, and then they realize, well, this isn't working.

Yeah, I mean, let me call out some specifics here. So if a patient's coming in on a regular basis, you know, we'll call it a month just to make it easy. It could be six weeks, eight weeks, whatever, and you're successful in orthodontics, then you're going to have. I like your analogy of a train or the snowball that's happening. And so you went from one patient's going to come every month. Okay, now I'm up to 100 patients. Now I'm up to a thousand patients. Right. Whatever it is, Coming in every month, taking up facility space.

Right.

And then I'm trying to make sure that these payment plans and other things are all running on Time as well. And to your point, you don't just say, you know, I couldn't find another orthodontist. Good luck, guys. I Hope the next 18 months goes well for you. You know, where do, where do you go from here? Like once you're in, you're kind of all in. And you have to figure out facility wise too and team wise, where things are happening. I'll do another call out on the specialty as well. And maybe you could talk a little bit about this. General dentistry, pediatric dentistry, or a lot of this is a very hands on sport, right? I mean, you're in there kids crying, adults whining, whatever it is, but you're in there, someone's assisting you with suction and other things. Orthodontics is very much of a philosophical. What would be the right word, a strategy? Sport. It's a chess sport of. Okay, I think we need to move this here now. Move this here. But the assistants are the ones that are on the hands on piece. More in that. So your assistant side is totally different. The level of sophistication you need them to be able to do. Am I calling that outright too? That that's a nuance. People aren't as.

You're exactly right. You know, general dentistry or all most of dentistry is very intense. It's very operator oriented, right? Meaning the delivery of care mostly comes from the doctor. Meaning the doctor's there one on one with the patient. I mean, certainly the assistant will bring the patient in and lay them back and do suction and they have certain tasks, don't get me wrong. But in the orthodontic office, the joke that is ongoing with me and maybe any other orthodontist that's in a DSO working with pediatric dentists or general dentists is that they like to take pictures of us and we put on our gloves.

That's the biggest joke.

Because there's a certain level of. The intensity is just not there. In turn, it is like a chess game. In turn, there is a certain level of commitment to your assistance that you have to give them in order to train them properly. Going back to another thing too is, you know, you just mentioned a little while ago kind of about facility, you know, one, one folly that we made as we, you know, kind of growing one of our practices in Texas and Killeen is we said, hey, you know, we have this really great pediatric dental office and it's just killing it. But you know, we don't see patients every day in this office. So let's try to do ortho in this office. And so we did ortho. And then, you know, it turned out that we went from one day a month to two days a month to three days a month to four days a month. And then we're like, uh, oh, now we have this big funnel of patients that want to come and see us. And now we start running, and we're starting to run out of space and said, oh, well, let's redo the facility. And we redid the facility, and then we realized, oh, well, we ran out of space again because we need more days. And then we redid the facility again, and now we're sitting there and we're still in this place where we're running out of space again because the pediatric dentistry side is growing, which is great, and the orthodontic side is awesome. But one thing that when you get into any specialty, you have to, like, you always want it to grow, you want it to grow, you want it to grow. But then you have to say, then there's a point where you say, oh, oh, you know, how do I get out of this growth? Or how do I handle this growth? Because that becomes the bigger piece of it. And again, kind of going back to what you said, you can't abandon the patients. I mean, this funnel's going, the train's moving, and so then you have to start moving facility or building out. And it's a great problem to have, but it's one that you have to be wary of for sure.

Tarek, how do you think about the practice manager who's caught between all these great visions? Right. So let's suppose you have a clinical director in ortho, and we're using that right now. But it could be OS or endo and these other things, and maybe the general dentist is leading this up. But where are some of the problems you see with practice managers and staff conflict and other things that they have to be ready for?

There's only one word to describe it, malalignment. So it's very, very common when you have. When you bombard them with different aspects, you bombard them with the mission and the. The operational components and the financial components. And so there's a lot of that they're thinking about, and they feel malaligned unless you spend a significant time on aligning the mission, vision, core values and objectives. Why are we doing this? Remember that patient that we're serving? Remember the community? So you go down from that approach to, okay, how do we get this done at a high quality? The systems and Processes that go behind the equipment and facilities and supplies and the clinical leadership and all that back down to the financials. Are we making sure that we are at the end of the day profitable? Because it is a for profit business, even though it is the we provide the highest quality of dental care, but at the same time we want to make sure we stay in business and grow and expand and hire more people. So it's that pyramid of, hey, let's align the mission and focus on it. Why are we doing this? The why, as Simon Sinek said. Right, the why. Then going down to the operations, what do we need to do? And then going down to the financials, are we profitable?

One of the places we've had a lot of challenges is we didn't have the metrics for the specialty integrated in a way that the practice managers and others really felt success as the specialty had success. In fact, sometimes what can happen is the specialty can kind of intrude on the other parts of the business model. And maybe it's an opportunity cost exchange that's worth doing, maybe it's not. But if you don't have the metrics aligned, then you got a practice manager who says, all I see is they're coming in using our stuff, making a mess. And I'm trying to get my metric up to these numbers. So, Dustin, I know you've talked a lot about as a specialist, you have very much that the general dentistry side needs to be the customer side within this, but just other principles that you think, you know, maybe you could talk about that principle or other principles you think are important in order to create alignment. And so you don't have that misalignment.

Right. And it hits on a lot of those topics that you just mentioned, really delivering KPIs to the team members, to the doctors, to the practice managers. That's super important to gain the alignment because I always laugh, you know, sometimes when we think about bringing in specialties. There's this one meme that's out there where he just has a guy sitting at a desk and then he's trying to do this work and then there's this big Labrador that's trying to sit on his lap to some extent. When you push specialties onto a practice, whether it's doing whatever kind of dentistry is doing, that's how the practice managers feel, right? They feel like this big Labrador just came in and sat on their lap and they're trying to look at the screen and do the work and they don't really know how to manage this thing, right? And so delivering KPIs and delivering expectation and delivering training is very important to gain that alignment. Because if you don't have the alignment, then it all falls apart. If the dentist is. The general dentist is not the customer of the specialist, it all begins to fall apart because, well, they don't really want to. If they don't have that alignment or they don't have. See themselves as the customer, then they're not going to want to refer over to the specialist. They're going to maybe overlook things. You're not necessarily intentional.

Yeah, let's talk about that trap. You finally get everything figured out. You feel like, okay, I've got this great clinical director, I've got this orthodontist, endodontist, you know, oral surgeon gonna come in. This is gonna be awesome. And I've looked at the numbers, I've looked at the patient types, and so you put them in there. And crickets. Zero referrals, right? Zero referrals over general. Dennis is heads down, doing what they do every day, and they're still referring out to the guy down the street, you know, so what happened there? Why does that typically the result? I mean, I've seen. I've seen orthodontists who, you know, they're bringing donuts to people and they're doing all this marketing, and then they get dropped in and partner on a practice and they just stop doing any kind of crossover to the other side, any kind of training or work. They're like, oh, now that we're all in the same place, you know, I'm going to stop making that effort. So can you kind of speak to that referral piece for both sides?

For both sides? You know, it's very important for a specialist to not take the position in the practice for granted. Right. You know, growing up and having had my own private practices, having worked with the DSO now for eight years and having my own private practice for another eight or 10 years, the one thing I've learned is that if you don't have that same intensity of communication with the general dentist in your office or pediatric dentist in your office that's making the referrals, if you don't have that established and you don't touch on it on a regular basis, then the relationship's going to fail. And then, like you said, you're going to end up with crickets. And what ends up happening is that, you know, we have private practices, we always have this big spreadsheet, and we say, okay, we're going to touch Dr. Smith, this month we're going to touch, you know, Dr. Allen this month and we're going to, we're going to do have these touches and then we're going to schedule something else a little bit later. Maybe it's cookies, maybe it's lunch. Maybe it's just some sort of like teaching of patients or looking over cases together. You know, that's super important even in a DSO environment, even if you're sharing the same space, because the more you can educate the person that's referring to you, the more referrals you're going to have and the more successful the relationship

is going to be. And can you kind of talk through and maybe Tarek, you could take this one on is. What about that referral process, right? I mean, the team is kind of. Inertia is a little bit against us, right? It's like, well, why haven't you made a referral to our specialists that's sitting right here? Why do you keep sending them down the street? It's like, well, because I already got those clicks figured out. Right? So can you kind of talk through? And you're on mute real quick. But yeah. What do you, what do you think?

Yeah. So again, it goes back to that word alignment. If we are focused 100% on aligning the team on the why, that eliminates a bunch of that. They're on autopilot, they're working out of habits, which is a normal human brain response. Right. It's a fright flight, fight response.

And they have a thousand things going on. Right. I mean, in fairness, they got a thousand things and we just threw one more in there. So.

Right. If you think about our lives in general, we make a ton of decisions a day, so we want to decrease the amount of decisions we make. So our brain is trying to conserve energy. Energy. And that's completely normal. And we want them to do that. We want him to work less, we want them to think less, we want them to and work on autopilot. It's completely fine. It's not a bad word, autopilot. But let's ingrain in the autopilot the core mission. Why are we doing this? Serving the patient comes first, the quality of care comes first. And then if there's any change, we have to make sure that that change is not complete until we're 100% aligned and our autopilot is on that mission. So going back to that cor, tons of training, following up, never point fingers, never say, oh, yeah, you should have done this, or instead of that now we go back to the drone board and say, hey, guys, look, this is the, this is why we're doing this. Focus on the why.

And eventually, in what ways could systems make things easier too? And in what ways could you use the assistant? You know, because it's easy to say, hey, doc, you saw this many patients, clearly some of them should have been referred. I mean, just law of large numbers here. So we could just like beat them with spreadsheets all day long. Right, but that doesn't build relationships. So what are some concepts people could use to make life simpler? Because if our job is to support clinicians.

Great question. So there's a book by Atul Gawande called the Checklist Manifesto. I recommend it, highly recommended. I read it a few times. And we implement checklists in almost all of our daily lives. I'm a pilot, I fly, and I can't even imagine flying without you using a checklist. Doesn't matter how many hours you surgeons use checklists. Construction workers use checklists. All the industries that have very, very limited number of failures, including construction and aviation. Think about it. You go in a building every single day. Do you ever think that building is going to collapse on your head? You don't, because the likelihood of that happening is almost impossible. How many buildings have collapsed in your vicinity? Almost none. That's because they are very well trained on using checklists. They know what failures, how failures work. Let's use a checklist to prevent from happening. Yet still in our industry, a lot of dental offices out there are not using checklist. Checklist is the epitome of autopilot. You're putting your brain on autopilot, saying, I know if I follow this, the patient's going to have the ultimate experience. So that that could help significantly is put.

So an assistant working a checklist could say, okay, hey doc, is there anything on the specialty? Do we need to think about oral surgery or orthodontist or whoever you might have? Right. And just that little spark could be like the dentist is able to stay in autopilot still to your point, and say, oh, yeah, they do need to go see the orthodontist.

Right.

These teeth are all out of whack and different angles, etc. So, Dustin, you had some thoughts on that?

Yeah. So like Tarte said, it's all about simplicity, right? You have to make it simple for the team, simple for the preferring document. And anytime you get them out of their comfort zone, if you just establish a protocol like a checklist. We love checklists. Checklist with my best friend. But it makes it so easy and so clean for them to carry on this referral and to think about this referral if it's simple, if it's just a click, if it's just a checklist. Because anytime you maybe ask the doctor to write a referral in an email, I mean, even that's too much. It has to be a button. It has to be just really, really simple and easy. Because for us, if we're hindering the doctor in any way, whether it be showing them too many spreadsheets or asking them why aren't they referring this many patients when they saw this many patients, that makes it hard for them and they don't want to think about it again, or it's bad somehow has a negative impact if we just make it simple, thoughtless, and we have it organized, that it's, like Tark said, going to deliver the perfect, best care for the patient. That's the ideal.

I'm just going to call out a couple other complexities, and part of this is because I think our tendency is just to oversimplify, but we're going to have a new doctor pay compensation structure. We're going to have to figure out, right. Every one of these specialties kind of has their own market value, and based on the region, it could be different. So you're going to have to figure that out. Which means accounting, your practice management software might have to. You might have to have a second, 1/3, 1/4, 1/10 one, whatever that might be, your billing process, to the extent you have finance plans or or so forth, you're going to have to figure that out. And of course, all this is going to have to roll up to your accounting processes as well. Is there any other little nuances that maybe we should just call out for our listeners?

Yeah, I think the number one is the compensation piece because it's constantly evolving. I think that there's a traditional model. But even now, what we used to use in the past in terms of compensation for the docs was like a per diem. And then we say, well, then we found out that doctors, they really aren't motivated by just a per diem. And then we said, well, okay, you know, we're going to give the orthodox a per diem maybe, plus some sort of bonus related to starts or something like that. And then, you know, that's kind of worked for a while, but now with the new generation of orthodontists that are coming out, they want to be paid on some type of percentage with oh my gosh. Percentage for an orthodontist, you know, how do you figure that one out? And it's really tough because they're looking at their friends and they're saying, hey, you know, we get paid, paid 28% or 30% or whatever the case may be. And so the orthodontist comes down and says, well, you know, we want to get paid that same sort of percentage. And then you're saying, well, how do you figure this percentage out? Because you have, you know, this ongoing collections that don't necessarily match the production and say that, so are you going to pay the doctor on collections? Are you going to pay the doctor on productions? So there's a lot of complexity that exists around that rolls up to the accounting, right?

Yeah, it's tough. Yeah, it's a really great call out because generally, and I think we're now kind of again focusing on the ortho piece and how different it is, your accrual accounting, your cash based accounting, all becomes so important to really understand what's going on. I mean, it's one thing if an insurance company isn't paying you for 30, 45, 60 days, whatever you've got, but when you're spreading it out over two years and you've got direct expenses today, you know that you've got to know how that cash flow is going to work. And if you're going into some kind of aligner therapy and they've got big lab fees, you've got to. Success could destroy you from a cash flow perspective if you're not careful. So I think especially on that ortho side, that accounting piece really gets complex quickly and just something you have to think through. Right. And make sure you have nailed down. All right? Yeah, this has been awesome. I think we've laid out a nice checklist of items that really need to be thought through. And I think though we didn't give every solution for each piece, maybe as this is posted on DSO Secrets, people can give some resources. Tarek, you gave some. Dustin, you gave some great feedback even on the customer intensity that needs to be within it and kind of the rollout, if you will, of these specialties. I think those are huge principles that if you just get those right, just take the time to get the accounting right, there's a high likelihood that you'll have much more success than I hired somebody. Hopefully this all works out. Is there anything kind of in closing here? Dustin, we'll start with you. Anything in closing you'd want to say to anyone looking to Add specialties.

Just take it one step at a time, right? Don't try to throw it all together at once. Think through every aspect of it, and if you do, you're going to be successful. You know, none of us do anything the first time perfectly. I mean, that's why we call it practice, right? So my best advice would be take baby steps, think through each opportunity, and then execute upon that the best you know how.

Really go back to the beginner's mind. That day you open that first practice, or you started that first practice, all that same thinking and intensity, you're doing it again. When you do a specialty, doesn't matter if you have 1, 5, 10, or 20. Adding a specialty is starting over and starting from the beginning. I love that. Tarek, thoughts?

Yes. Two thoughts. One strategic, one technical or operational? The first strategic one is really focus on the mission, know your why and make everyone understand the why. The technical part is KPIs. KPIs. KPIs. If you know anything about me, I love numbers and KPIs, and they are the X ray that you can look through your business just like you look through the teeth. So these are two summing up points here.

Yeah, no, that's great, because if you have the metrics figured out, you probably have figured out a lot of other things to be able to get to that point. So I think that's a good North Star. And I love how you keep coming back to that why? Because everybody's going to be asking you, why in the heck are we doing this? And as much as we've laid out, hey, this is what the patient wants. And maybe even the practice manager was encouraging it and now they're like, why did I encourage it? And this is great return for the business because of all of the acquisition costs you've already spent and now you're providing this better service, there is going to be chaos. So the more you understand the why, the better. Well, Tarek, Dustin, thank you so much for being on. I think this kept quite a few people of just kind of driving off certain cliffs or into different potholes that it's just easy to oversimplify. So for those of you who are integrating specialties, have more questions come over on our Facebook page at DSO Secrets. And until next time, keep smiling. Foreign.

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