Do you have a problem that you have to deal with every single day in your business? Every week? Every month? If you said no I’d question your grasp of the day to day operation of your office, wonder why you have so few customer interactions or call you a genius. If you said yes then this article is for you! Now, before you continue, take a minute and make a list of your chronic problems. If you have time, ask your spouse (because they have to hear about your chronic issues and probably know them well), your team members and your IT person and anyone else you deal with regularly. Once you have your list, let’s try and look at these problems for what they really are: OPPORTUNITIES! We are taught to think that problems arise outside of our control and are caused by customers. This happens occasionally in one-off situations but chronic problems are indicative of systemic failure in our organization. Meaning that if many different people have the same problem with our business over an extended period of time then that indicates there is one common denominator: US! Traditionally we orthodontists view these chronic problems as a pain in the rear and an indication that people suck (other people suck – not us or our people, of course). However, the more progressive way of looking at chronic problems is to realize that they are flashing neon signs pointing out shortcomings in the way we conduct business and thus give us a chance to correct said issue to improve our business to the benefit of all.

The good news is that we can change what WE do relatively easily – easily as compared to trying to change others (which is virtually impossible). Let’s look at some common examples of chronic problems in orthodontic offices along with their causes (perceived and real) as well as some possible solutions to each:

1. A lack of new patients – The question is why don’t you have enough patients. Generally orthodontists blame external forces for their lack. Complaining and blaming others for our state is a favorite pastime and one of the hottest topic on any given orthodontic Facebook group but this is both wrongheaded and a total waste of time. Even if external forces (competition, new delivery channels, the economy, whatever) were the cause of your woes, there is nothing you can do to change what other people are doing. You can only change what you do! And change you must if you expect to get a different result. How can you change? I’m glad you asked as there is a plethora of ways to attract new patients. The most obvious is changing the scale, price and/or financing of your product to make it more attractive/affordable but since this is such an unpopular topic let’s gloss over it. Other ways to increase new patient flow are simple things like: Running on time, being nice, answering the phone in a timely and courteous manner, ask fors, finishing cases when you say you will instead of running overtime, having a clean and relatively modern looking office, having an excellent, current and responsive web presence, having a professional marketing strategy instead of taking the shotgun/feel-good approach where you do whatever attracts your attention on that day or whatever your competitors are doing, visiting referring dentists IN PERSON (especially those that are hard to get to or inconvenient to visit), simplifying your new patient process so that it is easy for the patients, simplifying your treatment mechanics so treatment is easy and comfortable for the patients and generally having a good attitude so that you can lead your team by example! These things are simple but not easy. It seems many orthodontists are looking for some magic bullet that is different and interesting but the truth is that the most successful practices I know of are experts in doing the basics well day in and day out. They are consistency ninjas who focus on the fundamentals no matter how good they become or how much success they have. You can do well too, very well, if you focus on the basics, take the long view and don’t expect drastic changes in your results overnight. Huge practices are created with very small building blocks – affordable monthly payments stacked to incredible heights! Once you “arrive” you will know you are successful because your happy patients will be your best referral source by far.
2. Patients being late or not showing up for appointments (especially new patients) – This is a very common gripe that orthodontists always discuss whenever they gather in person or online. The assumption is that patients who don’t show up are just bad people and the wrong kind of patients and “those people”. Unfortunately the one common denominator for all your late and no snow patients is YOU. Plus, remember that we cannot control what other people do, only what we do. So the best way to look at this problem is to examine how we handle the new patient process and the scheduling process as a whole. First, if we doctors take the attitude that certain people from certain referring doctors, or certain parts of town “just don’t show up” or are “always late” then this prejudice will transfer to our team members who answer the phone and schedule appointments. Soooooo when Becky calls to schedule an appointment and our employee finds out she is a referral from Dr. PatientsDontShowUp, how do you think Becky will be treated on the initial call? Probably with some skepticism and maybe even some hostility! What do you think this does to the odds of Becky showing up? Can you see how these kinds of preconceived notions of how certain people will act become self-fulfilling prophesies? As to no shows for active patients, examine how you schedule and what happens when a patient no-shows. Odds are they are given a better appointment time in just a few days so why wouldn’t they cancel at the slightest inconvenience? Try no-showing for your next hair appointment at a popular salon and see what happens. There is a reason no one ever stands up their hairdresser! You can get the same results with consistent scripting and teamwork. You don’t have to be mean just consistent and fair to everyone – including yourself. Next let’s talk about late patients. First, do you run on time? From what I’ve seen in visiting hundreds of offices the odds are not in favor of that being the case. And, if you don’t run on time then how can you demand patients run on time and how can you complain when they don’t? Doctor, you need to run on time. Period. Once that is accomplished then you can set parameters for the habitual abusers and the lateness issue is easily solved but only after you run on time all day, every day. You may have to change your appointment structure or your schedule template but the main way to run on time is to refuse to accept lateness from everyone – especially yourself.
3. Too many “low quality” new patients – This is related to number two. EVERYONE who expresses an interest in orthodontics is worth your time. To think otherwise or judge anyone is foolish and bad business. I’m betting you’re none too busy so there is no reason to judge patients as anything other than awesome. What else do you have to do? Pretend every patient will start even if you don’t believe it. Fool yourself and your team until you do believe it. To the degree that you can do this you will succeed. If you persist in the idea that some people are “low quality new patients or leads” you will never have a top tier practice.
4. Recall/follow up with new patients who do not start is not being done – TCs hate recall. That’s just the way it is. Know this. Manage it. Know that occasionally you’ll have to let one go for not doing this vital task. Know that it’s probably worth a little incentive to get great results considering you’ve already spent 200-700 dollars to get each and every new patient in the door if you consider all your marketing expenses and related salaries. Make recall happen. Stay on top of it every day. Recall is vital. Oh, and remember that if you’d just do same day starts for every new patient you can then you’ll not only have happy patients who appreciate you saving them time, you’ll have a lot less recall that needs to be done!
5. Low conversion rate/lack of new starts – conversion rate is nice and all things being equal a higher one is better but don’t forget that it’s about runs scored not batting average! 100 percent of 10 new patients a month sucks when compared to a 60 percent conversion rate of 100 new patients a month. The point being that you want case starts much more than a high conversion rate if you have to choose. The best way to get this going is to see more new patients and the best way to do that is to have a professional marketing strategy and plan with all of your marketing efforts coordinated supported by an awesome web presence and phone team to collect and schedule the leads you generate. Keep working on your conversion rate. That’s great. But be sure to get the patients in the door and focus on the number of starts above all else! As career students it seems to me that we look at conversion rate like a grade on an exam. This is neither accurate or useful. Starts. That’s all that matters.
6. Lack of compliance by patients – This is another topic we orthodontists love to gripe about but, again, the common denominator for all our noncompliant patients is us. We need to own this and understand that psychology is probably the biggest part of what we do. We cannot expect good results without understanding how to get compliance from our patients. What’s that? You don’t like that assertion and believe in personal responsibility? You think it’s the patients’ fault and responsibility? That’s cool until you realize that we are the medical professionals who are responsible for determining the suitability of patients for the treatment we render and if we have non-compliant patients then either we are incompetent or we took someone’s money when we knew they were not a good candidate for orthodontics. I may be overstating this slightly but the point is valid when it comes to handling this chronic problem. Own the problem, understand that not everyone will comply, recognize this in the new patient visit and pull the plug when appropriate. It doesn’t happen often but it does happen. Work to improve your verbal and motivational skills. If you suck at it hire someone who doesn’t or go visit someone who doesn’t and copy them. Do something instead of just complaining and collecting the money at least!
7. Poor hygiene and parents getting upset with me when you point this out – This is related to non-compliance but touches on the psychology of how to handle the problem. To understand and solve this problem just read this: Don’t Piss Momma Off!
8. Patients/parents getting upset about their insurance benefits – Another chronic problem that we orthodontists complain about. “I told the patient that this is THEIR insurance company and that we are doing them a favor to file it for them” I hear all the time. How’s that position working out for you? Do you really believe this nonsense still? Getting benefits for patients is part of our job description and how we get paid. Own it. Stop trying to convince yourself and others it’s not your problem. Do your best, be kind, be understanding and understand that things will go fine most of the time. When there is an outlier insurance problem just grin and bear it and do what it takes to make mom happy so she send her friends to see you. Think big picture win and avoid petty squabbles. I still struggle with this but luckily Bridget is an expert and I keep my mouth shut.
9. Patients/parents being upset about lost retainers and/or relapse requiring more treatment – Retention in orthodontics is practically the bane of our existence. It probably always will be. Don’t fight it. Don’t do work for free unnecessarily. Set policy that is fair and apply it evenly. If there is an outlier, grin, bear, retreat for free, get more referrals… Retainer replacement plans and smile guarantee programs are easy fixes for these problems. Stop letting this dominate your life.
10. Patients not showing up for retainer appointments – Stop doing retainer appointments and have patients call you, come see you or text you a photo when and if there is an issue. They have better things to do and the problems will be problems whether or not you schedule the retainer appointments they don’t show up for.
11. Not enough parking – Lots of options here! You and the team park elsewhere, make a deal with adjacent landlords for parking or move. This is a tough handicap to overcome so avoid it on the front end if possible or make a change instead of just complaining about it at all the meetings and using it as an excuse for why your practice isn’t what you want it to be. Or own it and stay where you are and realize your limitations.
12. Not enough room in the waiting room – Put chairs by the treatment chairs and invite family into the treatment area, remodel, give up your private office and make it a secondary waiting room… or move. Same as above. Avoid this issue on the front end or make a change but don’t use it as an excuse for not achieving your goals.
13. High rate of declined CC and/or NSF drafts – Communication is the key here at the new patient visit and when there is a problem. Simple things like giving options for the day of the month the draft is performed, getting multiple payment options at the beginning and making sure patients/parents understand their financial responsibilities on the front end help a great deal. NSFs are part of the game so figure it out instead of complaining about it while doing nothing. Also remember that 95% of 4 million beats the hell out of 99% of 1 million…
14. Staff having excessive emergencies/no show for patient days/being late for patient days – honestly this is my #1 pet peeve and I just won’t tolerate it. Obviously stuff happens and emergencies happen and car wrecks happen but these are freak things. Someone who is consistently late or doesn’t show for work on patient days puts undue stress on the team and the orthodontist. If this is happening and the team member is resistant to change then you need to make a change. You must. For the good of the team and your own mental health. No matter how many people they know or how good they are clinically. I’ve had to remove these kinds of team members several times over the years – people I thought I couldn’t live without – and I’ve never regretted asking them to leave. In fact once it’s done I find out all kinds of crazy stuff they were doing that I didn’t know about and I always wished I had taken action sooner. You can’t have a little bit of cancer. Cut it out. Now.
15. Always running behind schedule – This is probably the most ubiquitous problem I see in orthodontic offices and honestly I don’t understand it. You create your schedule and decide how much time to give every patient. You hire and train the number of assistants you have. You create your template. How can you possibly run behind? You know this is a huge source of stress for everyone involved. Stop. Don’t. Quit. Now. RUN ON TIME! Period. If you don’t then you can’t expect patients to do so. Running on time starts with the doctor. If you don’t set a good example you will never run on time. Once you lead by doing then you can set a zero tolerance policy for running behind. This sounds rough but it’s the only way to get there. You will have to let some people go because people don’t like change. But once you get the culture in the office such that everyone works together to run on or ahead of time then peer pressure will work in your favor for any new hires you have. Look, to go home you have to see all the patients on the schedule and you can either see them behind schedule so they are upset and moms are upset and you work through lunch and you finish late and the team has to pay a fine for picking up their kids late… Or you can run on time or ahead of time, have a great lunch finish on time or early every day and even have time for same day starts. It’s simply a matter of choice. But to do this you have to create a schedule template and follow it. You have to have rules for sharing after school appointments and follow them. Bridget Burris described these processes in earlier blogs here on OrthoPundit. Have a look, make a choice, change your life!
16. Patients demanding after school appointments – Have a template and a sharing policy and stick to it. Make sure everyone schedules the same way or demanding parents will find the one team member who will “schedule in the gray”. Doctor it’s vital that you don’t undercut your team when they follow the rules. By giving a demanding mom the prime appointment right after your team told her no (because of the rules you made) you demoralize the team and blow your chances of everyone enforcing the rules you made. Don’t do it. If you aren’t going to follow the rules then change your office hours and see patients after hours and on weekends – though this brings up an entire new set of problems.
17. Front vs back animosity – The blame game is no fun and not useful. Chairside vs receptionist vs TC in the she said, he said battle is common and destructive. Everyone is responsible for everything but we all have specific jobs that we are accountable for. Make sure you have clear job descriptions that everyone knows. Create and nurture a culture of helpfulness and kindness instead of blame and fear. Do your appointment scheduling chairside so those who have to deal with the schedule are in charge of it by and large. Identify repeat offenders who don’t follow the template or the scheduling rules and help them change or leave. Put short term incentives in place for things you want to change and once they change then move on to incentivize something else. Once people do something for a few weeks it becomes normal. Make your office normally awesome!
18. Hour glass schedule – This is a schedule that is busy in the am, dead in the middle and off the hook after school. To control this you have to run on time, have a template and rules, follow the template and rules and make sure all team members are on the same page and one is not breaking the rules or doing favors. A great template and rules only work if they are consistently utilized by everyone. You cannot render good treatment if the school bus drops off 50 percent of your patients after 3:30.
19. Staff drama – It’s part of life in most if not all offices. Bridget is the expert here but some of the things she does to cut this down are: 1) If a team member has a complaint about another team member she gets them both in the room before she will hear it. 2) the 24 hour rule meaning that after 24 hours she doesn’t want to hear about the issue between staff members again or she will solve it 3) removing toxic, repeat offenders no matter how many people they know or how good they are clinically 4) Not having favorites
20. Too many phone calls to answer – If we are talking about new patient calls then this is not a problem, this is awesome. Make sure you have enough phone lines and people to answer all the calls in a timely manner. A missed new patient phone call costs you thousands of dollars! If you are overrun with other kinds of calls then better in office communication and/or more phone lines and people may be needed. First make a log of what people are calling about for several days. You should be able to identify a pattern. If, for example, people are calling to make an appointment because they didn’t get one at their last active appointment then work on making sure no one leaves the office without an appointment. Other problems can be handled similarly but you may have to add to your phone capacity as well. Make a plan and make it happen. No one likes to be sent to the answering machine.
21. Complaints about bond failure – We will always have some bond failure. What is acceptable depends on who you listen to but obviously you don’t want any more than you have to deal with. Bonding technique and adhesives are kinda like religion – faith based, fanatically defended and rarely changed – but if your results are not up to par it may be time to consider conversion. Before you do that an easy way to see if your problem is systemic or sporadic is to track bond failures by tooth, by chair, by assistant and by time of day. If you do this for a few weeks any chairs that have water in the air line, curing lights that don’t work, a chair that the afternoon sun hits or technique issues should become apparent. If nothing stands out then it’s time to visit someone who has low bond failure and copy them. Get yourself a curing light tester too and check them weekly while you’re at it.
22. Overtime patients – Take the braces off. Seriously. We tend to get 95 percent of the work done in the first 12 months then spend the next 12 trying to get “perfection” (whatever that is) and then we spend another 6-8 months thinking that something will miraculously change though we should know better. Get real. There is no such thing as perfection, we are in the Enhancement business and Straighter is what we do. The degree to which we are able to approach “ideal” depends on many, many variables – most of which are beyond our control despite what our ego tells us. Overtime patients will kill a practice. Trust me on this or find out the hard way.
23. Patients who suggest they should pay less because you finish early – I hear orthodontists get upset, worry about and fear this scenario all the time. We tell a patient that treatment will take about 24 months but things go well and we finish at 18 months. This should be a good thing – a great thing – but somehow we mess that up. In any other industry if you finish a job early you can charge more for that! The key here is communication in the new patient visit. I like to say, “Based on what I see here I believe we will finish the case in no more than X months. If things go awesome then we may finish early and that is preferable. If we struggle a bit it may take longer but don’t worry we will hang in and get the job done!” We also make it clear that payment schedule and treatment are totally separate. If I had TCs (we don’t) then after I said how long it would take and the TC went over financing you’d hear something like this. “Dr. Burris estimates a treatment time of 18 months or less and the financing we have in place will allow you to pay the fee over 24 months so that it will fit into your budget. The great news is that even if we finish treatment early (and we all hope we do) then you’ll still be able to pay the bill over 24 months and you will not have to pay in full before we remove the braces.” It’s all in how you say it!
24. Computer/printer problems like operating systems running slowly, slow internet connection, printers not working, etc. – Fix it or change how you do things. I’ve practiced in rural Arkansas where the internet connection left something to be desired but you can always find a solution. Your chronic problem is equally manageable. What you don’t want to do is keep dealing with the same issues in front of patients and team members and complaining about it. Patients and parents don’t know orthodontics but they can see if you have your stuff together or not.
25. Patients say treatment is too expensive, in person and on the phone when they don’t show up/start – Orthodontists treat a very small portion of the population and we believe that is because people are cheap and don’t value our services properly. It can’t possibly be that we price ourselves out of the market can it? As I’ve discussed ad infinitum you can set your fee to be whatever you want but you cannot blame a lack of starts or being considered too expensive on anyone but yourself. You also can’t have it both ways. You only buy things you think are worth the money and you shop around – how can you blame consumers for doing the same? The longer this thing goes on, the more patients’ decisions will center around price. Period.
26. Not having the inventory and lab work you need when and where you need them – This one is an incredibly common irritant but totally unnecessary. Simple systems and planning can avoid these issues. Have someone who is in charge of running reports for lab work due two days ahead of time and physically verifying that the lab work is in the office. That way you have time to get it if something is missing. Set up a par system in the office using sticky notes on the minimum number of packages of any given supply. In other words if you have ten boxes of X and you need a minimum of two then put a sticky note on the second from the last box and the last box that says to reorder. Simple.
27. Inability to keep sterilization of instruments up with clinical demand – First, make it everyone’s job to sterilize and turn over chairs. If you have a “sterilizier” this will make you less efficient because chairside assistants will be waiting on that person to turn the chair. Let everyone turn their own chairs and everyone be responsible for sterilization. If someone has time they wash and bag and load packs in the autoclave. If it’s tight then the office manager or TC can help out. If you have a consistent problem then you may need more instrument sets or another autoclave. Figure it out but don’t let this simple and inexpensive issue hold you up. You may want to consider getting rid of cassettes and expensive instruments so you can have more sets for less money. Just sayin.
28. Can’t find quality employees – This is something I hear every day I’m around one or more orthodontists. People are people. What we do is simple. Or it should be. If you have 74 appointment types 130 procedure codes, 43 different ways to wear elastics, 27 different wires, do a lot of Herbst appliances and you steel tie every day then of course you’ll have trouble training someone to do that crazy stuff. Simplify your life and your systems. There are much easier ways to do all of this and we have discussed most in the 550+ OrthoPundit blogs you can search here. This is not brain surgery. This is just teeth. Don’t make your life any harder than it has to be.
29. Too many Clinchecks or Clinchecks take a lot of time – This is a huge topic and the clear aligner space will become more complicated with more choices more and more rapidly over the next couple years. Consider all your options and understand that the answer yesterday may not be the answer today and the answer today may not work tomorrow. As to Clinchecks taking too long, I’m a big fan of what Dr. Anil Idiculla says about that. “You have to get the ball on the green before you can putt” is how Anil described it to me. So on your initial setup don’t worry about all the tiny details. Just get it close and work out the details on the refinement. This will save you a ton of time and repetition and frustration.

We have covered a lot of ground here and I hope you can see that chronic problems are opportunities if you have the right mindset. Don’t try to implement or change all of this it once. Pick a couple a month to work on and go through the list in order of what can help you most. You can do it. Why wouldn’t you?

Change is good!