All the boys got a paper route at age 12; it was required. And it was a great experience. We also had to go door-to-door and collect payment every month. That was my first customer-service, running-a-business experience. At the time, I didn’t realize how valuable that was. In my most recent book, The Bicycle Book: The Story of a Boy, His Father, and a Paper Route and 12 Secrets of Serving Others in Business and Life, are the lessons I learned from him and while doing the paper route that every business needs to know.

I cleaned offices during high school, got my real estate license at 18 and sold real estate all through college, and started a chapter of the largest fraternity in the country, Sigma Phi Epsilon. That was an entrepreneurial venture, and another great experience. During my junior year, I was introduced to a fraternity alumnus, a prolific entrepreneur named Walter Hailey.

Hailey challenged me to find a mentor to help me figure out what I wanted to do. He said, “Learn from them. Borrow from their experience. Copy their genius because you’ll learn more doing that than you can anywhere else.” I took on the challenge. I had such an amazing experience with my first mentor that I repeated it with 60 more people in different businesses. Gaining from all their wisdom and experience gave me the insight I needed to take the next step in my career.

A year later, I told Hailey I’d decided to work with him. He replied, “I’m not hiring.” And I said, “I didn’t ask for a job. We’re going to be business partners.” So, I packed up, drove to South Texas, and went to work for no pay. I knew we’d figure out how to do something together.

DSOPro: Tell us about that experience.

Hailey was doing marketing and sales seminars in his living room at his ranch in the Texas Hill Country, sharing his experience and wisdom from building and selling numerous companies. So, I started putting people in the seats.

We were training anybody who had anything to do with sales—insurance sales, stockbrokers, real estate agents, advertising. One day, a dentist showed up and we thought, “What’s a dentist doing in this course?” It was a total disconnect for us. He came back 6 months later and said, “You guys have no idea what you have here. Let me show you what’s happened to my practice since I implemented what you’re teaching.” And it was jaw-dropping.

He told his friends about us, and soon half of our attendees were dentists. We did some research and found that dentists suffer from a chronic psychological condition we call “approval addiction.” It’s the fear of rejection. All of us have it, but dentists seem to have a higher dose than other professionals for lots of reasons. One is that people walk into a dental office and say, “I hate the dentist.” Somehow, it’s socially acceptable to say that and everybody just laughs. A dentist’s need to be liked and accepted weighs heavily on their psyche and impacts how they interact with patients. Dentistry naturally attracts service-minded, caring, compassionate people and the nature of the business wears on them psychologically.

We found that underdiagnosis of disease is a far greater problem in dentistry than overdiagnosis because dentists don’t want to make anybody mad. Approval addiction results in tentative recommendations, like “Well, you maybe might want to think about doing this sometime, but we can monitor it and talk about it next time.” It’s not everybody, but it is endemic and can have serious consequences.

As an industry, we need to wake up. The Centers for Disease Control and Prevention says that 50% of American adults over age 30 have stage 2 periodontitis or worse. In the United States, stage 1 (gingivitis) and higher comprises 80% of the population. It is the most prevalent disease in the world.

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In our healthcare system, only one group is charged with diagnosing periodontal disease: dentistry. If we’re doing our job, we should be constantly diagnosing and treating the most prevalent disease in the world. If I did a procedure code analysis and looked at how much periodontal disease is being treated versus healthy mouth cleanings, the ratio should be 80% perio treatment and 20% healthy mouth cleanings, or at least 50-50, right? But what we find is the exact opposite, nationwide. On average, dentistry treats disease 20% of the time, and 80% of the time just cleans teeth. Why?

Often, it’s because we don’t want to tell patients they have a problem. Telling the truth takes courage and a really good communicator to explain what’s going on without offending the patient or running the risk of rejection or fearing how they will react.

We see the same thing with restorative—a hesitancy to tell the truth. Every person in every industry has this problem to a degree. It’s innate. It’s not about getting rid of it as much as managing it. It’s not about technique or skill. It’s psychology.

So, we focus on the two feet of space between the dentist and the patient. So much of dentistry relies on that small conversation space. At the end of the day, it’s how skilled dentists are at communicating and recommending treatment. We must communicate in a way that keeps the patient feeling like they’re in charge and that makes it easier for them to make decisions. There’s a whole science around how to make it work.

DSOPro: How did you modify your program to be more geared for dentists?

We decided to put the dentists in their own room and customized a course for dentistry, because it clearly was needed. We went into dental practices to really understand the dynamics of what was going on. It helped that we were outsiders, not dentists. Our perspective was not rooted in traditional dental thinking; we came from a totally different direction.

When we first started the Dental Boot Kamp, some of the biggest educator names in clinical dentistry came to see what we were teaching, like Drs. Pete Dawson, John Kois, Pete Roach, Bill Dickerson, David Hornbrook, Larry Rosenthal, Ross Nash, and many others.

Our training brand today is “ToPS,” Total Patient Service. It’s been a progressive journey for the last 30-plus years.

DSOPro: Tell us about ToPS, its mission, and what it offers.

My passion is to make dentistry the leading patient service segment in healthcare. No other healthcare profession sees more of America more often than we do. Fifty to 60% of the population goes to the dentist at least once a year, and patients are encouraged to have cleanings two to four times a year, so we’re seeing more of America than the general practice physician.

If dentistry leads in terms of contact with the public, we should also be the leader in providing a better patient experience than anyone else. We should set the standard, so when patients go to their physician, specialist, or dermatologist, they think, “I wish everybody in healthcare treated me the way my dentist does.”

On the micro level, how do we do that? If you do the right thing for the patient, then the right thing happens for the practice, in that order. So, let’s figure out the best patient experience and create an environment where it is easier for them to make the right treatment decisions.

In most cases, we’re reengineering the entire patient process. For example, most dental practices mistakenly adopted the “scientific method” taught in dental school as their business model: find and diagnose all the problems, create treatment plans to solve them, and then present that to the patient.

Here’s what it sounds like to consumers: “Come on in and we’ll charge you upfront to find all the problems you never knew you had. Then, we’ll create a solution that will blow your financial mind and expect you to get very excited about having it ALL done!”

The most frequently requested procedure by new patients is a cleaning. When they learn how much it costs, they say, “I just want a cleaning, no exam or x-rays.” If the dentist tells them they need periodontal and restorative treatment, they say, “It doesn’t hurt, that sounds expensive, and I can’t afford it.” It’s a total disconnect because the scientific model doesn’t fit a consumer mindset. When you really break it down, it’s amazing that dentistry works at all.

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We realign this so it is grounded in sound human psychology, in how people naturally make decisions. Nobody wants more problems, so we must move away from this problem-based model and shift to a consumer-driven “want” model. Beyond food, clothing, and shelter, what’s more powerful, needs or wants? Wants are. Often, we do what we want to do at the sacrifice of what we need to do. Everybody knows we’re supposed to exercise and eat right. We all know better, but we don’t do better.

So, we shift to the case-acceptance model, which is grounded in sound human psychology, not just clinical science. We need to deal with the person first, and then the teeth. Sometimes we forget there’s a person attached to the tooth and then we wonder why there is so much unscheduled treatment.

The average practice in America generates over a million dollars per provider per year of unscheduled treatment. That’s treatment they presented, and the patient just said, “No, not going to do it,” or “I’ll think about it.”

When the model fits how people naturally make decisions it’s amazing how everything just flows.

DSOPro: So, how do you do that?

We use different vehicles. One course called Total Immersion focuses on the building blocks for the ToPS case acceptance system. Our team of coaches go work in the practice and reengineer everything, then trains the entire team in all the philosophies and skills. We also have a training program for the managers, so they can train teams within their organization.

I believe there is as much to learn about the service side of dentistry as there is the clinical side. Our mission is for the team to have the skills they need to lead in healthcare and provide a great patient experience. Over a patient’s lifetime, they spend 80% of their time with the team and 20% with the dentist. The team can have a bigger influence, so everyone needs to be plugged in.

DSOPro: Give us more examples of what ToPS coaches are doing to help DSOs build strategies and get results.

We start at the top level. You must create the right kind of culture. We can’t teach a bunch of skills unless we can do it within the context of the culture. We help clarify purpose, develop service values based on that purpose, and then translate those values into skills. We make sure the foundation is in place, then train teams based on the proper beliefs and values.

In my book, The Culture of Success: 10 Natural Laws for Creating the Place Where Everyone Wants to Work, I focus on the culture component. This may sound counter to everything I’ve said to this point, but I don’t believe in a patient-centered practice. They give that lip service, but the culture is usually out of alignment. There is so much background noise in terms of how the team interacts that nobody can focus on patient service because they don’t work well together. Everybody’s got their claws out.

Part of the culture is agreeing on how to engage with each other, a process we call a “Culture Guide,” which is the behavioral expectations that we have of each other as teammates. That frees us up to focus on patients. We need to get the team healthy behaviorally before they can help patients get healthy.

In a large DSO, we work with the office leaders on organizational alignment, purpose, culture, and service values. We do the same thing with the doctors and then we put them all together. It takes work, time, attention, and investment in the long-term vision and purpose of the organization and it has huge payoffs.

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DSOPro: What other challenges are you seeing in group practices and small to mid-size DSOs?

One of the biggest is something so central to the structure of how a dental practice operates that it becomes a major obstacle. The only way a practice is successful is if everything works for the dentist. Because the dentist is the producer, the schedule has to be optimized. Hygienists are also producers, but the dentist produces most of the revenue. So, scheduling centers on helping the dentist be productive—the financial arrangements, the room set up, everything.

One challenge in some DSO models is the confusion between ownership and leadership. In a larger structure where ownership is diversified, unless we have structure, a system, and good training, we’re still centered on this owner-leader mentality. Training in what leadership really means can be a big hurdle for DSOs. Leadership is a personal responsibility, and everybody leads in some way. In the DSO model, we must develop strong dentist leaders. The spirit of the organization comes from the leader.

It is not practical to have the mentality that you are just an employee, so you can’t do anything because it’s “their company.” It just doesn’t work. You’re the leader.

DSOPro: What trends are you seeing or any predictions on where the DSO industry is heading?

I talk about challenges in terms of opportunities—whoever figures out how to tackle the biggest challenges will have the most opportunities. A big challenge today is that the cost of a dental education has exploded. Dentists are graduating with staggering amounts of debt and need to pay it off.

How do we deal with this as an industry? I teach in several dental schools, and there isn’t enough coaching on personal financial management. If DSOs address the debt issue head on and provide the resources and assistance to help dentists figure out their financial future, that helps DSOs thrive as well. Basically, if you solve someone’s biggest problem, you won’t have to worry about your problem. It naturally follows that many of them will be loyal to the organization.

Clinically, one of the biggest issues is standardizing and treating the airway. Nobody else in healthcare is looking at it and it is an epidemic. It is estimated that one out of three people in America has some type of airway obstruction problem, and it’s lethal. Dentistry is where it needs to be diagnosed because it starts in the mouth.

It is now trending in higher-level education (not in dental schools) that we start with the airway and diagnose out. So, it’s airway, occlusion, restorative, and then esthetics, in that order because if the airway is not healthy the mouth is going to be destroyed. Bruxing and grinding happens when people are asleep, and it is airway related. Dentists are perfectly positioned to be the leaders who diagnose and treat it, and that will change the way we treatment plan long-term.

I’m a personal living example of that. A dentist identified a genetic airway problem, and I ended up having double jaw surgery. It opened up my airway and that changed my life. It was amazing.

So, this is another way to grow your DSO. Think about it: if 8 out of 10 patients have some form of periodontal disease and 1 out of 3 have an airway problem, that creates some interesting opportunities. If you’re trying to structure a business to serve the public and help people get what they want and need, these are two huge public health problems we are perfectly positioned to serve.