Recorded live at Townie Meeting 2019.
VIDEO - DUwHF #1166 - Michael J. Hoffmann
AUDIO - DUwHF #1166 - Michael J. Hoffmann
Dr. Michael J. Hoffmann received his dental degree in 1988 from The University of Texas Health and Science Center at San Antonio. He completed residencies in Hospital Dentistry and Dental Anesthesiology and is currently the only St. Louis area general dentist certified in Deep Sedation and General Anesthesiology by the Missouri Dental Board. He is a diplomate of both the American and National Dental Boards of Anesthesiology. Dr. Hoffmann is very active in organized dentistry. He is a Past President of the Greater St. Louis Dental Society and a member and chairman of various committees at the state and national level. He is a member of the faculty at Forest Park Community College and is on staff at Mercy Medical Center where he lectures to residents on anesthesia protocol. He also continues to educate his colleagues and their dental teams on safe oral sedation in their own private practice. In 1991, Dr. Hoffmann opened a state of the art dental facility that enabled him to provide dental services accompanied with Deep Sedation and General Anesthesia. He is dedicated to serving individuals with dental phobias; gag reflexes, the inability to become numb, medical, mental or physical disabilities, as well as young children unable to cooperate.
Dr. Thoms was born and raised in northern Illinois. He received his Bachelor’s degree from Southern Illinois University Edwardsville in 2008, his Master’s degree (M.S.) in Biomedical Science from Barry University in 2009, and his Doctor of Dental Medicine (D.M.D.) from Southern Illinois University School of Dental Medicine in 2013. After graduation from dental school, he attended a three-year Dental Anesthesiology residency at the University of Pittsburgh Medical Center (UPMC) which certifies him to provide deep sedation and general anesthesia for dental procedures by the Missouri Dental Board. He is a Diplomate of both the American and National Dental Boards of Anesthesiology and holds faculty positions at the University of Pittsburgh and Saint Louis University.
Dr. Thoms has a primary focus in treating children and patients with special healthcare needs such as autism, cerebral palsy, down syndrome, and Alzheimer’s disease.
Howard: So we're on the Salt River Indian Reservation right next to Scottsdale Arizona Townie meeting, are 20th annual meeting and I thought this would be so timely dental anesthesia just got voted in by the American Dental Association as their tenth specialty?
Howard: So there used to be nine special ease now this anesthesia deal the politics minded I think they fifth time they applied for specialty it was rejected four times and no one will say it in writing no one will say it in public so I'll obviously say it, it was always fought by the oral surgeons.
Howard: So congratulations on getting the specialty , so tell him the story about the specialty.
Michael: Well it was it was a long plot battle we started many years ago probably that the person who we give most credit for the initial applications the late Johnny Galia from UCLA because the donor anesthesiologists also wrote books on pharmacology as a PhD pharmacologists probably the probably one of the brightest guys in dentistry there no doubt not hardly any dental ase geologists could leave a candle to him and but also all that effort and all that time.
Howard: and he was in Southern Cal?
Michael: Yeah he's a UCLA
Howard: If he was really that good Michael Jackson would hire him.
Michael: Yeah you know what actually hired Chris Quinn who worked with John at UCLA and that's how Michael Jackson got his first taste for propofol and she went in a dental office and sedated him and when he woke up he said oh my god what was that girl what did you give me would you come to my house and she's like no that's completely inappropriate I can't do that so I that's what started his journey looking for somebody who's gonna sedate him.
Howard: Well isn't that a bizarre drug to get addicted to because it doesn't really make you higher and you just put you to sleep.
Michael: Yeah and that's what he was looking for.
Howard: He just wanted to be put asleep.
Michael: Yeah he couldn't sleep at night he had horrible sleep issues and so he would he had gone through all the different medications everything else and then when propofol came around but then even from the wall after a while you'll after night after night next night you'll develop toxicities and things into that plus he wasn't monitored.
Howard: Now you own a modeling agency or are they dental related at all?
Michael: Oh yeah
Howard: Well you know the one thing I'm every time anybody isn't a huge survey of the American dental market right from the consumer point of view it really only shows up as to markets these are afraid of the dentist or they're afraid of the price. So they're either insurance driven like oh my god I got dental benefits and they'll drive clear across town if you take your benefits and the other half were just scared and that's where you guys come in and
Michael: Well actually 60% of our patients are special needs mentally handicapped so that's our greatest outreach and when I originally started to practice I didn't really reach out to that group very much at all but they found us.
Howard: So what exactly you're in st. Louis are you in december most you're in Clayton?
Michael: Clayton Missouri
Howard: Ok Clayton Missouri so that's a suburb of st. Louis.
Howard: You have one office?
Michael: One office
Howard: All these people in one office and there's three anesthesiologists/ dentists?
Michael: Two anesthesiologist and one general dentist who did a GPR she takes our patients that are too sick to be treated in the office to the hospital and and treats him there and she goes there every other Friday.
Howard: and does she do the anesthesia and the dentistry?
Michael: No in the hospital she has a md anesthesiologist anesthesia and then also she has other medical specialists there cardiologists neurologists.
Howard: So what are you doing in the office then?
Michael: We do intubated general anesthesia and we work as the operator NESTA's model where you the anesthesia in the dentistry will we use very highly trained assistants to help us monitor and it's very similar too...
Howard: So you're doing the root canals fillings and crowns?
Howard: both of you are
Howard: While they're asleep?
Michael: While they're asleep.
Howard: While they're intubated?
Michael: While they're intubated and what is shown is if you look at the Canadian model and they have probably the best statistics actually gang has who's done one year I think on local anesthesia he did one thing about dentaltown on when you're CE's and provided a lecture there she's got great studies and statistics on safety dental anesthesia in Canada and they do the operator anesthesia model where they do the anesthesia and the dentistry and they have a highly trained assistant helping monitor and also assist and in the first I think result was a 15-year study first 15-year study there was one death and in the second 15-year study there was no deaths and this was in hundreds of thousands span aesthetics and so their safety is well shown, well proven.
Howard: and safety is so emotional because like I'm like I have four or five very good friends that are afraid of flying and last year one guy died in airplane America on Southwest Airlines heard a little piece the engine flew off and hit the window which to me is no big deal because now I just moved from the window to the aisle seats like ok I'll sit on the aisle no big deal but then thirty thousand died in a car and people drive all around the car but soon when they start talking like this 737 that went down and the whole government is all freaking out about one airplane that went down and might on just the day that that plane went down more Americans died in a car.
Michael: Oh absolutely
Howard: If they treated it like I've been in Ahwatukee for 31 years and there's this one intersection 48th and Ray, 48th Street in ray road and someone dies every month since my dental office has been there and they're all I want to talk about this airplane are the one anesthesia death and I'm like why don't they shut down 48th and Elliott until someone can 48th and Ray until they find out why somebody dies every month.
Michael: Isn't that where the driverless car the person died or something like that the accident with this?
Howard: Yeah and the day the driverless car killed someone I think 11 people were killed by a human driving a car and that doesn't even make the news. So risk is very emotional so 70% of your practice is special needs?
Howard: 60% and define special needs...
Michael: These are people with autism, severe palsy, Down syndrome just the whole mental handicap spectrum.
Howard: and what do you do with those you can IV sedation do you intubate them?
Michael: Well most of our anesthesia is done whether they call teva total intravenous anesthesia and well maybe given an injection maybe midazolam ketamine to get them to go to sleep initially and then start an IV on them after that we may also use SIBO a gas to put them to sleep and then after that done we'll intubate them get them all squared away and then we go about our dental business and then wow these are all expanded function dental assistants as well.
Howard: So you're Missouri so you have expanded duty function assistance, so what are they allowed to do that are not a lot of notice states?
Michael: They can place composites they can besides all the x-rays and all the other things that they can do but mainly place composites take final impressions for crowns.
Howard: So are they a dental therapist?
Michael: They're not a dental therapist.
Howard: What's the difference between a dental therapist and an Efda?
Michael: A dental therapist actually does an irreversible dental procedure which is to kinda choose or to remove it to you there I think also a lot of them are also hygienists are kind of dual trained as hygienists.
Howard: I'm not aware of that but you think a lot of them are?
Howard: Yeah I don't understand I'm the dentist some so historically when Bob Barkeley was going around the country when when Bob was going around telling people they need to have a hygienist who fought it the dentist's cuz they said we're so busy pulling teeth doing immediate dentures we don't have time for this this this hygienist thing and then and then they had to realize well do you want your daughter to have all of her teeth pulled and get an immediate denture order her CI hygienist and they fought that tooth and nail. So then historically it's always the same people the same process they just think in fear and scarcity so now they're now the dental therapists are coming out and it's like like when EFDAs is like I mean I'm in Arizona I almost stayed in Wichita Kansas where I was born and raised just for the EFDAs because my dentist friends in Phoenix or in Wichita they would they would numb numb numb three rooms then they'd go back and prepare the MODs prepare the MODs prepare the MODs and they have to sit in and place rubber Dam do them I'm like who is fighting that oh all the dentists well why would all the dentists fight that I would rather be in my office surfing dentaltown then placing all the fillings. Why do the dentists always fear?
Michael: I think a lot of them have control issues I know one.
Howard: Control issues
Howard: Yeah yes because we used we like to use our EFDAs to their full function but our one associate Dr. D she doesn't use them as much she likes to place her own composites.
Howard: See what I had to do is I had to use my assistant beyond the legal scope and going to Kansas EFDA stuff and that's why she worked me so long because I could fire her because she'd sue me for all the illegal stuff I made her do for 30 years but that's a joke I'm kidding but no I just I mean to me like is this whole anesthesia thing it's so is so simple if you just put the customer first.
Howard: What's the customer want like with implantology as much they I mean if grandma wants to get an implant and an over denture and she wants one guy to do the whole thing well then there should be implantology and the oral surgeons say no we should place it the general well that might work with you and the dentist but it doesn't work for Grandma and if you just keep putting only the customer first patient focused like pediatric dentists like the ones growing the fastest are the ones that added an orthodontist to a pediatric dentist because know what busy mom wants to go to pediatric dentists say oh here's a slip you need to make it appointment go across town fill out another charge to save your kid needs braces well no why don't you bring that orthodontist in here I've already come here I've already filled out a chart one-stop shopping it works in retail and it works in dentistry. So I'm special need so you're but you were talking about profile with Michael Jackson are using Propofol?
Michael: Yeah we use quite a bit of Propofol.
Howard: So what year did you graduate dental school?
Michael: 1988 so we're the same age we're like two weeks apart in each other.
Howard: Okay so you're almost dead is what your saying.
Michael: Yeah August 16th 1962.
Howard: So my deal is but has anesthesia changed a lot in 30 years of the drugs change a lot since 30 years ago?
Michael: Oh yeah quite a bit safer the Propofal was just coming out when I was a resident and that was you know 28 29 years ago and that was a game changer because with drugs like Revitol and a lot of oral surgeons are like Revitol but you know you get more bronchospasms and other other problems that heightens the pain threshold things like that so if we can avoid medications like that the better so Propofal was a great replacement to that but the inhaled anesthetics sevoflurane has been a game-changer because it doesn't have a lot of cardiac side effects and any things that the old and inhaled anesthetics did.
Howard: Was the old inhaled ether a hundred years ago actually porous wells.
Michael: Yeah there's some dentists out there they'll do some of the old guys who still talk about the good old ether days yeah.
Howard: I think it's funny I saw a study of all the prescription medications available in the United States in the year 1900 and almost all of them had cocaine morphine and alcohol they all had those three ingredients times have really changed it's really hard to get a prescription with cocaine and heroin morphine you know. Do a lot of special-needs kids need the sedation on odd what is what is who needs it the most?
Michael: Mostly autistic.
Howard: The autistic because they don't like the noises in the sound.
Michael: They're very orally sensitive they have a lot of sensory issues.
Howard: and do you think there's more autistic people now or do you think they're just measuring it...
Michael: Unfortunately yeah
Howard: Do you think the percentage is actually growing?
Howard: because I know when we were little everybody just had that kid in the class right like my sister's that has that so back then I was just okay you have that kid in the class but you think it's actually increasing?
Michael: Yeah the more today originally I thought it was maybe just because they were more aware of and they were decorating and more things like that but a good friend it's a head of the stainless Children's Hospital head of Pediatrics psychiatry said no there's it's growing and it's growing at a significantly accelerated rate each year.
Howard: Do you have any ideas why?
Michael: You know there's definitely a genetic component there there's a lot of people like to play the blame game spread it around things like that.
Howard: Everyone I know that as an autistic children has another one in the family somewhere just like I just try was a day that my grandfather was short fat and bald I was I was shocked I did not see that coming. Yeah everybody I know that has autism it's a family thing but I mean.
Michael: and we see that in some of our families where they have more than one child with autism so it's a shame I mean it's really you know it's really difficult hard on some of those families especially with the more difficult children yeah.
Howard: I noticed I know it's growing up with them with having a sister or special needs that it was it was kind of an IQ test number when like we'd be at a grocery store and she might do something bizarre and high self-esteem people would just instantly see it you know and was like yeah you know you know and the people that were scared around I always thought it was like an IQ test hey you don't get my sister you just really not that smart cuz all the smart people got it they just looked at it and they just instantly knew okay so something's not quite right and the ones who are scared just like you know what are you afraid of ghosts.
Michael: Well I think really has helped that is the mainstreaming a lot of these kids in the public schools and so they have somebody working with them and they keep them in the main classroom with the other kids the other kids understand now are growing up understanding what's going on.
Sean: I graduated from dental school in 2013 and the dental schools have really been pushing general dentists trying to treat special needs patients so you know as dentists we're actually seeing a lot more the special needs patients in training so it makes it a lot easier for treating practitioners to actually get out and private practice and attempt to treat some of these patients.
Howard: So what and all the things are doing dentistry what made you attracted the special needs where does that come from?
Sean: The special needs came after the anesthesia portion of things you know I trained at the University of Pittsburgh trained at the University of Pittsburgh and we had a special needs clinic where every day we would run 3-hour cases of anesthesia for special needs patients and you know the dental students and some of the faculty would run there and perform the Dentistry why we put them to sleep so that's where the special needs I really got you know a taste of special needs for the first time and actually being intricately involved in the work that we were doing. In dental school you know we had rotations but it was usually you know we would observe well you know a dentist or a pediatric dentist would sit down and do the work on them and try the behavior management techniques and things like that. So I got my first taste in my anesthesia residency and that kind of joined his practice through almost three years ago now and again that's 60 percent of our practice at this point so you know it kind of snowballed.
Howard: So I think with the hidden camera I mean you know you just when everybody has a recording device I mean people are crazy I don't think it dentists can really do the Papoose board anymore, I think one mother taping a child strapped down a Papoose board and posts on Facebook that could be that could, so do you think the Papoose board because of the iPhone is now dead?
Sean: Honestly I definitely because the iPhone but I feel like the Papoose board you know as you know your dentist doing dental work is very intricate and detail oriented if you can't do it well I mean the kids even if they're Papoose they can still move around you can't do dentistry on a moving target not possible to do it well at least make sure margins are sealed so you know that's one of the things that I think as practitioners I think that's one of the one of the things you know in Pediatrics you know you get the job done the teeth unfortunately fall out in a couple years anyway so it really doesn't matter if they were papoosed, when you start working on adult special needs patients you know those teeth they're going to be in their mouth for a long time or potentially and it's just not feasible and again one social media hit and you know you take a video of a dentist strapping somebody down that's not going to be good advertising for that dental practice just trying to do the work with the patients struggling.
Michael: Well also back in the day you know everything was amalgam and everything else you know moisture control and all that didn't matter and now you know everybody wants to colored fillings and especially our special needs patients we think amalgam and heavy metals and everything else are also contributing to that so you have to do bonded odontics and so we kind of take extra steps when we place our composites things like that because we know we're gonna see a pretty high recurrent decay rate and and we place gluma down not to the relic Christian's in two minutes but you know place it down for 30 seconds to prevent sensitivity put a glass ionomer liner under there because I help try to protect us from recurrent decay a little bit and then composite on top and we really do a lot of small increments and make sure that's cured so our patients don't have any sensitivity issues afterward because you get a some of autistic kids with sensitivity issues on a composite or something they'll begin to self mutilate though start to bang their head against the wall but they won't be able to tell you that hey this tooth hurts so you got to take all the precautions and everything upfront make sure that that kid has no problems afterward.
Howard: It's sad because I'm amalgams I mean dentists so many people just believe what they want to believe they don't care about any facts repairs but the average amalgams lasting 38 years and the average composite lasting six years because it'll fail from a bacterial infection and amalgam is half mercury which you'll never find that in the multivitamins you know they never say flintstone mercury vitamins and then silver silver diamond fluoride the hygienists use fluoride it's tan I mean everything and amalgam kills bugs and then moms like now I want the plastic stuff. So what about you anybody we you want to add anything?
Michael: I wanna introduce some of these guys because part of the anesthesia team is their training and so all the assistants all went through what they call the dance program dental anesthesia is a national certification exam and we and that's the program they were lowered the dental anesthesia assistant national certification exam. Yeah they have a website it's on the Amos website so as a program that is this website, it's American Association of oral maxillofacial surgeons and it's a program that they have to help train your assistants and become better anesthesia assistants.
Howard: Wow they let non oral surgeons offices use that?
Howard: Well the oral surgeons surprise me when this one because usually that the ones that think in fear and scarcity are the orthodontist. I mean even though dentaltown they have to have their own separate website but most of the oral surgeons like if you're in dental school and you say can i watch you pull a wisdom tooth they say sure, you ask an endodontist can I watch you do a molar sure, you know you there everyone will help that dental student except the orthodontist.
Howard: Oh well can i watch you do ortho, no. It's like what I mean so it always surprised me that the oral surgeons fought this dental anesthesia, especially when I'm in Phoenix I'm in Ahwatukee, so my oral surgeons Greg Edmonds he hired an anesthesiologist 10 20 years ago just for the business of it. I mean he doesn't have the anesthesiologist go there and set it all up and then he just goes in there and does his thing so for him it was like being able to do it faster easier higher-quality but anyway but anyway so the ACLS website has a surgeon program for dental assistants and all of yours took it?
Michael: and then you know all the assistants here are all ACLs certified bands cardiac life support they're all pediatric advanced life support certified and then how many we have four of them right now that are becoming ACLS instructors.
Howard: Really who's doing that? That was intense that's pretty intense so tell us about that.
Michael: Well they started as BLS instructors there how many here are BLS instructors here?
Howard: What is a BLS instructor?
Michael: Basic life support.
Howard: Okay so they start out Basic life.
Howard: and now four of them are gonna do ACLS
Michael: They are going to become ACLS instructors and they were asked by the...
Howard: So let's talk about some of the cases that are all over the I mean we all know about the case in Hawaii and I mean that what are these offices doing wrong?
Michael: Well one you have to start out first of all with the person providing the anesthesia that the highest level of training possible. So you look at you know what dentling and see geologist brings to the table a minimum of two years now there are three year programs in anesthesia then on top of that you look at the training you know especially Pediatrics because majority these are pediatric cases so in Pediatrics Dental anesthesiologist we do to 200 has to be a minimum of 200 cases Pediatric seven and under, oral surgeons do 150 cases of 18 and under. So if you're just moving wisdom teeth on 17 year olds and that's your pediatric should you really be putting a six-year-old to sleep.
Howard: Explain to the kids in dental school why is anesthesia on a five-year-old so much more risk than at 50 year old?
Michael: It's all about the respiratory reserve things just happened that much faster with children so we set up and we have any kind of issue every all the drugs are drawn out ready to go they can't be in a crash cart down the hall your we have and we secure the airway right away and that's one of the major problems they have a lender spasm bronchospasm or just airway obstruction and so we're intubating the patient so we just secured the airway we've taken that out of the equation from the get-go.
Howard: So you intubate if there's an emergency?
Michael: No all our patients are intubated.
Howard: So review the Joan Rivers thing, she had a laryngospasm.
Michael: She has a laryngospasm so and unfortunately they knew they had a problem they just weren't prepared to treat it and they weren't really from my understanding allowing the anesthesiologist to get in there and treated the EMTs wanted to continue to do their exam and look at her vocal cords and so on. So they really attended it to it way too late I mean you have to have the drugs ready at succinylcholine by things like that the majority of laryngospasm we can break without actually having to paralyze the patient.
Howard: but what do you what do you say I mean because you hear the argument some but some people's argument saying that that should only because it like Joan Rivers like that should only be done in the hospital no more private practice settings, what do you say to that?
Michael: Actually look at the California study they when they did on pediatric anesthesia that majority or a large portion of the kids that died, died in hospitals and died in surgery centers not that many in dental offices.
Michael: and then three of them we're due to local anesthesia there's apparently a local anesthesia death almost every month in the United States.
Howard: So you know the pediatric deaths that I've seen in my 31 years is on the hygienist goes and numbs up to child and their gonna do like four quadrants and then the pediatric dentist comes in and doesn't know the child is already numb and then he renumbs them and that's what happened right here in Arizona and then to make the matters ten times worse what was the first knee-jerk reaction of the dentist to change the chart oh yeah erase the chart and change the chart so now you've gone from I made a huge mistake so now I'm a criminal and the Attorney General can put me in a cage. So um you know so that panic thing when someone's caught doing something bad this is like rule number one just don't lie I mean all Bill Clinton had to do is say hey you wanna be married to Hillary yeah I did it and everybody would have said wow wow too much information now all would Iran but what did he do he lied and when the dentists lie it's always on the chart and it takes it from Arizona State Board of Dental Examiners to the attorney general's office so goes from civil to criminal and the same thing with substance abuse I'm lots of dentists the DEA will walk in there and say you know what are you doing with all this vicodin and the ones they just raise her hand and said dude I'm so I can't quit eating vicodin I got no worries and they put them in a program they pee in a cup they go to inpatient outpatient and they get them off and it's all good the dentist says oh no I'm dispensing these to my patients and then they've made all these journal entries and start lying to the DEA and then it ends up you get sober because you're in prison for years and so rule number one is just don't make it worse by lying you know when you when you screw up you screw up and just be honest with it.
Michael: Always admit your problems.
Howard: Yeah but I'm lucky because I've never had a problem and it's been 50 56 years problem for you and imagine that. So now that dental anesthesia is a specialty. How will that change anything well what's different now that that's a recognized specialty?
Michael: You know we already had some things in place like Centers for medicare/medicaid they already recognize us as specialty so the federal government are you know because the ADA is a boys club you know.
Howard: It's a membership organization.
Michael: Right and so and then then they have the lawsuits that went around from state to state where anesthesiology and implantology were suing the dental boards and getting the ADA specialties removed from the don't practice acts so a lot of the dental boards just went in proactively and just pulled all the ADA specialty a specialties in Kota actually removed all the ADA specialties as well they said you're all advanced education and general dentistry training programs so that we have no specialists right now as far as clueless concerned.
Howard: and what is Kota?
Michael: Kota is that side Council on yeah it is for dental education accreditation dental schools hygiene programs Dental Assisting programs specialty programs and so they have a credit all those and it's part of the Department of Education but it's also kind of jointly run or funded by the ADA.
Howard: So where do you get your client your patients is a more referral because the general dentists has a hard time treating special needs or is it marketing and advertising?
Michael: We have a very wide base referral base we just found out because we worked with them yellow group and looking at our what's our merger and everything else in our partnership and they said wow you have quite the referral network of over like four hundred dentists and so we get and a dentist never knows when hey you know what this patient is too much for me I'm gonna refer you to these guys that can take care of you and pediatric dentists are probably our biggest referral but also the homes that help house special needs patients and there are organizations they refer the patients in as well.
Howard: So do you consider yourselves pediatric dentist? What percent of your clients are under 16?
Michael: About twenty percent
Howard: Twenty percent
Sean: We do alot of pediatrics but pediatric dentists no.
Howard: So the biggest country you know there was really no controversies in I mean know very many controversy Piedra see the police board was one and I could see either way because you know it if you managing a puppoose board well that might be safer than someone taking it to the OR. So you know that was their show but now it says silver diamine fluoride it seems like this seems like either loved it or hate it there doesn't seem to be any middle, where were you guys on your thought since?
Michael: We're using silver diamine fluoride in our practice.
Howard: Do you agree that its controversial?
Michael: Yeah and you know I've seen some of Gordon Christensen's reports on it where he says it doesn't kill all the bugs and it doesn't stop all the decay and so and then you have to apply you know have multiple visits I have to get it to be effective but there's times where we're trying to slow down the decay rate on somebody and so we can spread their treatment out maybe over a couple of years something like that or we may have a one-year-old or two year old that we don't want to have to go to sleep so we'll have them in and we'll just paint that on.
Howard: What's bizarre to me is that the mom doesn't want a silver filling but she'll take the black silver diamond fluoride and so because a white composite is inert plastic it's kind of like it's dentistry to me is like a Kansans you know they they always build these wood barns and they're always freaked out the termites eat it, you say well if you made an aluminum barn termites can eat aluminum so if you made a silver filling you know it would just last but but now I think the next generation of some what people aren't talking about is pediatric dentists so this is 2019 in 2014 Japan started selling more adult diapers and baby diapers. So when you look at the 20 richest countries you know at the end of World War Two in 1950 the average American woman was having 5.1 kids that's sound at 2.3 and then the fastest-growing segment is women over 100 seconds women over 90 third is looking over 80 go to nursing home there's a hundred women and one man named Lucky lives there for like one week. So in a country that's selling that's starting to sell more adult diapers than baby diapers with dementia as I merge the silver diamine fluoride actually has more implications in nursing homes okay so we have first set of Americans we'll finish your life in a nursing home and it's not going to be one of us three guys it's gonna be all you girls.
Michael: Well some of our scariest patients that we do in further Alzheimer's facials because you know by the time they get to us they're in there pretty late stages of dementia they're not verbal they can't say hey by the way you know a lot of chest pain today before you put me to sleep that kind of thing you know so we don't know any of those things going into it. You try to get as much work up as you can but even the physicians are limited as to what they can do so you know if we can get them in there and you know just do something quickly maybe take out the abscess teeth things like that but then just paint silver diamine fluoride on everything else and they get them out of anesthesia as quickly as possible.
Howard: So do you have silver alerts I don't know if it's in Arizona do you have silver alerts we're on your with oh yeah and I've already witnessed that you know I'm already starting to get silver alerts on then you're driving down the interstate and it's a Silver Alert but I saw one my first time in McDonald's were they called the police because this gorgeous man was just smiling at everybody and but he wouldn't leave and and and I was observing at all the police police came and they said him so how are you doing and he's like good how are you doing and he goes and he goes what's your name and the guy looks and goes well what's your name yeah but like he had a wallet so he retired to the wallet they radio in they call the wife but he'd been gone you know he'd be gone six seven eight hours so it's it's really a growing thing because people are living so long.
Michael: Yeah it's then we're kind of wondering what the causes of it are now their calling it type 3 diabetes it's like that's how that mechanism works I'm not exactly sure.
Howard: Well I was I was lecturing I was in Omaha I was talking to a guy at Creighton University of studies at full time and how he was explaining it to me and but he's a full time researcher on it that you either lay down all that low-density lipoprotein and in your heart and you die of cardiovascular disease 10 years earlier or you're the Alzheimer deal and you're laying it all down in your brain and you have cleaner heart so you live 10 years longer but your brain has the the long slow goodbye whereas the heart is the fast goodbye. He thinks it's the same disease you either lay down in your in your arteries and veins or you lay down in your brain and that was his oh but the one thing you do know the Alzhimers people live a lot longer so you know would you rather die of a heart attack at 65 or Alzheimers dementia at 85 even even Mrs. Reagan Nancy Reagan called Alzheimer's The Long Goodbye you know because the heart you just it's goodbye and Alzheimer's slow goodbye but do you think that's gonna be more and more and more a part of your practice?
Michael: Well unfortunately yes and I think we're gonna see more and more in that because especially when the spouses are involved now the homes it's a different story a lot of times they'll just let things go unless Elson there's swelling or abscess or February they're trying to figure out what reason why they having this infection going on the body if it's not just a urinary tract infection or something like that and they're trying to track it to the teeth and you know like the hygiene there's poor diets awful high carbohydrate you know it's just a recipe for disaster and then medications and mouths are dry and it's just it's all rolls.
Howard: It's a perfect storm.
Michael: Oh it really is.
Howard: I've gone too many nursing homes in Arizona and and observed you know followed them around if they if they don't mind and they find out your a dentist they don't seem to mind and it was just amazing because is everything is a catch-22 goes since you're all elderly missing a lot of teeth so for the cafeteria it's all gonna be much salt pumpkin pie and macaroni and cheese and just carbohydrate mush and then why are you in a nursing a lot of it's for dementia Alzheimers I mean they can't take care of themselves. Well if you're in a nursery just just by definition you probably have our time brushing and flossing your teeth and then this little nurse is in charge of like this whole wing and she's got to feed him bathe and clothe him and get him I mean she's got it so when it came down to brushing all I ever saw was a toothbrush one of them disposable ones that's horrible a little bit of toothpaste swish swish spit in a cup done. It's like you might as well just apply deodorant to her lips I mean was I mean it wasn't a dove it's been easier. I mean so there's no homecare they're only fed mush but that's how four and a half percent of America knows so how does that get addressed?
Michael: You know it's a cost it's a dollar issue you know.
Howard: Money is the answer what's the question.
Michael: Always and they have done more staff that they're really difficult time getting staff in those facilities getting well-trained staff and then getting somebody is going to go around I know there's some proposals with Oh was it the digital learning are they where the hygienists can go in there and take x-rays and camera do an exam do all the dentistry.
Michael: Yeah and so maybe that something like that will help but again it's always a dollar issue you know how are they gonna get compensated for it you can't go in there and do it for free my forty my dad's in a nursing home you know.
Howard: How old is your dad?
Michael: Ninety one
Howard: Ninety one that's amazing.
Michael: Well he's had three strokes and so if we didn't go in there and brush his teeth and floss and do all that other stuff it wouldn't get done.
Howard: Yeah well it's weird cuz who lives the longest in America single women who lives the shortest bachelor men and when bachelor men marry women woman's life expectancy goes down men goes up. My two older sisters are Catholic nuns and one of the nunneries in Lake Elmo Minneapolis is like the average nun lived to be like 95 and women when men marry women we sucked the life out of them and so that's actually the answer it's a nursing home all nursing problems just be born a man and you'll die before you get there so you don't have to but your dad made it but yeah I'm gonna be 91 so you got some really good genes.
Michael: Yeah well we'll see yeah you know I guess my best friend's dad just died you know the night before they went out to a steakhouse at stake creme brulee two glasses wine went on never woke up I was like I'll take that one yeah if you can pick that's the way I want to go.
Howard: Yeah I don't want Alzhimers I want to be reaching in my refrigerator for a big chunk of cheese and a beer and then just hit the floor dead that's the way to go. So EFDA expanded function I mean could you do what you do if you didn't have all these EFDA people?
Michael: Absolutely not
Howard: So why do my homies I mean you talking about like dental therapists and they just like go psychotic I mean they they just said though they're ready to fight it with everything they got and they did it with hygienists like I go into dental office and I say well why don't you fire your hygienist and you do all the cleanings they like he like well why would I do that and it's like well that's what everyone said in the 40s and the 50s and the 60s and the 70s fighting it tooth and nail and how they're doing it with EFDAs and what I've seen with that possessed but if a dentist has to place all the fillings you know try to do like a whole quadrant in like one hour he's always trying to go really really fast but in the dental with the EFDA they have to do it there's not that time pressure so much and they're allowed to just go at a better pace and it turned out to be a better quality restoration do you agree with that?
Michael: These these guys do a great job I mean you know it's really far as you know they're placing the restorations things like that we always are under a little bit of a time crunch because the patients are under anesthesia so very different there I think where a lot of us are worried about it is maybe with the DSOs and so they're gonna start hiring a bunch of therapists and letting the dentist go and then they'll have this large mill but doing it again you know it's a licensure issue and other things like that the DSO would probably control the purse strings more and control that therapist more and say hey you're gonna be doing this and this and this and this and like well you know I may not agree with that diagnosis yeah a dentist would probably argue with them but the therapist may not.
Howard: The problem with the DSO argument is like like where I'm from Wichita so yeah like for you have like 400,000 people you know you have five six hundred dentists whatever and one one Heartland will open in the middle and all talked about that that one Heartland or that one DSO so I did they're not even they're not even fifteen percent of the market and they can't keep their dentists for a year so the business. So what I'm thinking about how the business model of Dentistry works is like I'm not gonna think differently because the DSOs because those haven't proven themselves if they prove themselves they would go public but when snapchat can go public but a DSO can't it's not a business and I am old enough the first round Orthodontic Centers of America when I got at school there's one on the New York Stock Exchange a dozen on NASDAQ and they all imploded then they went away now they're back Wall Street didn't forget it none of them will touch them but the dentistry is all worried about it's like well when you're telling me you're worried about the DSO across the street and it has a different dentist every year well it's like well why does your staff quit every year you know because that's all you do is slow down and staff turnover maybe you can I mean how long is your staff been with you?
Michael: My office manager Mary's been with me long as twenty years...
Howard: So look at this wounded veteran twenty years see but that's the thing we have a dental office where the dentists and the receptionist have been there 20 years well you ask them these DSO scan competing inside because you know they're gonna come back and say well I went there but every time I go there it's a different dentist is it ever receptions that ever and I just and they said I needed 15 crowns which is weird because I only have 12 teeth Wow they overshoot their crowns my three teeth. So I'm not worried about I'm worried about that is model and I just I just don't know why the dentist wants to do their own cleanings and place their own fillings to me that's just I mean call me old fat dumb and lazy but...
Michael: I know I'd much rather have a hygienist.
Howard: and the only people I can't convince to do that are my dentist friends and it's like it just doesn't make sense you don't want to do your cleanings if you can have a hygienist do it and we're EFDAs raise your hand do you guys like placing fillings you like doing it and what types of fillings do you place?
EFDA: All of them
Michael: They can do all classic fillings yeah
Howard: Well does anybody else want to say something after hearing all this guy's all just shy what's up?
Michael: Well they're all licensed phlebotomist and IV therapists as well.
Howard: What is a phlebotomist, a vampire?
Michael: Yeah essentially they go and suck the blood.
Howard: Is the sun light bothering you since you're all vampires?
Michael: So we place we use a lot of PRF in our practice which...
Howard: but you said they're all licensed phlebotomist?
Howard: Explain to someone what a phlebotomist is and why are they licensed.
Michael: Well they go in they went through a training program that this certified by the state of Missouri and they now can go and draw blood and start up now they're also certified IV therapists so they can go in and start IVs I can't start administering medication seems like they can't do but they can start IVs.
Howard: and what's so important about I remember in dental school a lot of the people that were in dental school their undergraduate degrees in biology chemistry or whatever and all through dental school they were working at Circle K for a minimum wage but the ones who became hygienist first they already learned about half everything you're gonna learn to dental school but during dental school they had a good job being a hygienist and one of my guys one of my friends Steve was a phlebotomist and while we were working at Walgreens for $3 an hour he was making bank as a phlebotomist in the hospital. So I think your undergraduate degrees should be degrees where you actually get a job cuz then during dental school you actually have a better source of revenue all through dental school, I'd really be a phlebotomist or a hygienist all through dental school than working at Circle K.
Michael: We had some people in our class or pharmacist and they work moonlight part-time while they're going through dental school.
Howard: Plus that education is all the same stuff.
Michael: Transfers right over
Howard: I mean healthcare, dentistry humans.
Michael: They actually make some of the best dental anesthesiologist with the pharmacology backgrounds.
Howard: Is there anything else you wanted to talk about?
Michael: Well you know there's some people you know one to thank as far as the specialty of Dentistry Mike Mashney, Steve Gansberg, Chris Quinn, Bill mcdonald great guy Lee Lichtenstein, Joe Juvenetty University of Pittsburgh just it was a lot of people came together to make that happen and I think this right now that is recognized especially I think we're gonna start to see it grow it's it's kind of funny the response you get at first is you know they all knew that we had the special training and it's one of the only areas the dentistry that kills people and you know why weren't we recognized as a specialist you know that we had to have a special training to be able to keep our patients alive and so without these people you know the specialty would have never happened.
Howard: Well Adam Smith was the first economist who wrote the Wealth today it's kind of a weird history a 32 year old Scott in 1776 writes the Constitution United States to free people Thomas Jefferson well a 32 year old Scott Adam Smith writes The Wealth of Nations free markets. So the United States really the whole thing happened when two 32 year-old Scots collided in 76 were the first time were free people hit free markets and you had this huge economic explosion where a quarter of a millennium later you got this little country America with four and a half percent of people with about twenty percent of the world's 80 trillion dollar GDP but Adam Smith said whenever he saw two or three men meeting it was always to conspire against the masses there always trying to make a cartel and and most people agree that all cartels can only be effective if you're in bed with the government so you need a criminal government and a criminal cartel to conspire against the masses to pass laws that only we can do the IV sedation not you. You know so when you look at all these regulations all the regulations are really not to help the people almost all regulations are to help the cartel. Like I can go to Mexico and go buy penicillin at any pharmacy but in America I have to go to a toll booth I have to go to a doctor and give you a cut go to the pharmacist give him a cut you know I got to give all these people a cut and that's why everything's so expensive well because there's regulation and most people think about regulation they think oh that's a good idea to regulate that almost all regulation is a cartel to prevent free trade lower prices less profits so so it's always gonna be a thing.
Michael: I think there's some good parts of regulation there I mean it's protect the public so...
Howard: Well that's how they sell it yeah they sell it..
Michael: Sedation started right around 2005 and these guys were taking out full-page ads and Yellow Pages will put you to sleep 100% guaranteed so I called one of them up I said what are you doing was like well this doctor says I can go in there and give them pill after pill of triethyl and it's not gonna kill them and they're gonna sleep through the whole appointment is that gonna be an issue. Well since that time they've killed multiple patients killed six patients in the state of Missouri.
Howard: One office killed 6 people?
Michael: No no several offices but I did give I went to Missouri Dental Board I said hey there's a list of my top ten candidates you guys don't get on this rarely so these dentists are gonna kill somebody. Now it's a top six of us four of them succeeded.
Howard: Four of them killed?
Michael: Yeah it was predictable it's very predictable reversal agents don't save anybody flumazenil doesn't save anybody. You look at all these death cases and I reviewed quite a few from malpractice claims almost everyone receives the antidote flumazenil and they all died it's not gonna say you have to learn how to manage an airway but more importantly patient needs to be verbal and responsive as Salem mountain light always says nobody verbal ever died, if they're talking they're gonna breathe and that's a good thing.
Howard: Yeah I mean that one case in Hawaii they the child they set the chair up well they set the chair up and her head was hanging down well they all ran down the hallway it's like...
Michael: Yeah I've reviewed other cases like that.
Howard: So we had Stanley Malamed on the show probably the greatest anesthesiologist around but the one he said that is so controversial is septocaine.
Howard: Some people still think septocaine and causes paresthesia because when I give a block right how do I know the needle didn't punch you know hit the lingual nerve and mechanically caused the parachute or it was a septocaine?
Michael: Okay so that's that's a great thing so let's I love to talk about this because I research this quite a bit actually have a video on it and some other things a lecture on it and you look at the studies on lingual nerve and it's always a lingual nerve okay it's not the other ones because the lingual nerve may be as little as one fascicle okay so that's one little bundle of nerves surrounded by one little layer of insulation and the thing is is that these studies you see coming out from Setadine and others they're looking at the toxicity on one neuron that's not the issue. The issue is tonicity okay hypertonic or isotonic or hypertonic solution well inside that Pascal is a hypertonic solution okay so when you inject a local anesthetic the higher the concentration on the outside the more it imbibes fluid into the inside of that fastball and puts pressure on the nerve now when you look at those cases where there's been injury to the nerve it's always to the outer the mantle fibers of the nerve and that controls taste, touch, pressure or temperature things like that. The inner portion the corpora so if you blast it with a needle okay would be the inner portion that would be affected that's the muscles the muscles are never affected the motor fibers so it's always the outer portion not the inner portion. So it's due to the toxicity so studies by a pillar up over in Denmark and and Dan Haws and university headband designer show you talked about this he'd be a great person to have he's also the use of dental anesthesiologist and the Dean of the University of Toronto dental school and because he also says there's possibility of something involving calcium channels which I haven't researched as well but they're statistically as an increased number. If you actually look at Malamed's initial Studies on Septocaine it was the amount of nerve injury and paresthesia with Septocane was almost double data lidocaine and he said was statistically insignificant I don't think so.
Howard: So you don't use septocaine then?
Michael: Not for a block now you could use it for an akinosi block you could use it for infiltrations you could use a gal gates where is the lingual nerve but it's at probably they estimate maybe thirty percent of the population has a lingual nerve with just one fascicle now if you have multiple fascicles then there's another layer of insulation around that helps protect that nerve from that tonicity issues but with just one fascicle you run the risk of nerve injury.
Howard: So you guys do not use septocaine?
Michael: Not for blocks but we use it for infiltration you know other issues.
Howard: Well you know no matter how many times Malamed's has saved the push back from the dentist is still know there's something there's something more to it and you guys agree this.
Michael: I've reviewed quite a few cases of lingual paresthesia.
Howard: and how many of our permanent?
Michael: Majority of them are permanent.
Howard: Majority are permanent?
Howard: On a lingual nerve paresthesia.
Michael: Yeah so ones that I've seen I do think it referred to me because they are permanent. So basically if it goes out at three months it's usually gonna be permanent.
Howard: Wow so you think there's a lot of them out there?
Michael: I think there's you know a lot of patients just you know they just end up living with it and everything else they can still move their tounge around and everything else and that the deficits not that great they have just a little bit of numbness to the side of their tongue those kind of things.
Howard: So no more septocaine on blocks.
Michael: No more Septocaine on blocks.
Howard: So how hard did you kick him to break your knee like that every day you kick him higher kick him hard was how much?
Michael: She's my numbers person so Mary likes to crunch the numbers on the practice everything else we got dental intel.
Howard:and how long has she been with you?
Michael: Was it twenty three
Howard: and that's all you young kids that it's the thing I can't tell you're never gonna build a great company if you can't attract and retain quality key people and keep them. I mean you the dentist always want to learn about the Septocaine and the lidocaine and they always want to learn also that's what I love you guys man I love the fact that you love your art of dentistry but if you can't figure out HR you're never gonna go anywhere you're gonna be miserable. When you have I mean I'm to the point where if my assistants gonna call in sick she has to call me first so I call in sick and then she can call in sick. I mean when you work with an assistant for fifteen twenty thirty years you certainly don't want to work with a temp I mean when I hear we're going to get you a temp how about I wrecked the car on the way to work claim it was a DUI so I could get arrested and not, you know what I mean.
Michael: Oh I know exactly, we have to staff heavy a little bit just in case because you know I these guys are you know they there's a lot of frogs here.
Howard: and imagine how hard it'd be for you to have a temp.
Michael: Oh we cant have a temp we'd have to cancel the case.
Howard: Yeah so give them some HR tips because if you figure out HR and you're a lousy dentist you'll probably be a happy live happily ever after but if you're the best dentist in the world and you can't you can't figure out HR you can't attract and retain and all you do is have staff turnover you'll be miserable.
HR: I think the key to that is he gives opportunity to his team members and that in itself provides opportunity back for not just the team and the doctors but for our patients too because our practice really excels I feel in patient care and you said earlier if these guys could just remember that it's all about patient focus that's just really how it started in our practice that's what got the wheels going because he was safety first.
Michael: Actually I had you in town for a lecture I was with a Greater St. Louis Dental Society it was our Council on scientific sessions and was around 2008 I think I had you in for a lecture and I picked you up for the hotel and taking you over to the Missouri Athletic Club and it was like what do you do and I was like how booked out are you and I said over three months and you said you don't charge enough and I was like well you know when 60% of my patients are special needs mentaly handicap doesn't look good to gauge the mentally handicapped I was like and that's right I always believes like you know treat your patients like you'd want to be treated and that's the way we go you know but and it's served us well it's grown the practice all the staff members are supportive and behind it because they know were open and honest with our patients that goes a long way though like I'm reading Stephen Covey's book right now the speed of trust and so they talk about trust and organizations and everything else yeah and but it's a great book I recommend that to a lot of people.
Howard: Yeah he fell off his mountain bike he fell his mountain bike in his head and died right?
Michael: I think that's, yeah.
Howard: Yeah there's a Seven Habits of Highly Effective People.
Michael: Yeah that was Covey as well.
Howard: Yeah trust is everything and and it's tough because we're in a very special business because I know if I go to Hobby Lobby I can figure out what this is when I go to Verizon store I know what iPhone is but when you tell me I have four cavities I mean I don't know I have no idea it's like when my engine light comes on I grew up with five sisters I played Barbie dolls till I was 12 so I've never changed I don't know what a spark plug is I've never changed my oil I've never done anything like that I can cook really well and I can change Barbies outfits really well but so when the engine light comes on it's just a matter of trust. So as you're talking you know I always loved that peanuts because whenever the adults talk what it was always wah wah wah wah wah wah so in a dentist is telling you have four cavities and need a root canal and have gum disease my mom because I don't know so I always go to I've been going to the same guy for 20 years cuz I trust him yeah and you're going and you have people coming to you because they have to trust you so how do you convey trust?
Michael: Well one you know we educate the patient so a lot of internal cameras a lot of pictures we have big screen TVs and all operatories we blow up the x-rays with them going with and what their decay issues are with the pictures or what's shown on there and then they're referred to our practice so a referral right there it adds to the trust level I think quite a bit from the get-go. Again referred from there other dentists or referred from a friend.
Howard: So what opposite of though when I'm seeing people come in you know it's always why went to this DSO and it was a different doctor every time so I hear the turnover thing a lot and then they'll come in to you and say will you have been cleaning my teeth you know you your hygienist has cleaned my teeth for 12 years so I think a lot of the trust you're saying a lot of its visual showing.
Howard: but I think a lot of it is to reduce employee turnover how can I make relationship with you have every time I come in there to different you.
Sean: One thing I want to mention as far as trust goes is you know we can as dentists we can always fix the problems that they come in with it's it's talking to the patient and making sure that they understand what's going to prevent that in the future and spending that just little extra time with them going over their diet going over how to hygiene you know things like that and that I think really sets the standard from that first visit that you know and they enjoy that extra time and really learning about what their problem is and that's something that I know we do a lot of in our practice is really go through it and try and prevent it in the future.
Michael: Yeah especially with a lot of our special needs patients they come in it's like okay you know that what are they drinking at home you know it's like well Gatorade soda no this is like okay you know we just need to remove all that out of a diet and then what do they like to eat well so everything crunchy and salty and all that and I was like well you know eating pretzels and chips all day is just like eating candy you know your the bugs in your mouth take it and turn it right into acid and go to work on your teeth. So you got to work on changing your diet and lifestyle things like that if you want to not see me in the future so it's like it's one of those things it's like only brush the teeth that you want to keep that kind of thing so.
Howard: Yeah and there and they're not there and they're not gonna change it because the bottom line with obesity and decay and all these things like that it's in 1950 it's at 30% your paycheck to feed the family because of our success in economics now it only takes 10% I mean when I was a little kid you guys are too young to remember what I was a little kid only well-to-do families could go to McDonald's and they'd go there like on my a special holiday liked it kids birthday or something but your generation you can afford to go there every day on the way to work. So food is so cheap we were so successful in free enterprise that food is so cheap and it tastes so good and it's on every corner and America they sell salt and sugar and Pepsi and cheese burgers and so I mean the only way you could actually make it go away would be a 200 percent tax on all food like it was in the 50s because if you pulled up to them and that thirst buster instead of a dollar forty was like five dollars you would drink less but it's that's not gonna happen you know that's not gonna happen so it's not gonna go away.
Michael: Yeah we're gonna plan healthcare in this country we could do two full thing one tax sugar tax sugar and you'll see a drop in that in the utilization of sugar and you'll see an improvement else.
Howard: Right and in all democracies what happens if you say I'm gonna tax you more oh yeah you know get elected.
Howard: So if you say I'm gonna tax you you're dead on arrival and if you say I'm gonna give you free stuff you'll win. So that's why you see obesity and decay spraying all over in fact the fastest-growing places of obesity right now are in the Middle East because the Middle East got oil money and now what do they do they start building thousands of Burger Kings and Dairy Queens and McDonald's and all that stuff and you go to Saudi Arabia UAE Kuwait I mean their obesity rates have now passed the United States of America and then I was in four or five countries in Africa last year they Africa is a billion people and they're so excited they just found out what subway and Coke and Pepsi and McDonald's and they're so excited that your going to have a billion Africans going in this same whole process of it tastes good but we know what's gonna have you're gonna gain some weight and have 12 cavities.
Michael: The famous western diet is really killing killing the world. I'm like about 8 years ago I started the Paleo diet my wife and I just was a way of was it trying to lose weight do other things and then along the way after one month of doing this we did what they call whole 30 really clean eating for and I was like for how many years my life I had asthma and acid reflux they don't went away so I went back to eating a little greens and everything else it all came back and I'm like I'm never going back I don't want to take medications you know I'd rather be medication free and live healthier and since that time when my allergist can't believe it that my lung function as you age your lung function should decrease the my lung function is increased. So it's going the opposite way he still blows him away and then we go to see this one physician every year does this little big workup on my wife and I everything else and he looks at inflammatory markers my little peroxidase levels things like that which for the standard u.s. population is around 400 and if you get around 485 or something like that they get worried about your increased risk for heart attack stroke and my wife's this last time was down around a hundred mines around 200 and he's never seen levels that low. So I think we can I think was Thomas Edison said we can fix ourselves by just changing our diet then we'll have a health care system.
Howard: Yeah I personally have switched from Marlboro to Marlboro light Coors to Coors light so I'm I'm 50% improve my diet but well hey thank you does anybody else want to add anything is there anything that we didn't bring up that you should have brought up? You guys are really pioneers I've known you for a long time congratulations on anesthesia getting on a service it's so neat that you were able to build a practice around special needs. Having a special needs sister I know that you know that they scared half the people half the planet doesn't want to interact or deal with someone you know.
Micahel: You know you got to love them you got a hug hug them you got a laugh with them and it makes it all okay.
Howard: Yeah, do you guys like it? It's challenging
Michael: Yeah we have some war wounds out there I mean you know we see some violent patients and others.
Howard: So you saw my sister?
Howard: Okay well hey thank you so much for coming on the show today thank you so much for coming to the Townie meeting, thank you very much.
Michael: Thank you Howard.