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AUDIO - HSP #159 - Bryan Laskin
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VIDEO - HSP #159 - Bryan Laskin
Stop with the 'verbal vomit'; patients want clear, concise communication--in consumer language; not dentist language.
Dr. Bryan Laskin graduated from the University of Minnesota School of Dentistry and formed the progressive family dental practice Lake Minnetonka Dental in Wayzata, Minnesota. The goal of Lake Minnetonka Dental is to exceed patient and staff expectations, using the latest technology in a friendly and comforting environment. The practice has a keen focus on efficient, esthetic long-term restorative dentistry.
Dr. Laskin is the founder of Prehensile Software, developer of OperaDDS, which allows dentists to communicate simply and securely with staff, patients and colleagues. Dr. Laskin is a basic, advanced and in-office Patterson-certified CEREC trainer. He co-founded and is the moderator of the Minnesota CEREC Study Club; one of the best-attended and progressive advanced CEREC study groups in the nation. Additionally, Dr. Laskin serves as a consultant for a variety of dental manufacturers and dental laboratories in product innovation. Dedicating hundreds of hours annually to continuing education as both a student and educator, Dr. Laskin pursues the most advanced dental techniques and materials.
Howard Farran: It is a huge honor today to be interviewing a fellow dentist, Bryan Laskin, turned IT communicator. How did you go from a dentist to a technological communication expert communications guy?
Bryan Laskin: Good question. I think it all sprang from my office. I built an office, merged with another practice about 4 years ago, and, frankly, just had frustrations with the inter-office communications systems that were available. I complained to the right guy, who was a friend of mine that had some developers on staff and that kind of kick-started what's become OperaDDS. Since I've been digging down this rabbit hole it's been going further and further, and with what's come on with HIPPA, and the importance of protecting patients' secure information online ... it's kind of been ballooning from there. It's transformed from basically a way for us to increase case acceptance and doing inter-office within the office to just spreading to all sorts of different communication.
Howard Farran: You know, they say necessity is the mother of invention, and I love finding fellow dentists like you that had a problem and that's what necessitated the invention. What problems were you having and how do you solve them with your developers, your software OperaDDS?
Bryan Laskin: The very first pain point I had was when I built the office we had that light-box system that communicated at the last office ... you know, half the lights weren't working, it was wood panel. You'd put 2 lights on and it would, eh, buzz you like Pavlov's dog. I hated the thing, but it was necessary for me to know what I had to do in exam. The quote I got was $16,000 for my new office, and I was like, "I'm not spending $16,000 on this thing that I hate." We went down to the Chicago dental meeting, bought a few different systems and I didn't like any of them, and so I was complaining to my friends, "Why don't we just make it so you can slap an iPad on the wall, and then not just get buzzed, but get all the information discussed, like a pilot's checklist, before I walk in the room so I know what's going on before I even walk in there." That way, the debriefing from the hygienist or from the assistant is for the patient's benefit, not for me. I already know what's going on.
It's like lots of things, you get an idea like "oh, that sounds like a good idea," but then when you go and practice, those subtle variations make the difference between a little bit ... from good to great. Before, we would pass sticky notes around the office and stuff, but when you go from doing it the old-fashioned way, to getting all the communication that you want, instantaneously, wherever you are, in an organized fashion every time, it's a game changer. It really does ... The case acceptance in our practice has just sky-rocketed since we retooled all of our communications, so that rather than having to have that in front of the patient or kind of going off to the side and having a private discussion, you're getting all of that information wherever you are instantaneously. That was really the key for me that went "wow, this is it." I showed it off as sort of a demo to lots of dentists, and the ones that get it, get it right away and go, "oh my gosh, this is awesome." We've just kind of been building on it from there.
Howard Farran: Well okay, let's get specifics. You just said something, we manage people, time, money, we make something, sell something, watch the numbers, you said it increased case acceptance. How does an interoffice communications device, and iPad in each room giving you information, how does that increase case acceptance?
Bryan Laskin: Great question, and it's a long answer.
Howard Farran: Take your time. You've got an hour.
Bryan Laskin: Well thanks, sir. I can't think that far ahead.
I think the biggest thing is that, in my philosophy, the most powerful words in treatment plan case acceptance are "I agree." I think that patients tend to want to hear from dentists all the verbal vomit, the buccals and things that we talk about, they want it typically from an auxiliary member, in language that they can understand. And when we come in and say "I agree. Do you have any questions?", in my experience that's what patients really like. But to be able to do that you have to have excellent communication with your staff. They have to see what you're seeing, so that you can ...
We use a process called calibration, which I know one of your buddies, Bill Rossi here locally in Minnesota, taught me, which was basically you have your hygienist or assistant look in the patient's mouth, and you can calibrate on anything but typically it's indirect restorations, so if you look in the patient's mouth, and if their mouth were your mouth, or their mouth was your mom's mouth, if you like your mom, and you would do an inlay onlay porcelain veneer or crown, that's one, and just count them up.
We have, through OperaDDS, the auxiliary member sends that number to you, you go in and if the hygienist has 2 and you're thinking 6, you should have a discussion about how things aren't the same. You do that for a couple weeks, and you are seeing things the same way, or at least you understand how each other think ... That comes through to my watch, to an iPad that's stuck on the wall, and then I can come in and say "well, Jane, your hygienist" ... It's best if you do a third party endorsement ... "You've got the greatest hygienist in the world. I completely agree. Do you have any questions?" In my experience that's what patients want.
The more you talk, the more glazed they'll get, and I don't know if you agree with me, but to get that level of ... To have it be that simple requires a sophisticated communication system. That's what we've tried to build out.
Howard Farran: The first things these dentists are going to say when they're listening to you out there on their commute to work or their way home, is they're going to say, "Yeah, but your hygienist can't diagnose." They always throw that out to me. I agree with you. I don't think an x-ray or an intraoral photography is rocket science. You have a whole in the tooth. What do you need? An MRI? A cat-scan? A Ouija board? Why can't the hygienist just say, "Yeah, you have a cavity, and I'm pretty sure Dr. Laskin is going to say that this is going to need a filling," or a crown or an onlay, whatever, because you've calibrated. So what are your thoughts? That dentist is going to say, "Your hygienist can't talk. She should have duct tape on her mouth because she's not a real doctor." What would you say to that, or he?
Bryan Laskin: I'd say that's fine, but I like the way that you said it. "I believe Dr. Laskin is going to say this," because they're not really diagnosing. What they are doing is they're informing the patient on the front end what they think you are going to say. Of course, there's many times that I disagree, and I may be more conservative, or I may bring up something that the hygienist didn't see, but the goal here is that hopefully you hired these people because they have a good brain and a couple good eyes, like you're saying, and if they don't get it, then either you have to redo your system so you don't do it this way, or else you change people so that you have the right person that can get it.
Patients that have, like you said, a big hole in their tooth, that shouldn't require me coming in and letting the hygienist know, "Boy, that patient has a hole in their tooth." If you don't feel comfortable with your hygienist sort of teeing it up for you so you can say, "I agree," you can add more verbiage as much as you want to, but in my opinion, for all the times that you're complicating it in the patient's eyes, case acceptance is going to drop. It's not that the hygienist is always going to be right and they can't diagnose, but they certainly ...
You work with somebody and you go through a process of training, they should be able to say what you're going to say most of the time. If not, either your treatment planning is completely erratic and you're not mindful of why you do things, which is a whole other issue ...
That's the other thing. Calibration is as much for me as for the hygienist. When I go through a process of calibration it's keeping me accountable for what I'm going to say, and if I'm busy in the next room I still need to say well, it's keeping me accountable for being consistent in my treatment planning, so that we can be on the same page. 4 eyes are better than 2 in all cases, in my opinion.
Howard Farran: The calibration is also good for ethics and morals, because a lot of dentists will say, "This crown needs to be redone because it has an open margin," and the hygienist is saying, "Our last patient, you did a crown a year ago and it had an open margin too." Why isn't it calibrated? I think it builds communication and trust and wow, and I believe the patient does want 3 opinions, and doesn't always want the opinion from the doctor who they perceive as making more money than the hygienist.
Bryan Laskin: I agree. I just had this discussion with my hygienist that calibration isn't about you seeing things the way I see them, it's what would you want if the patient's mouth were your mouth. If you think I'm being super aggressive I want to know that you think I'm being super aggressive. I just had a dentist ... I did a lecture in Chicago last week, and the dentist came up to me and said, "I think I'm way too conservative. I want my hygienist to help keep me accountable." Great, this helps you with that. Like you said, it's great ... Consistent care is quality care, both from procedurally, in my opinion, and also from a treatment planning standpoint. Not every tooth is so unique that it has to be looked at from a new set of eyes every time. We should have reasons why we do things, and a philosophy that we follow. Obviously there's going to be the outlier cases, the 1% or 2%, but 95%-98% of the time we should be able to agree without having a meeting about that specific tooth, in my opinion.
Howard Farran: And you know, your hygienist has to wait for you sometimes, sometimes you have to wait for the hygienist, whatever, but I always, when I had a new hygienist over the last 28 years, and she called this a watch on MO, and I said, "No, it's an MO." As soon as I broke through the contact, and was about to grab my #4 [roundberg 00:11:00] to take out oatmeal, I would buzz her, and I'd say, "Hey, come here, sit down. You wanted to watch this, and remember, what you see on the x-ray is only 40% of the lesion, so every oral and maxillofacial board certified radiologist says you're only seeing 40%. You called this a watch. You probably thought I was aggressive. I want you to sit down with a spoon excavator and take out oatmeal so you can see this." It's all about communication.
I'm going to ask the crude, rude, get to the point ... How much is OperaDDS? What is it? It's an iPad for every operatory? Is it at 12 o'clock behind the patient? How much is it, how do you install it, how does the dentist get this? Do you have a demo video if they went to OperaDDS, o-p-e-r-a-d-d-s, and of course, if you're listening to us on iTunes you don't get OperaDDS. If you're watching this on Dentaltown or YouTube, this guy has more musical instruments so I already know why it's OperaDDS. It looks like you're doing an opera right now. So where did you get the name OperaDSS? How does someone see a demonstration of it? Do they buy it through Patterson, Schein, Burkhart, Benco? Tell us. Be more specific.
Bryan Laskin: Lot's of great questions. The name Opera actually comes from ... Initially it was the intraoffice communications system only and it was OperaPager, it was for the Operatory Paging System. Kind of a play on words because communication, opera, like you're calling down, like most people are yelling down the hall for communications, so we kind of did a play on words. When we built in HIPPA compliant email, laboratory and specialty communication, I kind of dropped the paging, because it's kind of old school. We still have the intraoffice communication piece within OperaDDS that's still called Pager.
It's free to use, so everybody can get on and just start using it for free. You asked about partners that I sell though. I'm a general dentist, like you. I saw what I was starting to develop, the intraoffice communications system, and some people were trying to do similar things to what I was doing, and what I really liked the idea of, I like small, self-funded companies, and so I decided that's the way I wanted to go and I thought that to do this the way that I would want to do it, if I send you an email or a case, I don't think you should have to pay to communicate with me, so I make it free for everybody to use.
There are some, if you want additional users, if you have a staff of more than 4 and you want to communicate with everybody, or if you want to have some advanced email features, like viewing who opened your messages or retracting emails, then there's a pro account that's $49 a month. We're going to be doing more demo videos that that sort of thing, but really if you go to OperaDDS.com, like you said, you can register for free. There's no credit card needed. Just go on, create a user name, you have to do a email verification just to prove that you are human, then you can get in and start playing with it. That's really the best way. You can start sending messages.
We have an Apple Watch application, which for me has been a big game changer. I thought it was going to be kind of a gimmick initially, but to get your interoffice notifications on your wrist while you're practicing is just phenomenal. You know exactly right then what's being done in the room that you're being called to and you can decided, should I go there, should I stay here, just with the flick of a wrist. It's pretty cool.
Howard Farran: Wow, that is amazingly cool. My walnut brain never even saw that one coming down the pike. I never thought ... I mean, I love my iPhone. I love the fact that I got an Apple TV, so if I'm watching a YouTube video or a podcast or whatever I can throw it up on my big screen. My brother, Paul, he's 17 years younger than me so he's a little bit more high tech, he got the Apple watch and just loves it.
I already have a smart watch, a Garmin, which is the biggest brand name in Kansas, and I can not wait until Apple includes all those features because it has 6 buttons and you basically have to be an electrical engineer programmer to figure out how it works and it seems like so many of my buddies that had their Garmin for years are still asking how to find this, that. So I'm sure Apple will make it classic, Apple intuitive where an idiot can figure it out.
So explain in detail, what is showing up on your watch? You're sitting there doing a root canal. Does your Apple Watch, does it bing, or beep? How do you know there's a message on your Apple Watch?
Bryan Laskin: Good question, and I should mention to that you don't need to have an Apple device or an Android device. You can use any web browser. You can just log in, you don't need to download any software. You can use your computer operatories. I like Google Chrome, but you can use Safari or Explorer or Firefox. Just basically you log in to OperaDDS.com. There's a log in and you're ready to go. So you don't need to use a mobile device. A lot of dentists say to me, "I don't want my staff on their phones." Well neither do I, I'm not ... So my staff don't use phones. If you have a float assistant, you can give them an iPod or a non-phone Android device to carry around.
To answer your question about the watch, what pops up is it gives you a vibration. What's nice about that is there's no tone. The vibration is more subtle than, I don't know what your Garmin is, you could use your Garmin too, but you get a subtle vibration so the patient doesn't notice that anything happened, but you feel it. Then when you flip your wrist and you see that it's an OperaDDS message.
In your settings you can make it a different type of vibration so you know what they are, which I don't know about you with your smartphone, but I've had to turn off some notifications because you get them all the time. You can make it so whatever notifications you want to receive while you're practicing you get, and then when you flip your wrist, whatever message that the staff member sends comes through and you can see it right there. You can with one tap confirm it, or you can dismiss it, or you can do actually a text to voice reply where there is some predefined messages, so if somebody says, "Are you going to be here in the next 10 minutes," you can just click yes with the tap of a button too.
Howard Farran: What percent, in your opinion, what percent of offices are using intraoffice communication, and why are the ones using it, using it, and why are the ones not using it, not using it, and what do both camps need to know about the other camp?
Bryan Laskin: I think that a very small percentage of dentists are using intraoffice communication. If I had to guess, I'd say 20-25%. About a few years ago, the headsets were quite popular. If you went to a major dental meeting 5 years ago there would be all sorts of headset companies, now you go and you'd be lucky to find one. I think the reason why is because they are annoying. In Dentaltown you guys did a survey and 80% of dentists that had that in their office don't wear it. The reason why is because they are annoying and if somebody says, "Hey, can you check the buccal of 19," you're not going to remember by the time you finish your root canal and go in the room.
Also, one of my biggest pet peeves, the reason why I don't like that notification be noticeable to the patient, is if your hygienist comes in and says, "I'm ready for an exam in room 2," the message you're sending to the patient that you're working on is that my focus is elsewhere now, you're not my sole focus. If you have a headset in the patient's getting the message that you're always listening to other stuff in addition to listening to them, which I think is the wrong message.
I think that people use interoffice communication systems. My light-box communicator was better than nothing. The little buzz let me know that I needed to be somewhere, but the patient could hear it, and like I said it was like Pavlov's dog. Which all notifications kind of are, to a point, but what's nice about getting a checklist message in particular is that I'm a linear thinker, like a lot of dentists, and so if I walk in the room now and the hygienist starts talking about the perio before talking about the medical history it throws my brain for a loop. I want everything in the same order every time. There's a reason why pilots do it that way. There's no reason why we shouldn't too, so that's how every message comes through to me. It's in the same order every time.
Howard Farran: I'm so glad you said, because I used to always think that's a lot with me because the assistant will come in and start telling me all these words and stories, and I'm just like, "stop, stop, stop, stop, stop." Which room? 4. New patient? Existing patient? Emergency patient? You know. You can't start telling me about the symptoms until ... I need to know much ... Yeah, exactly.
What is your checklist? Or what are the checklists on this system?
Bryan Laskin: It's all customizable, so I can tell you what mine is, but it might be different than yours. In my office it's the patients' name, chief complaint, because I always want to start off with the chief complaint, changes in medical history, perio status, restorative status, what radiographs were taken, and then any restorative needs that were discussed, and any additional information. That's what I get every time. Again, you can create whatever checklists you want ...
A calibration is in there ... we take it on or off depending if we are going through the process of calibration too, and that goes right beneath the chief complaint. What's nice about that is when I walk in the room if we are doing the process of calibration I know that, let's say Emily did, her number was 5 and as I'm looking in the patient's mouth I can be kind of seeing, it's obvious which 5 are the teeth that could use indirect restorations. Or let's say you are doing, like you said, carious lesions, which teeth are carious, and if I don't see the same, if it's not obvious we can add that discussion. That's the checklist that I have every time.
Howard Farran: When Bryan Laskin is talking about calibration, it's Bill Rossi, and he has an online course on Dentaltown about how to do that, and so that's a must watch.
You know, when I got out of school the big boogeyman was OSHA, and everybody was afraid of OSHA, and finally one day I actually decided, I was hearing all of these mixed messages, this was back in '87, and a lot of it was brought on because of HIV was out and everybody was panicking and freaking, and I finally called OSHA and I left message after message, this was before computers, internet, anything.
I finally got the head OSHA guy in DC to call me back and I said, "I'm hearing all these confusing things. Why am I buying a manual from different companies saying different things? What do you need to know?" And he says, "Who is this?" And I said, "Howard Farran." He goes, "What do you do?" I said, "I'm a dentist." He goes into his chart and he says, "0.001 or less dental employees die each year on the job." He goes, "Dude," he goes, I forgot the numbers. It was something like 3 out of 1000 agriculture workers die each year. No, I think it was 3 out of 1000 miners, 1 out of 1000 construction workers, and 1 out of 1000 ... miners, construction, farm workers, and it's funny because that week in the news somebody lost both of their arms in a combine, a crane had fallen over and killed some employee.
He goes, "Dude, if an OSHA inspector walks into a dental office I want you to call me back and tell me why they're at a dental office not at one of those copper mines out in Arizona or a construction sites." And so that kind of fizzled away and it got rational and now HIPPA is kind of the new big monster and everybody is living in fear.
What is HIPPA? Explain to the viewers, what is HIPPA? How much of it is a fear reaction? When the tires hit the pavement, what is real world HIPPA, and why did you add HIPPA to OperaDDS?
Bryan Laskin: I love the fact that you equated it to OSHA, because I do all the time too. It's these big, federal regulations that ... If you take a step back, there's a reason that we all wear gloves today, beyond getting AIDS, right? There's a reason why we wear gloves and eyewear. Now you get to the specific details of the width of your side shields, it'll drive you crazy. I think that were exactly where we are with HIPPA today that we were with OSHA in the '80's. "I'm not going to get AIDS from my dental patients. I've been practicing this way for 20 years." Well, in reality, there's cross-contamination to deal with, there's just general ... it's nasty not to wear gloves, in my opinion, because I grew up after ... I graduated dental school in '99, so I can't imagine without wearing gloves, but I had dental instructors who would ask patients if it was okay, because they felt like they didn't have the manual dexterity with it.
I think we are going through a similar transition with HIPPA. Right now, there's a lot of people spreading fear. "Oh, you're going to get these fines" and that kind of thing. They are out there, but, like you said, the risk is like getting AIDS from practicing without gloves. It's low, but however, the spirit of the law, which is protecting patients' electronic information, or just their privacy in general, makes a lot of sense. There's a lot of problems that go on when you send things through traditional email. There's a lot of risks that happen. That's why banks are doing their PCI compliance, going through the same thing. Why people send stuff through a fax machine that's grandfathered into the laws, but it still doesn't make it the best way to do things.
I think that protecting patients' private information is very important and in dentistry, just like in medicine now, we're going through these weird growing pains, where everyone wants all the software to work together and be inter-operable, at the same time keeping everything secure, and those two things can be at odds with each other. I think most of the people talking about HIPPA compliance focus on the fines and the big problems that are very low risk but high impact if they happen. I personally feel that secure information is actually better communication. It allows for you to create tools that are more effective that doing them in traditional ways.
For example, you can have you periodontist, your oral surgeon, your lab, all working online using a single CT scan. Discussing your fees so you can package them together so when you talk to your patient, you're not giving them a range of fees that confuses them and so they go, "I'll just have a bridge instead of an implant." You can coordinate your care because you had this online portal where you can all collaborate together.
Howard Farran: And also, it seems like whenever your specialist is in between patients and gives you a call, you're not in between patients, and not really wanting to give a call, but you really feel like you have to go take the call because the last time you called, your oral surgeon said "Can you see this guy right now", and now you're not taking a phone call. How does it smooth up that scenario?
Bryan Laskin: Oh, for sure, it takes it away. Why would your surgeon want to call you versus go online, open up the case, create a comment and be done. Then you can see their comment right next to your comment, time-date stamped. It makes total sense. There's all sorts of online collaborative portals. Pretty much every company in the world uses these system. Lots of them don't have the secure piece, like Slack is a big online portal, there's Workboard, there's a lot of these for ... Using email. Even traditional email is cumbersome when you are talking about collaborating, so you want to have everything organized in one place. The fact that we, as dentists, tend to write out a paper slip that says the patient has a stinky draining abscess on #3, and give it to the patient, and then he might leave it on the counter for everybody to see, and then we wait for something to come in the mail from the endodontist blows my mind. The patient wants to have that tooth restored right away, but that letter is coming in the mail in 3 days, but the patient is there, so you have to call up the endodontist and go, "Boy did you actually do the root canal?" For those of us that do it this way it's kind of an archaic system I think.
Howard Farran: The other huge advantage of a specialist is ... If I send you an oral surgeon for a wisdom tooth to be pulled, it really helps me if the oral surgeon says, while the patient is numbing up, "Um, by the way, you have 3 cavities you got that scheduled? Because I've been an oral surgeon for 20 years and you don't want those 3 cavities to turn into 3 root canals, and if you can't afford 3 root canals, you'll be back at my door needing 3 extractions. Did you ever get those done?" And then they're saying, "Oh yeah, yeah." Because the patient may have been thinking after I pull these 4 wisdom teeth and max out my insurance then I am done. I don't want my endodontist to look at a toothache, I want them while that's are numbing up or in consultation to look at the whole treatment plan and say, "Yeah, okay, so this one does need a root canal and then of course this one over here needs a filling and over here you need a crown and gum disease is a big deal so I hope you get those 4 quadrants root plane curettage," and et cetera.
How does this eliminate phone calls for staff though?
Bryan Laskin: You mean with other staff members within your office?
Howard Farran: Yeah.
Bryan Laskin: Multiple ways. You can replace email. Email in a lot of ways can replace phone calls. Because you have secure email you can not ... instantaneous communication can be handled that way. Again, if you are working on an individual case, you can use an online portal that everybody logs into that case to view, or if you ... for the interoffice communication it's kind of like a fancy text message. That's why there's a dedicated iOS application and a dedicated Android application, because then you can get the push notification so if you're not even logged in, if you don't have the application up on your phone it just pops up like a text message. It comes up and says OperaDDS and it has the message, or you can send it privately so people have to open it up to view it.
Howard Farran: Tell them about your online CE course, "Getting Staff and Patient Communication Right for Increased Profitability". How long is that? Would that be the ultimate staff meeting where the dentist goes and springs for some pizza or sub sandwiches and the whole team watches this together? Talk about that course.
Bryan Laskin: That course talks a little bit about what we are talking about with the online tools, but it also talks about effective communication. I think that communication is really the key to an effective practice, so for things like ... I go through things, like I call it a testing phase ... One of my favorite threads on Dentaltown is "Patients that I want to punch in the face." I think just the title of it makes a little bit of happiness because we all have those patients, right?
When patients say "I hate the dentist", what are they really saying? They're not saying that they actually really do hate dentists, but they're saying that they don't feel in control and they don't like giving the control over to you most of the time. Really if you get beyond the actual words the patient is saying to the meaning, so if you tell the patient that always says they hate the dentist "You're in control. Just let me know whatever you need, anything. I'm just going to present you the options and you tell me what you want to do." You're going to just see the situation diffuse.
Also, just subtle variations in communication. We all know that sit the patient up and look them in the eye, you would think, but I see it in my office all the time where just basic communication skills are dropped. We want to be on eye level with the patient speaking to them. Just put yourself in the patient's shoes. Particularly for staff members, like you're saying, who might not have the experience with communicating with patients. There's all sorts of tools in the Dentaltown CE video that goes through, in my experience, what creates good communication and high case acceptance in a practice.
Howard Farran: What would you say to people who say ... You're also very well known for CEREC. You're an amazing instructor. You have probably the best Patterson CEREC training in your state. What if the dentist says, "I don't know if I'm high tech enough for this?" What other behaviors would this dentist to that would make you think, "Yeah, you're high tech enough." Then I want you to talk about ... Well, answer that question.
Bryan Laskin: Yeah, that's a great question, because I just spoke to a CEREC group last week, and there are 2 different buckets, but I think they are equally affected. One of the reasons why I love CEREC is it's same day dentistry. You are finishing the restoration you started today. Patients love that. Talk to any dentist that does that. They love it. It's way more impactful than I thought when I bought CEREC 13 years ago. I was blown away with it. You're there in the office every day, so if a patient has to come back it's no big deal, but the effect on the patient, it's huge.
I like to call, when you have effective communication in your practice, I like to call it no visit dentistry, because the patient comes in, they have a broken tooth, rather than saying, "Okay, come back, we'll do it in one visit", you're saying, "I'm sorry you ..." You walk in the room. The hygienist hasn't left the room. The front desk has already looked at the financial arrangements. You're assistant already has the room ready and you walk in and you say, "I'm sorry, Mrs. Jones, you broke that tooth on the upper right. Abby's got a room read for you. Let's get it taken care of now if you'd like." And patients, it blows their mind.
You're going from getting the restoration done at another time with CEREC, to getting it done that same day, and you don't need to have a CEREC to do that obviously. If it's a filling, you can do it today. If it's Invisalign, you can take records today. If you're doing a traditional crown, you can at least get the tooth temporized today. It doesn't really ... If you don't have computers in your operatories you can slap an iPad on the wall, but realistically if you don't have computers in your operatories you probably don't see the value in a cloud-based communication system. People who are using film x-rays, which blows my mind that half the dentists still use film x-rays, frankly, in the US ... but they are probably not going to see the value, but I think, just like with x-rays, some pieces of technology just make things explode. This one's easy. You don't have to buy anything. If you have a computer in your operatory and start using it for free and you can ... Unless I pay you to use it, you can't get any better than that.
Howard Farran: I want to be ... a good interviewer throws the hard questions, no softball stuff, so I want to go after the biggest complaint of CEREC, that dentists used to take an impression, send it to the lab, and go off to the next patient, and now he's sitting in the room being a lab man. He's paid $150,000 to demote himself from a doctor to a lab tech. I kind of think that they work best like how I use it, delegating with my staff.
Just like you said earlier that hygienists legally can't diagnose but we can get around that buy saying in my opinion. Listen to talk show hosts. The reason they never get sued, if I said "Bryan Laskin is a heroin addict," and I was joking .. well, that's not joking, and if he sued me, I'd have to prove that you do heroin, and if I couldn't prove it you could sue me for slander or what have you. But they always say, "Well, in my opinion, Bryan Laskin is this" or "In my opinion" or "I think" or "I heard" or they always do these disqualifiers, which our hygienists do, but I want you to go specific to the claim that this dentist bought a CEREC machine and now they're doing the whole process and it's taking them 3 hours in the room.
So they used to have an hour. You would come in. Bryan's got a broken tooth. I'd numb you up. I'd take an impression for a temporary. I'd prep it. I'd take an impression. I'd make a temporary. About an hour, then you come back in 2 weeks for 30 minutes. Now I'm in this room for 3 hours making a CEREC crown, and the dental consultants are saying, "My god, he spend $150,000 to demote him to a lab tech." I want you to address that. What can you delegate out on your CEREC, because you used to use a lab man. I mean you used to have a man sitting on a bench in another building making this whole crown so why can't your assistant make it in your office? What is the maximum length of time that this dentist is doing this CEREC in a crown before it's no longer profitable. And by the way, some of these patients are not happy if they are sitting in a chair for 3 hours. So can you address that?
Bryan Laskin: Yeah. We're very efficient in my office, so the longest a single unit is going to take is an hour and a half if I'm doing it. Some of my associates might take a couple hours if they are doing a difficult e.max crown, but it can be very efficient.
It blows my mind. We are about as by the book as you can be. My assistants, I'd let them drill in my own mouth when I'm done training. They've prepped the models. They're fantastic, but I still check the restorations before we hit no, and they won't remove the screw from the restoration because they called the Minnesota Board of Dentistry to see if they could do that and they said that's altering a final restoration so they said no. Can you do that? I don't know. Like you said, you probably have a 16 year old that just got off heroin that's making a restoration at the lab, but my assistants that I'd let practice in my own mouth don't feel comfortable removing a screw because it's not legal. It comes down to how the dentist wants to practice.
Right now, still, it blows my mind that only 10% of dentists have CAD/CAM dentistry, because I've been doing it for 13 years and I just see the success in my practice. People haven't had the same success, so people don't want to design and mill. That's fine. You're still going to get a much better restoration doing a CAD/CAM system and then temporizing, and then getting the patient back in a couple days and putting a permanent restoration on it. There's a reason why all the labs are going to CAD/CAM now, just because it's more predictable, just like the checklist messaging, and predictability is quality, so you don't have to do it in the same day. I think you're going to have much higher patient satisfaction if you can be efficient about it. If I do a CEREC crown, my average one is like an empress crown it would take about 40 minutes. Early on patients would say "Oh, I paid you $1,500 for 40 minutes." Right, you probably should have paid me $3,000 because it only took 40 minutes. Patients aren't looking to pay by the minute in dentistry. They don't want to be there longer.
Maybe a little bit on the hygiene side you might, but not operative-
Howard Farran: You're an elite trainer. What is the person ... Because some of these CEREC machines are sitting in the closet because they couldn't get their times down under 3 hours. If you're a dentist listening to this now, or an assistant, or a hygienist and your doc is in there for 3 hours, and you just said you can do a single in 40 minutes, and you'd like them all done in under an hour and a half ... How do we close the gap? How does the consultant world close the gap between the whole staff screaming, "He's in there 3 hours with that thing?" How does he get from 3 hours to an hour and a half, let alone 40 minutes? Is that just a time thing? Or what would you say?
Bryan Laskin: I have a Dentaltown CE video on the efficient all ceramic preparation that kind of goes over a lot of it, but what it really boils down to about being mindful of every step you do. It has nothing to do with rushing. It has nothing to do with moving fast. It has to do with, for example, using 2 high speed burs. When I do a ceramic crown I use 2 high speed burs, and often times I'll have 2 high speed hand-pieces there so I don't have to change burs. So each bur has multiple purposes, and-
Howard Farran: What are those 2 burs?
Bryan Laskin: It's an egg bur that's 2 millimeters in diameter, so it acts as the gross reduction for the occlusal surface, and also a depth gauge because it's 2 millimeter in diameter, so then you just sink that in the central fissure and go across-
Howard Farran: You said egg bur? E-G-G, like an egg?
Bryan Laskin: Yep, exactly. And I use 2 new burs every time.
The second bur, it's usually going to be, for a molar, it's going to be a 1.6 in diameter modified shoulder bur with 6 degrees of flair. So I bring down the occlusal table in the central fissure down 2 millimeters, then I take off the buccal and lingual, staying occlusal to where I want my margin to be. That's when I'm going to switch burs, go around the shoulder preparation with 6 degrees of taper built in to your modified shoulder bur so you just kind of go around it, drop things down apically if you need to, and then I lay it flat. I create the [papal 00:42:11] floor to be nice and flat because you don't want any discrepancies for CAD/CAM. Then just round the corners and you're pretty much done. If you have to do restoration, lower carious removal, that's when you grab your round bur and go back with your modified shoulder to refine the preparation. Some dentists are taking 40 minutes to prep a tooth. If you gave me 40 minutes to prep a tooth, and I went as slow as ... I would probably have to use the round bur to do the whole thing.
Howard Farran: Do you use an end cutting bur? A cylinder with an end cutting for the floor of the prep?
Bryan Laskin: I use the one bur, and so it end cuts and side cuts.
Howard Farran: It has an end cut too?
Bryan Laskin: The whole bur, the whole thing cuts. It's all diamond coated. I use 1.6 millimeters in diameter because then you can have the bur hanging off the margin so then you get a flat margin. You don't have to go back with an end cutting bur. I've been doing this for 13 years now, so if you need to go back with an end cutting bur to refine your margins that's fine, but I think you can cut a rough prep with a smooth bur, and you can cut a relatively smooth, depending on the roughness of the bur, you can get a nice smooth-
Howard Farran: You know what I actually love the most about CEREC? What I love the most? It was when you come out of school, you use your naked eyesight. You had to listen to older dentists for years before you got smart enough to get magnification, and then that opened up a whole new world. I remember getting these props and look at them on your computer screen, it's probably got to be 40x, and it just wow. You just don't know what a good prep is until you've seen how horrible your prep looks at 40x, and then it's just a whole new world.
Bryan Laskin: I don't know if you were using it with the redcam days, but they went from normal definition to high definition, and suddenly my prep sucked again.
Howard Farran: So you got out in '99. I bought my first CEREC, CEREC 1, in 1990.
Bryan Laskin: Oh, wow. That's awesome.
Howard Farran: And I got to talk to the guy who actually invented it in France. We're going to do a podcast, but he doesn't feel comfortable doing it in English because he speaks French. I've either got to learn French or we've got to get an interpreter, but I just want to get him on here because that was his baby, it was his baby forever. I just think that's so cool.
Do you think it's anal also ... Do you finish that prep with a Soflex disc or anything like that? Do you think that's too ... I do that. I always want to do the adjacent teeth, the prep. Do you think that's just silly or do you think that ... You don't see a need for that or ...
Bryan Laskin: I don't think it's silly, and I think that it depends, obviously if you nicked the adjacent tooth you have to polish it. I think ... I've gotten used to using diamonds for my preparations, just because that's what I'm comfortable using for the most part. I don't use Soflex discs or ... The product that we use is a Super-Snap. Again, I like things that are predictable and efficient, so we have the one packed with the mandrels built into with all the discs, and it's disposable so then you're not searching for all the mandrels. Everybody has things that they like to do and ways that they like to do them.
It just comes down to we are very obsessed with having a purpose for everything we do, and I go through the same process pretty much every time so I don't even think when I practice anymore because my assistant is just passing me what we're doing. Teeth, typically speaking, particularly when you're talking about CAD/CAM dentistry, where you want a more simple preparation because you want to mill it out with a bur that's usually 1.2 millimeters in diameter, so you don't want these subtle variations, you want things to be smooth and rounded and flowing. There's not a lot of thought that needs to go in to the preparation most of the time. Even if you're doing a 15th-16th crown, you should have the restoration in mind before you go ahead and do it. Just like an athlete, let's say a pole vaulter, they are going to visualize what they're doing before they do it. You want to go in with a plan. You're going to execute the plan, and you're going to get better results all the way around.
Howard Farran: That's true. I don't do that with pole vaulting, but when I walk in to a Mexican restaurant, I already know what I'm going to order before I walk through the door. That's my version of pole vaulting.
So Bryan, 10% of American dentists probably have a CAD machine, 90% don't. You alluded earlier that only half are up to digital x-rays, half won't. What would you say to the 9 out of 10 dentists listening to this that do not have CAD/CAM? Because let's be honest here, this is what they're telling me, "Dude, I just walked out of school with $250,000 in student loans, now Bryan Laskin is telling me drop $150,000 on a CEREC, and then some other guy is saying drop $100,000 on a CBCT, and then they want me to buy a laser for $75,000." Should a dentist ... Address that fear. They're saying, "Bryan, if I listen to you I'd double my student loan debt." And I'm trying to be the voice of reason saying, "Yeah, but your student loan debt and all those things combined will only be half the cost of your divorce, so just knock yourself out." What would you say to that guy? Should you come out of school $250,000 in student loans and drop another buck and a half on a CAD/CAM?
Bryan Laskin: That's a good question. When I signed the paperwork on my first CEREC, I had just bought my second practice in 3 years, and when I signed the paperwork I almost cried. My CEREC rep, we laugh about it to this day, because I knew it in my head that this was probably a good financial decision, but when I was signing that paperwork I was going to cry. Now I have 2 full systems that I just thump money. It's easy for me to say, because I bet every piece of technology I focus, I protect my downside, I look at the upside, it's been good. There's been some things that I've done, obviously, as we all have, that you know ... We just talked with my clinic administrator today about an ad that we did that just totally stank. Well, we don't do it anymore but we were protecting the downside.
I would say that, for the most part, people who start using technology see it, embrace it, and start using it. Start off with the easy things, like digital x-rays. In my mind there's no reason to not use digital x-rays. An interoffice communication system that's cloud-based that's free. I mean, my god, start there. Once you start doing that and you go oh, this is great, then if you want to take the baby steps you could do CAD/CAM dentistry that you don't know and design like we were talking about before. Get an intraoral scanner. I think that, just like I'm a big proponent of getting the dentistry done that day, I think getting it done in a single visit, there's just so many pluses to that it's hard to ignore.
You want to start off with what are the priorities. If you just got out of dental school, in my opinion, you go learning a new CAD/CAM system and designing it and milling it, maybe that's not the place to start, but getting a case acceptance sure is. You want to know that ... You want to track your case acceptance. You want to do the things that are required to increase case acceptance and get people coming in and then work on the other pieces of technology.
I wrote an article that's coming up in the New Grad edition of Dentaltown too, on ... it's basically from the perspective of a new dentist that joins a practice that doesn't have any technology and the safe places to start. You want to use things like ... things that are free so you can see the benefit, or things that you're going to be able to shift the cost. Digital x-rays are far less expensive than film and all the stuff that you need to use a Hazmat suit to change the tanks and whatever, so why not shift. If your lab bill is $10,000 a month doing crowns, then it's an easy shift. My lab bill went from $7,000 the month before I got CEREC to $2,000 the next month and I haven't looked at it since. My first CEREC took me 4 and a half hours. It was a BOL inlay on a friend of mine and I had no idea what the hell I was doing, but it's still there. That restoration today would probably take me about half an hour.
Howard Farran: Why did you do it on your friend instead of your mother in law? What are friends for, huh?
Bryan Laskin: I like my friends.
Howard Farran: You like your friends. I want to go back to, you just said you did a marketing piece that didn't work, and no return there, but you also said something genius, that you bought another practice. Why do you think it is, in the Fortune 500 company ... Well, take a Fortune 500 company that we all know, Henry Schein. They have, over the years, under Stan Bergman, have mergered and acquired 36 companies, and a dentist will be figuring out that it's costing them about $250 or $300 to acquire a new patient, and then here's old man MacGregor across the street retiring. He's got 1,000 charts. His practice will sell for $100 a chart, and they don't even think about it. They don't even look at it. So talk ... Do you spend your time in 2 different practices, or did you do a merger and acquisition, bought the charts and moved it into your practice? Talk about your merger and acquisition, which I think is one of the most overlooked marketing piece, business event, in all of dentistry.
Bryan Laskin: Yeah, I just bought one last week. I bought 4 practices over the course of, well 2001, so 14 years, and I've merged them all in one location. Now, it's getting a little hard because we just put in 3 more operatories in March and we're already bursting at the seams, so ... I agree with you. Those of us that have done it ... It's not always an easy, seamless transition. There's staff mergers, fee scheduled and things, but the pluses far outweigh the negatives in the majority of cases, and for every practice I've purchased, I've probably looked at 5.
Howard Farran: Your in Wayzata, Minnesota? Is that how you say it? Wayzata?
Bryan Laskin: Wayzata.
Howard Farran: Wayzata. Is that a suburb of ... ?
Bryan Laskin: It's a suburb of Minneapolis. We're 5 to 10 minutes west of Minneapolis.
Howard Farran: Would you tell yourself it's a urban practice, or are you driving out of Minneapolis and going through country before you get to your town?
Bryan Laskin: No. It's a first ring suburb.
Howard Farran: How far away can these practices be, and what percent of the patients roll into your office? If you bought these charts, how far ... and you said you bought 4? Or 5?
Bryan Laskin: 4.
Howard Farran: How far were these 4 practices distances and did that affect them rolling into your office? And I'm smelling your third online CE course. I really think you really need to do an online CE course on mergers and acquisitions. I just thump my head, especially in rural America. I just can not believe how this is so overlooked. You should always be scouring the practices for sale in your neighborhood. Sometimes you'll tell a dentist and they didn't even know the practice was for sale. You know, the classified ads on Dentaltown are free. You can list a practice for free, you can look at them. It's a very busy section on Dentaltown, business minded people looking at mergers and acquisitions. So talk about that. You got 4 practices. How far away were they, how many of the patients, and do you have a dollar amount on that practice that you went out and compared to what it would cost you to go out and get them through other forms of marketing?
Bryan Laskin: I've done it several ways, and I think each practice comes with its own opportunities and challenges, but again you just have to protect your downside and look at the upside.
To answer your question about do patients come from those practices, it blows my mind. Every time I think there's going to be some attrition, and in reality, these patients are going to have to go somewhere. They are either going to go to somebody else which is totally new, or their going to come to see you and give you a shot, and everybody comes and gives you a shot, and as look as you have the type of service that blows people away, they are never gonna leave. We have people come in from Europe that they come back and when they're in town they still see us, and they weren't even patients of mine. The dentist retired 6 months ago.
I think dentists grossly overestimate the amount of attrition that will happen when you purchase a practice. People drive by 150 dentists to come see me all the time, and they maybe met me once in the hallway, so it's really about ... Patients are willing to drive, and if you're in a rural area it's probably 1,000 times more likely that they'll drive to you, but people drive way out of rural areas in to me, and across the city to come see me even though they haven't seen me as a dentist.
Now I'm going through the process where I've hired ... I have 4 full-time associates. The senior one is 3 years, then one that been with me for 1 year, one 6 months, and one for about 2 months. I see the same transition. As long as they give them good service, patients are, for the most part, willing to see another dentist. You just have to give pain-free anesthesia and treat them well, and have the staff treating them well. I don't think that people are going to go somewhere else.
I agree with you, the cost ... Where I am, it's not a growing community, so the cost for me to market and acquire a new patient, which we do a lot of, is high, so if I can buy another practice it's a fraction.
Howard Farran: And how far away were these practices?
Bryan Laskin: Several miles.
Howard Farran: Because I know a practice for sale from this guy that shot a lion, and I was thinking that maybe I should buy that, but it's 1,000 miles away. How far were these practices and ... ?
Bryan Laskin: I'd say several miles. The biggest one that I did where I purchased a practice, I had never practiced with the guy, but I'd known him since dental school and I liked him and wanted to work with him for a while before he retired, and neither one of our facilities was big enough. He was about 10 minutes away from the building, and I was about 5 minutes away from the building, so I purchased this practice, never practiced with him, 6 months later, we both moved into the building the same day. His patients didn't just have me buy his practice, but they were totally transposed to a new building. His practice had looked the same for 40 years. That transition was very seamless. You need to keep some staff in place, communicate the message to the patients. We had given them an offer to come in and see us that first time and then you give them a tour, you blow them away, you talk about everything that's the benefit to the patient, expanded hours, expanded availability, we now have CAD/CAM dentistry so we can do your crowns that same day. Patients are very willing, as long as there lots of benefits for them, they're not going to go somewhere else.
Howard Farran: What are your hours and availability?
Bryan Laskin: We're open Monday through Thursday 7-6, Friday 7-4, and then we have some Saturday appointments too.
Howard Farran: So you have early morning, evening, and then some Fridays and Saturdays, and I would say, probably what, 85% of all dentists are Monday through Thursday, 8-4?
Bryan Laskin: You probably know that better than I, but I know that-
Howard Farran: And just to make sure you know that they are not friendly, they even close down for lunch the same hour of your lunch hour. They are like, yeah, we're just going to go ahead and follow that left jab with a knockout right punch.
Do you have a dollar amount ... When you go to a merger and acquisition and you're looking at an office, what is your definition of an active chart? Is it someone who has been in in the last 12 months, or do you go 18 or 24, and are you doing valuation on that chart, or are you also tallying up dental equipment and Goodwill and all that kind of stuff? I mean, it costs me $300 to market to get a new head in my office and I can buy this practice for $200 and thus, no decision, buy. How do you wrap your brain around that business deal?
Bryan Laskin: Yeah, it's different today than it was previously. At one point I bought a practice for the physical location, which I would never do that today because the physical space I think is cheap now. Back then it was ... It's just like we were talking about with CEREC or incorporating a communication system or something. Once you go through it, you gain the knowledge and now, it has nothing to to with equipment or space. You can always build space, you can always buy equipment. For me it's all about the patient base that is there. There are some specifics about if that dentist is going to stay on or not, or if I want them to or not. There are different ways to structure the deal and whenever I look at a practice I kind of weigh all the options and then I would structure... I look at it so that I structure in a way that works for me given all the variables that are there, and if it works for the other person great, if it doesn't then I'll move on to the next practice.
Howard Farran: How many years will you finance this practice over?
Bryan Laskin: It depends on the practice. If it's big enough I don't have a problem financing a practice my ... Well, I shouldn't say that ... I don't know what the ... At points in time it's been difficult for some dentists to get financing from banks, but I've never had a problem with that because we've shown a history of being aggressive with paying off funds and things like that, and as long as you can make a good business case, as you're alluding to, for the most part dental practices are inexpensive to buy, so all you have to do is show the bank a way that they're going to get their money back and they're probably doing to loan you money at a very low rate, because dentists are just about the least default rate that there is out there.
Howard Farran: Oh yeah, it's less than half of 1%. That's why they love us, and that's why so much venture capital money flowed into corporate dentistry because they just saw that.
We're completely out of time. We're 2 minutes over time. Are you going to CEREC 30 in Las Vegas?
Bryan Laskin: I am. We'll have a booth, yeah, for sure. Come buy.
Howard Farran: What are the dates for that and tell them about your booth?
Bryan Laskin: It's September 17th through, that's the Thursday through that Sunday. Yeah, it's going to be great. It's just going to be a fantastic event. I don't remember the booth number, but it's going to be OperaDDS, so if you stop by we are giving away an Apple watch, and everybody that signs up for a pro account, we have our little Wolfgang the monkey mascot that he's a slingshot monkey, you can come by and pick one up.
Howard Farran: I just got to end with, man, I mean you've been a townie since 2003, you're coming up on 1,000 posts. You're a legend in so many people's minds. Thank you for your online CE courses. Thank you for ... You're the busiest guy I know and you just spent an hour with me and my last question, I have to go, please explain all those musical instruments, and I'm totally loving Darth Vader's hat over there. Everyone's idol. What's all the musical instruments? What do you play?
Bryan Laskin: I play guitar and bass, but I just love to play. For me, it's a hobby. If I got too into it, I probably wouldn't enjoy it as much so I just like banging away. And thank you for Dentaltown. It's just such a great community and newspaper, or magazine, and online forum, and it's just a force in the industry and you yourself are just a dynamic lecturer that I've seen many times and I appreciate what you do for the profession.
Howard Farran: I want to see you lecture with the Darth Vader hat on. Are you counting down to Star Wars, what is it, their 7th movie?
Bryan Laskin: If I tell you the details of the nerd-dom of Star Wars that the layers in my family I would be very embarrassed. Yes, we are very into it. Right now there is a bid going on so that you can buy 6 tickets to go see the new movie at Lucas Films in California, so I'm trying to rustle some friends together to see if we can win the bid.
Howard Farran: Wow. I have to tell you, Star Wars is ... I can't even get my mind around it because I've got 1,000 books over here if I panned over to my library over here. I've got 1,000 books. I just can not read a fiction book. I always think if you're reading something you're not learning. You're wasting time. I don't get fiction at all, but I love Star Wars. My 6 favorite movies of all time are the 6 Star Wars movies and I just say to myself "how does a guy that doesn't do fiction love Star Wars so much?" I just think that's everyone's movie.
But hey, thank you so much for your time. Good luck with OperaDDS. Let me know if there's anything else I can do to help spread the word in there because I love getting dentists great information they can do dentistry faster, easier, better, higher quality, lower price and that's everything that you're about.
I do hope you do a course on mergers and acquisitions. It is the most overlooked thing. Corporate dentistry is growing so well because these guys go raise a bunch of money from Wall Street and offer these retiring dentists liquidity. And why aren't the other dentists offering these dentists liquidity. And then 5,000 graduates roll out of school and these dental offices, they are sitting there 160 hours in a week and they don't hire any associates, so corporate dentistry hires them. So corporate dentistry is giving liquidity to retiring dentists and hiring your associate. And you're the master you've acquired 4 other practices and you've provided 4 jobs. If 5% of the dentists were like you, there wouldn't even be corporate dentistry. I tip my hat. Everybody needs to know more about how you're thinking. I hope you do a mergers and acquisitions online course.
Thank you for your time.
Bryan Laskin: Thank you for your time. Appreciate it.
Howard Farran: Now I have to leave. I've got a date with Princess Lea right now.
Bryan Laskin: Okay, have fun.
Howard Farran: Bye-bye.
Bryan Laskin: Bye-bye.