Office Visit: Dr. David Paquette by Sam Mittelsteadt, editor

This Orthotown editorial advisory board member, who’s well known for practice efficiency, shares his secrets of success

by Sam Mittelsteadt, editor

Orthodontists spend most of their working hours in their practices, so they don’t get many opportunities to see what it’s like inside another doctor’s office. Orthotown’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of their practice protocols.

In this issue, we visit Dr. David Paquette, a member of Orthotown’s editorial advisory board who’s a sought-after consultant and lecturer on the topic of practice efficiency. He’s also a key opinion leader (KOL) for Henry Schein Orthodontics, helping the company create and develop new products that help practitioners become more profitable and—you guessed it—efficient when treating patients.

Here, Paquette discusses some of the inspirations he’s used to shape the way his team treats and interacts with patients, the typical duties of an orthodontic KOL, and the biggest challenges he’s faced as a practice owner.

How did you first get interested in dentistry?

My father was a management consultant, and my high school aptitude tests and guidance counselors all said that I should go into medicine. I knew that I didn’t want to own my own business—nobody told me that a dental practice was a business until I was deep into it!—and I didn’t want to be on call, like physicians were. The father of one of my classmates was a dentist, and his family always went on vacations and had nice cars, so as a patient who’d never had a cavity, I went in thinking, “That’s a great job!” Then, once I was in dental school, I was shocked at everything that was actually involved.

How did you keep going?

I developed interests in pediatric dentistry and orthodontics, because the most impressive member of faculty, Dr. Henry Fields, had specialty training in both degrees. He always had the answers to questions, or was able to find them quickly, and I wanted to emulate him.

After I graduated from dental school, I practiced pediatric dentistry in Durham, North Carolina, for a year as an associate. Knowing I was interested in orthodontic training, I did not want to build a pediatric practice. At that point, I joined the U.S. Air Force.

I had been talking with the department chairman in pediatric dentistry about how I didn’t know where I wanted to live, and he mentioned that a previous resident had entered the Air Force. It sounded great—I was single, and traveling around the world, spending two years in England and two years in Japan. Both locations were the terminal hospitals, so as a consultant I traveled to other bases and was referred pediatric patients regionally; patients whom general dentists couldn’t treat. I had no “nice kids.” I was in the operating room one full day a week, doing general anesthesia for patients, and gave fundamental refresher courses on pediatric dentistry to other dentists. If they needed equipment, I made recommendations to the commanding officers.

You were relatively young to be a consultant and telling the Air Force what to do! Did that feel unusual to you?

The military is interesting because in medicine and dentistry, your rank and your training might not be equivalent: There might be general dentists who are full colonels, and you might have a specialist who’s a captain or major. You have to recognize both specialty training and the rank system, so if someone’s a full colonel, you have to approach how you make recommendations to them differently than if you were a specialist looking over a department. It was a good learning experience for me, now that I’m in the corporate world with one foot—how to navigate the difference between someone’s knowledge, experience and their person.

Your experience in the Air Force also set you on the path toward being a speaker and consultant.

When I was in the Air Force, the military went through the transition toward contemporary sterilization methods. I was a department head and had to navigate between having my department upended and applying the new methods.

Back then, we didn’t sterilize handpieces; we had one set of instruments and wiped them off with alcohol. The only time you wore gloves was in surgery. I remember the endodontist in our Air Force clinic defying the higher-ranking decision-makers, saying there was no way he could practice endo wearing gloves. They came back and said if cardiac surgeons can wear gloves, so could he. Back in the day, dental offices had carpet in all of their treatment areas!

When I got out of school and designed my first practice, I applied all of the contemporary principles I had learned. My orthodontic practice was probably one of the first to have a central sterilization area, and to have multiple sets of instruments and multiple extra handpieces so they could cycle through sterilization. By today’s standards, the practice would probably be kind of shabby, but back then, it was state of the art! I had custom-made foot switches for the chairs, so I wasn’t using dirty gloves to adjust chair position for patients; when I went to Dome, they kept asking why I wanted to have the foot switch made.

The practice was designed from the ground up for this new approach in mind, which allowed me to navigate around efficiently. The challenge was trying to do it and maintain overhead and efficiency. The military has all the money in the world, but how does a single practice owner make those changes?

People would come by and look at the office, and soon I was going to Australia and Europe to discuss aspects of the change. Over time, my presentations gradually transitioned to more and more about efficiency as people began asking for more information about that. Superimposed on that, I was asked to join advisory boards for some companies to discuss and try clinical aspects of treatment that maybe were not mainstream at the time.

Now, I’ve been speaking for some extent or another for 30 years. The amount of speaking has gone up and down over the years; when I opened my first practice, I had maybe four patients a day, so speaking wasn’t an interference with the practice. When I got married and had kids and family, they took more of a priority.

What are the responsibilities of an advisory board member?

There are several levels. Appliance design is much more regulated than most people are aware of, so I work with engineers, giving them an “I really wish I could do this” wish list and having them go back to labs and try to create something that fits the bill. If I were trying a new appliance in the office, I’d try it on friends or staff members to get a gut feeling of whether it’s going to work, so I’m not experimenting on a patient.

I actually spend a lot of my time providing feedback to the research and development team: Whatever appliance they’re working on, they need clinical feedback. An appliance designed in a laboratory setting, without clinicians’ input, might not meet our evolving requirements. My role, in these innovations, is to be the voice, the pulse and the face of the orthodontic community. My collaboration as a KOL can start before a product is developed: By understanding orthodontists’ existing frustrations or wishes, the engineering and marketing teams can try to develop products that have features that address those concerns. Then, during the development process, I can clinically test the products and give feedback on their effectiveness.

At times, I advise the leadership team concerning general business strategies, industry activity, new technology or vendors, and I also help them with the evaluation of potential acquisitions. I even collaborate with the regulatory team, which is required to get clinicians’ input to validate some testing they need to do. Right now, we’re working on the development of an expansion wire series that would be ideal for expansion and would address crossbites and/or Brodie bite corrections. I actually came up with the concept—it’s a preformatted, narrow or wide copper nickel titanium wire. Once that’s available, I will no longer need to manually shape my wires.

In some cases, we’d actually get the products intended for market, six months to a year ahead of time, so I’ll tell patients, “I have this cool new product that I’d like to try on you, if you’re game—as long as you understand we might have a few hiccups. Let’s see how it works.” We give them consideration for the inconvenience—you have to take a lot more photos for records, for example—so it’s a win-win for both sides.

I’d say the success rate of those products is well over 95%. It’s not as much as a pass-versus-fail scenario; it’s more of a process where the product you’re evaluating needs to be modified or adjusted. The only one I remember that didn’t work out well was years ago, when a bracket worked well for six months but then fell apart because it couldn’t endure the rigors of the oral environment.

What were the challenges of becoming a practice owner and manager?

The biggest was that I was completely unprepared to manage staff. I think anyone who goes through college, dental school and residency is pretty much a self-starter; if you have a task due, you put your head down and get it done, even if things are less than pleasant. In the military, if you ask someone nicely to do something, they do it. Hiring staff and realizing that their motivations and drives are completely different from yours was a shock. To this day, people management is still a challenge.

Second—and this has been a transition over the past 30 years—is dealing with the overly demanding parents with their lack of respect of professionals. You’ve got parents standing over the patient while you’re doing treatment and questioning what you’re doing—they’ve done their internet homework, so they’ll ask, “Did you notice this?” Yes, it’s a process and we’ll take care of that in the course of treatment.

I learned a new term this past year: Instead of helicopter parents, they’re lawnmower parents—instead of hovering, they clear the way so their kids never have any bad experiences. They’re the ones who say, “Is that going to hurt?,” which only predisposes kids to worry about what’s going on. They’re the same parents who are asking soccer coaches when their kids are going in, or constantly having meetings with teachers.

Over the past decade, it seems like no children can miss school for appointments anymore. That becomes difficult, time management-wise, for scheduling. Not every patient can have an after-school appointment, and my team is trained to nudge them into the right appointments by presenting it in a way that shows it’s in their best interest: “Longer appointments take a lot of close attention, and that’s a busy time of day. I’m sure you’d rather have your daughter or son here when there’s not such a rush.”

When you decided to open a second practice, what did you decide to do differently there?

During the design process, I juxtaposed a few experiences I’d had outside the office and applied the principles to my practice. For example, I went in for my annual physical, filled out all the same stuff I’d filled out a thousand times, and I’m standing there talking to the receptionist and when the phone rang, she held up her finger, like, “Shhh, you have to be quiet!” We’d been in the middle of a conversation, and she literally ground it to a halt so she could answer the phone. I thought, “Does that happen in my office? We’re trained to pick up by the second ring, but this seems rude.” And sure enough, I found it did.

Then, my wife and I went on vacation to a smaller hotel, where the reception area was about 10 feet inside the building. When we walked in, the receptionist said, “Dr. Paquette, Jenny, it’s so nice to see you.” We hadn’t told them our names, and when I asked her how she’d known, she said, “We get about 10 new guests a day, and based on the fact that your flight landed about an hour ago, we can usually determine who’s arriving when.”

Now we have a person at a concierge-style desk who greets patients and makes them feel welcome. And our phones are answered separately, away from that desk at the front. We have maybe six to eight new patients a day, so we can apply the same level of knowledge the hotel had to greet our patients when they arrive. The concierge also prepares information for morning huddles, handles any correspondence that needs to go out, looks through the charts of that day’s patients to see if there’s someone who just had their wisdom teeth out, etc.

How about structurally?

To ease traffic flow, before we did the build, we took a day’s typical schedule and used different-colored pencils to draw the traffic patterns in the office, to look for “choke points.” We realized that we needed to create more room in some areas, so some hallways are 6 feet wide to make it more comfortable to pass by, and the area coming out of sterilization is 8 or 10 feet deep, so you don’t have people running into each other. We also wrapped our compressor room in 1-inch-thick rubber, so you don’t hear the compressors throughout the office.

I moved my personal office right next to the clinic and I have what we call a “virtual patient” chair—a computer in the clinic where I can do all of my aligner setups without disappearing into the office, so the patients can see me working, and I also don’t have to take anything home. I have one staffer whose role is to pull the setup for the next patient onto the computer, so I can be ready for it.

Tell us about your practice protocols related to scheduling efficiency.

We strive to do same-day starts. When we have new patients, the idea of them starting treatment the day they come in for the exam is discussed at the first phone call. If someone goes to a doctor, they don’t go to the office and only discover what’s wrong there; similarly, orthodontic patients already know what they don’t like about their smiles. If they come in prepared to start treatment that day, it’s a different mindset.

All new-patient exams are scheduled for 55 minutes, of which I spend seven minutes. This appointment includes the record taking, diagnosis, patient education and financial planning.

We treat patients following the “sagittal-first” philosophy, treating the AP aspect of the malocclusion first, at the beginning of treatment, using the Motion 3D Appliance. Appliance placement is a 20-minute procedure, so we can bond while they’re there or do the scan for the retainer, or both. If the patient is in Class I and doesn’t require Motion 3D, the bracket placement procedure is also reduced in time because we no longer do full bandings or bondings on the initial visits; we bond the upper and lower anterior teeth, to get them used to wearing braces, and have them back about a month later to bond posterior teeth. If they’re aligner patients, we use 3Shape scanners to scan them while they’re there, to get them started.

The other thing we’ve done for efficiency is record the patient instructions. There’s an education booth just off the clinic area where the patient and parent sit down and get the home care information that normally would be delivered by an assistant. Because of that, appointments can be of a more consistent length; we move patients away from the treatment chair into viewing the video, and the assistant can see another patient. An actual start appointment takes about half an hour now.

Our treatment protocols are really well-defined now, with a few rare exceptions. My staff knows what we’re going to do for each next appointment. They know what’s expected because of the three-archwire sequence we now use: a 0.015 CuNiTi, a 0.020-by-0.020 CuNiTi and a 0.019-by-0.025 beta titanium. Most patients do not require the extended treatment intervals that have been used by many orthodontists for decades.

And your efficiency as an orthodontist?

Typically, a lot of time is wasted toward the end of treatment, where you’re making adjustments to get things exactly right. Because we have 3D printers and scanners, we’ll do one or two sets of artistic detailing appointments, when we’ll do an intraoral scan for the retainer, write down the adjustments on the lab slip and replicate changes on the computer so the retainer can be available at the next appointment. Typically, when I’m making adjustments on computers, I might have one, two or three stages of retainers—and on the computer, teeth are four times bigger than seeing them in the mouth.

There’s a big benefit to getting patients out of braces sooner, because they’re happier and the increased chance of having loose brackets or wires is gone. Loose brackets are the single biggest nuisance to both patients and orthodontists. Most of the time, they’re due to inadvertent shortcuts—no staff members do it maliciously; they usually veer away from protocols, thinking they’re saving time. We monitor loose brackets and revisit bonding protocols as needed.

What percentage of patients are opting for braces over aligners?

About 60% of our patients get braces of some kind and 40% are aligners. I’ve found that aligner patients usually fall into two major categories: those who will do it for about a year, and those who will never, ever be satisfied and constantly require refinements. There are also those who think that they want aligners but get sick of taking them in and out, and just want to switch to braces.

Many patients opt for hybrid treatment—braces for 6–10 months, and maybe three or four aligners to finish. Or if they have severe rotations—usually on the bottom—then braces on bottom and aligners on top.

Are you worried about the rise of direct-to-consumer or DIY aligners?

All the negative PR of places like Smile Direct Club has, to me, raised the general public’s awareness of what their general appearance is—so to me, they’re doing marketing for me. Patients come in and ask those questions. If we can use products like Dental Monitoring so that patients can visit the office less frequently, then I think the world is wide open. I’m having more fun than I ever have.

 

 

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