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Office Visit: Dr. Paul Trotter by Kyle Patton, associate editor

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Categories: Orthodontics; Practice Management, HR and Accounting;
Office Visit: Dr. Paul Trotter 

This Georgia Townie honors his father’s legacy by crafting his own through streamlined systems and smart investments

by Kyle Patton, associate editor
photography by John Robeson for Wier/Stewart

Orthodontists spend most of their working hours inside their own practices, so they usually 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 how they practice.
Those who take over the family business often have thoughts of expanding and building a business empire, but Dr. Paul Trotter wanted to keep things small after taking over for his father. No plans for additional practices. No hiring of associates. And the team—many who have been with the Trotters for decades—travel between two offices in the Deep South depending on the day of the week.

While at first glance this might sound like an antiquated way of doing business, this Townie is anything but stuck in the past. With a suite of 3D printers, scanners, integrated CBCT, advanced patient communication tools and more, this doc’s digital workflow should be envied … and then replicated! Trotter’s even happy to tell you how in our exclusive Q&A, in which we head to one of his Georgia practices and chat about what makes a digital office productive, how to simplify the patient experience (without stressing about the numbers), why practices are worth more than common evaluations believe, and a lot more.
OFFICE HIGHLIGHTS
NAME:
Dr. Paul Trotter

GRADUATED FROM:
Furman University;
Dental College of Georgia

PRACTICE NAME:
Trotter Orthodontics

PRACTICE SIZES:
Augusta: 6 chairs, 2 exam,
1 records; 3,500 square feet

Evans: 6 chairs, 2 exam,
1 records, conference room; 4,500 square feet

TEAM SIZE:
16
How’d you find your way into orthodontics?

My dad is an orthodontist, so I grew up around orthodontics. He would always treatment-plan on the weekends in his home office and call me into his office to show me interesting cases. My interest was piqued. In high school, I expressed an interest in orthodontics to him, and he let me start working in the office during the summer and school breaks. First, I started in his lab. Then, he started letting me do simple adjustments on patients.


Is there a memory about your father practicing where you look back and know you were hooked?

Definitely watching him review all of a patient’s records and treatment-plan was like observing him piece together a puzzle. At my young age, I didn’t fully appreciate the amount of time he dedicated to treatment planning for each patient. We have it much easier now with digital radiographs, digital photos and digital models, which offer greater convenience in work settings. However, this convenience can also present challenges. In the past, Dad used to carry a large, durable briefcase filled with model boxes and charts to work on treatment planning or reviews for the upcoming week. Among dental specialties, none demands as much administrative time as orthodontics. But putting that time in on the front end saves so much time and headache on the back end of treatment!


Tell us about the practice, the area and what it’s like to be a part of a community so consistently.

Dad opened the practice in 1981 upon completing his residency. He had already practiced general dentistry for six years before pursuing his orthodontic residency. The office he established during that period still remains our Augusta location. As the greater Augusta area has expanded, this location has continued to serve as the geographical center, despite significant changes in the surrounding area (some positive, some not).

When it came time for me to join the practice in January 2014, it became evident that the Augusta office could not adequately accommodate both of us. Identifying a growth area in Evans, which was five miles from the nearest orthodontist, we proceeded to construct a second office. These two offices don’t function as a primary and satellite office; rather, they operate somewhat like two main offices. We dedicate two full days each week to each office, with a rotating schedule for our presence in each location.
 


 You’ve made a conscious effort to keep things relatively small and simple. Tell us about this philosophy and how you act on it.

The practice has more than tripled in size from what it was 10 years ago (in employees and in starts/revenue), so it does not feel small or simple to me on many days! But relative to many other orthodontic practices, it is.

I’ve considered an associate many times, but each time I think I’m ready, I hear a horror story from a friend or colleague about something that has gone horribly wrong or an HR issue they’re having with their associate. While I’m young and energetic, I’ve decided to get as efficient as possible and see as many patients as I can. We have a three-month wait for new-patient exams right now, so I know I’m leaving some money on the table, but I’m probably also leaving a new set of headaches on the table as well.


When your dad retired and you took over, you decreased the number of doctors in the office but still grew the practice. How’d you do it?

Part of becoming as efficient as possible involved overhauling our schedule template to optimize one doctor, and also discovering a digitally customized solution to reduce the number of appointments needed for each patient’s treatment.

We engaged Mary Beth Kirkpatrick with Gaidge 360 Consulting to completely revamp our schedule template, and we transitioned all of our braces cases to the Stride system from KLOwen. The synergy between these two elements was remarkable.

My dad retired at the end of 2021, making 2022 my first year as a solo-doctor practice. Emerging from the orthodontic boom of 2020–2021, 2022 posted as a milder year for many practices, but through the integration of our new schedule template and the personalized KLOwen braces, we achieved 17% growth in 2022, despite operating with only one doctor compared with the previous 1.5.


While you keep things simple, you by no means shun tech—you’re big into analytics. What are the most important things to track? What tips do you have for other docs?

You can easily become immersed in analytics. Gaidge is replete with numbers and data points that are trackable. It’s possible to become consumed by it! I used to take golf lessons from a teaching pro who referred to it as “paralysis by analysis.” I prefer simplicity and concentrate on a few essential metrics. While we were enhancing efficiency, I narrowed my focus to revenue per appointment, because the quickest way to boost this metric is by reducing the number of appointments required for each patient’s treatment. Gaidge’s nationwide data averages suggest that a $1 increase in revenue per appointment corresponds to a $4.65 increase in profit. With the incorporation of the KLOwen custom braces system, we elevated our revenue per appointment from $371 (our average with directbonded, MBT brackets) to $694. An early lesson I acquired from my father that’s valuable to share with other doctors is this: What you monitor tends to improve. Select one or two pivotal metrics in your practice that you believe warrant enhancement and track them.


Run us through the most impactful technology and clinical tools in your office. What kind of difference have they made?

I definitely wouldn’t want to practice without our intraoral scanners. We have three Medit i600 scanners. About a year ago, I made the switch to Medit because of my dissatisfaction with another company’s high monthly fees and the inconvenience of transporting two large pelican cases between offices daily. Using Macs as our chairside computers, the Medit scanners seamlessly integrate and operate smoothly, eliminating the need to maneuver a scanner cart throughout the office. All three Medit scanners fit into a single compact pelican case, and the monthly fee for Medit is a mere 99 cents. Our CBCT plays a vital role in pinpointing and planning treatment for impacted teeth. While I continue to capture panoramic and cephalometric images as my standard records, I supplement with limited-field CBCT scans when addressing impactions.

To enhance our aligner procedures, we incorporated Grin remote monitoring. This has significantly reduced the frequency of appointments required for our aligner cases, much to the delight of our patients who appreciate minimizing work or school disruptions. This ties directly into our goal of increasing revenue per appointment, all while delivering an enhanced patient experience. We are in the process of expanding the use of Grin to cover new-patient exams as well, enabling us to address our backlog of three-plus months. This approach is anticipated to be particularly beneficial for the numerous 7- to 11-year-olds awaiting exams who may not be ready for treatment. By conducting their new-patient assessments virtually, we can allocate in-office appointments to older patients who are more likely candidates for comprehensive treatment.


Explain the digital workflow in your practice.

Once a patient is scanned, the assistant completing the scan must complete a Jotform digital prescription. This notifies the digital lab technician via email about the scan and what it’s to be used for (retainers, aligners or braces). If the case requires retainers, she then removes brackets in EasyRx (as needed) and 3D-prints the case. If the case requires aligners, she loads the case into the correct portal (uLab or 3M). If the case requires braces, she loads the case into EasyRx.

The Jotform digital prescription form allows us to avoid having a lot of paper floating around. We created a similar Jotform for when a letter needs to be generated for a doctor referral for a patient.
Top products
STRIDE CUSTOM BRACES BY KLOWEN
Without a custom appliance, I could not have grown my practice after my dad retired without hiring an associate! This system had the most reasonable price point, so it made the most sense to me. Now KLOwen offers both clear and metal options, so it has been the most essential piece of our practice’s growth over the past two years.

MEDIT I600INTRAORAL SCANNERS
If you use an aligner system other than Invisalign, using a scanner other than iTero is a no-brainer. Medit’s small form factor allows us to transfer all three of our scanners between offices easily, and the 99-cent monthly fee is refreshing.

PAUBOX EMAIL
I wanted an encrypted email solution that made it easy for my team to send HIPAA-compliant encrypted emails and also for recipients to view them. Paubox delivers that by encrypting every outgoing email and automatically decrypting it for the recipient. The recipient need not log into a portal or click a link to receive a code; instead, the email is in their inbox, as any other email would be.

GAIDGE
In a period of growth and change in our practice, Gaidge made it easy for me to monitor key metrics and statistics. Combined with consulting from Mary Beth Kirkpatrick, it supercharged the growth we were able to experience in 2022 and continue to experience in 2023.

EASYRX
We use EasyRx for digital bracket removal, model trimming and also case submission to KLOwen. It is an essential part of our digital workflow.


A lot of your team has been with you for 15 years or more. That’s rare, especially in today’s job culture. What do you think is the key to long-term employee retention?

My dad didn’t have many employees, but the ones he had stayed with him for 20-plus years. I learned from him that turnover is expensive and disruptive. It’s important to create an environment where your team feels appreciated and valued and has a sense of purpose in their work.

Our workplace is very much like a family atmosphere. My employees take vacations together on their own time that are not work-related because they enjoy being together. It’s important to ensure that new hires fit into that culture. A potential new employee might be the most qualified applicant for their position, but if they’re going to disrupt your office culture, it’s not worth it!


Contrary to the thinking of a lot of numbers-oriented docs, you don’t set financial goals or start goals. What is your approach instead?

One of the best ways to explain this is with a story: My dad asked his longtime (30-plus years of work) receptionist to please make sure she greeted each patient as they walked through the door. She replied, “Dr. Trotter, I don’t think patients expect that.” To which my dad responded, “Exactly. They don’t expect it, so that’s why we’re going to do it.” We want to provide patients and their families with a level of customer service that they’ve come not to expect anymore. Our treatment coordinators call new patients before their appointments to introduce themselves and tell them what to expect. We email new patients ahead of time with their anticipated insurance benefits. We call the oral surgeon or periodontist to facilitate the scheduling of appointments when we’re making a referral. Our goal is to always put the patient’s interests first, rather than financial gain or a start goal. I’ve never set financial or start goals. I also don’t incentivize my treatment coordinators, which allows them not to be pushy or “salesy” with new patients. We get a lot of compliments about this. My grandfather once told my dad that if he made money his goal, he would make himself miserable and cost himself a lot of money. But if he focused on taking care of people and doing the right thing, he would love going to work and the money would be there.


Consulting can be hit-or-miss. For you, it was a hit. Run us through your experience and what kind of changes it led to in your office.

Our consulting experience was more than just a hit—it was a home run! Our schedule template was a mess, so I called Mary Beth to ask her to revamp it, and I ended up getting a whole lot more than just that. Not only did she help make our schedule much more efficient and add places for starts—which facilitated the growth we are experiencing despite shrinking to a single-doctor practice—she also helped us use our practice management system more effectively, streamlined our new patient process and helped distribute some of the workload among our administrative team.


You’re an advocate for digital scanning, 3D printing and having an in-office lab. What are some things other docs might be missing out on by not leaning into these advancements?

Our in-office lab is more of a throwback than an advancement. We have kept that fairly traditional with the in-house fabrication of space maintainers and expanders. The huge advantages are quality control and turnaround time: I can fit bands on a patient on Monday and deliver his appliance on Tuesday.

We have modernized our in-office lab with the addition of 3D printing, but I tried to do it in a cost-conscious manner. I’ve always been tech-savvy and willing to tinker, so I decided several years ago that I would dip my toe into 3D printing with a hobby printer from Amazon. Today, we have three Anycubic Photon Mono X printers, which print six models horizontally in about 45 minutes. We have loved scanning for retainers before debonding. We provide patients with two vacuum-formed retainers and their model. Rather than a subscription-based retainer program, we will replace their retainer for one fee if the patient brings the model back and another (higher) fee if we have to rescan and print a new model. If you don’t have this capability in your office and have to outsource this, it would be difficult not to have to make a program subscription-based to cover the additional costs.


What are the biggest obstacles that corporate dentistry and orthodontics pose to new grads and new docs? What are some potential solutions?

The biggest obstacle comes in the valuation of practices. Because corporations are willing to pay such large multiples of earnings before interest, taxes, depreciation and amortization (EBITDA), it makes it difficult for a new graduate to compete to buy that same practice.

I recently read an article by Roger Hill in the McGill Advisory in which he proposed a potential solution. He has proposed an EBITDA+ valuation for private sales, in which the value of a practice is not valued based on traditional metrics of production or collections; rather, he values it on a modified version of EBITDA that makes more sense for a private buyer. This values the practice higher for the seller, but also still cash-flows for the buyer.


What’s the next piece of tech you think you’ll adopt?

I have been intrigued by the robotic lingual retainer bender, but I’m waiting for it to be able to bend beta titanium (TMA) wires. We use 0.027- inch TMA for our lower 3–3 retainers and the last time I looked, the bender machine was not able to bend TMA.


What kind of cases excite you the most?

Because we are working on efficiency, right now I’m most excited about cases that are finishing months ahead of their estimated treatment time. No matter the initial difficulty of the case, it’s always fun to make a patient’s day brighter by telling them they’ll be getting their braces off much sooner than they expected. This has been happening more and more lately with KLOwen, and it never gets old.


What’s a trend in the profession you love?

I like that digital custom treatment seems to be catching on more and more. It seems like companies such as KLOwen, Lightforce and others are starting to gain market share. This allows braces to be as efficient as aligners, while retaining all of the control of a fixed appliance.


Let’s talk golf: Favorite course? Best score? What do you have in your golf bag? What’s piece of advice would you give any novice golfer?

Living in Augusta, my favorite course is of course Augusta National. I’ve been fortunate enough to play it a few times, and it’s breathtaking each time. The first week of April is the best time of year every year, because it’s time for MLB Opening Day, the NCAA Basketball National Championship Game and the Masters!

My best career score is 65 at Augusta Country Club while I was in dental school, but that seems like a lifetime ago now. In my bag now is a Titleist TSR2 driver, a Taylor Made Stealth 3-wood and hybrids, PXG 0311T Gen 5 irons, Titleist Vokey SM8 wedges and a LAB Golf Mezz.1 putter. That’s probably more than you bargained for on that answer, but golf is my true passion!


Give us a snapshot of your life outside of dentistry.

I have a beautiful wife of 14 years, Liz. We have two children, Jackson (7) and Annie (5). Jackson is obsessed with golf, so much of my free time is spent caddying for him. Someone asked me the other day, “When do you think Jackson will be better at golf than you?” and I told them, “I think he already is.” Annie, meanwhile, loves anything to do with animals (especially horses). Liz and I love to travel, and the kids are sometimes the beneficiaries of that as well.

I also spend a lot of my free time on various boards in the community. I serve on the board of the largest community bank in the Augusta area, Queensborough National Bank and Trust. I also serve on the vestry of our church and the board of our country club.
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