Some days, I feel so very inadequate and underachieving.

I'm 31.  I'm very single.  I've dedicated myself to just getting very good at one very specific skillset--dentistry.  I like to think that I'm pretty good, but I'm only human.  I've found a few people who are better than me...some phenomenally so (Basta, Misch, I'm looking at you guys).

Meanwhile, there are people outside doing cool things like building a treehouse in Hawaii or organizing 1000 people to play a rock concert https://www.youtube.com/watch?v=JozAmXo2bDE.

Anyways, been recently obsessed with more efficient storage and tiny houses.
My dental office is pretty and fancy looking, but ergonomically it's not that great.
I plan to make some cabinetry over the next year.

Ideally, I want to create a system to minimize the time to transition.
I want it pretty.  I want it minimalist.  I want it flexible.

My belief is that a better setup will lead to better work, and better outcomes for my patients.

-Matt

Website up

We've been working on this the last 2 months or so, but Monday we launched our website.

It's been 6 months.  There have been substantial improvements: new chairs, new team mates, digital imaging and X-rays, and better tools.

It's been grueling and mentally draining.

The first two months was survival.  I'd found problems in the practice that jeopardized patient safety and privacy.  Billing was wrong.  Accountability was missing.  Core equipment was missing or broken.

Through all this, God provided just barely enough to pay the bills.  No surplus.  No deficit. 

As mom says, like mana from heaven.

A very patient patient--going to the extreme to deliver my very best dentistry--ie: the crown seat from hell.

I have to thank my patient Larry for allowing me to indulge in my vanity.

Some time ago, there was a problem with his previous crown.  It was leaking.
He told me, "just do what you think is right, doc."

I told him gold was king.  He let me do it.  We took the impression with hydrocolloid...twice.
Retention slots were drilled in the second time to improve longevity on a very short, worn out tooth.

Then, I spent 8 hours waxing his crown...attempt 1 was useless since we needed a new impression and retention slots.  After another 8 hours, the second attempt at waxing his crown was a fail (wax cracked during storage).  After yet another 4 hours, the margin broke off...my mentor told me to use a different wax.  And after another 2 hours, we had a wax pattern...we casted the crown in JCB gold from Jenson industries--about $700 worth of gold (including the button).

It was a fail.  The sprue was too short.  There was a bubble right in the middle of the crown.

After another 4 hours of waxing, I presented another wax pattern to my mentor...which was deemed "not tooth shaped."  He rewaxed my crown in under 20 minutes.  We resprued, and recasted the crown.

Today, I spent 2 and a half hours to cement a crown.
I'd repolished the mesial contact to a perfect, wide contact.
The crown would only seat in one direction, with a 2-5 degree tolerance of seating.
Also, this is tooth 15...the last tooth in the mouth.
Lastly, the crown would be almost impossible to remove once seated...even without cement.

Translation....good God this is hard!

5 attempts later, we finally have the thing perfectly seated.
The calibrated, single dose glass ionomer cement would set before I could fully seat this thing.
The margins were burnished and polished flush to the tooth.
The occlusion was adjusted to have 3 point contacts on each teeth.

This is the very best dentistry that I can humanly do...but I wonder at the cost (to me).

Anyways, I owe Larry a debt of gratitude for his patience and understanding.

I'm getting FICOI. Layaway at Detroit

This is I'm not sure what to make of Detroit.

It's 3:25 am California time.  There's a godawful eyesore from concourse A to concourse B:

This is the self styled "Vegas Light show."  Aargh!!!! 

On the plus side, the sunrise is beautiful.

It beats the crap out of San Francisco fog.

However, I think SF beats Detroit in many other ways...

I have TMD

As of yesterday, I have a temporal mandibular disorder (TMD).  I've included a work up because it may be helpful for others to see how I work up a case.

"I've been working 6 days a week, 10+ hour days, and my responsibilities have increased (with no increase in pay, and more bills to pay).  I'm having a dull ache on opening on the right side, but is fine at rest.  There are no joint noises noted.  My right jaw muscle is sore to touch.  I can open, but it hurts to open all the way,  Chewing makes it worse."

My thinking sequence:

1. What is affected?

         The Temporal Mandibular joint is comprised of nerve, muscles, and a joint.  Each type of injury will manifest differently.

2. What caused it?

          Masking pain is bad.

Removing the cause of pain is ideal.

Diagnosis is key.

3. What do we do about it?

          The best situation is to create conditions for optimal healing.  Often times, the best treatment is nothing. 

         Merely managing pain is a second resort, and only for various severe circumstances.  Pain pills, muscle relaxants, and surgery all have side effects.

Okay.  Hete's my work up:

1. What is affected?   

+Muscle, specifically right masseter.   

     The area is tender to the touch.

     There is a soft end feel---max opening is possible, but with effort.  Think of forceful over stretching a cramped muscle.

+There are no joint noises, possible indications of osteoarthritis. 

+The pain is only during function, ruling out nerve damage (constant pain, no pain)

What caused it?

-no trauma noted.

-no fever noted, ruling out infection/inflammation

-no medications were noted, thus ruling out inflammation 

+ elevated stress was indicated.  

        Because of the muscle pain was likely from elevated stress, the cause of pain is likely psychosomatic.  This is fairly common in today's society with more stress.

What do I do about it?

+ The cause is psychosomatic.

+ In my case, I need to reduce my stress, exercise, and relax more. 

I hope that this is been helpful for you. Thank you for checking out my blog.

Traveling tips

I'm on my way to a wedding--red eye flight.  This is my first non business related trip in a long time.

Here are tips that keep me from going crazy:

1. Good Luggage--

+mine is slightly smaller than standard, so it won't get rejected.

+great spinners--less strain

+expandable.

+lifetime warrantee

+my policy is one carry on bag, no problem

+packing cubes and folders make for fast TSA approval--no wrinkles, on the clothes at least.

2. Smartphone

+eboarding pass

+econfirmations

+infinite maps regardless of terrain

+in a pinch, it accesses currency via PayPal and bank sites

+with the Sleep Cycle App, it acts as a very effective way to combat jet lag.

3. Flashlight

+Mine is the 4sevens quark miniAA.

+you never know when you'll need it, my best use of a flashlight was to explore the ruins of Siam Reap at 3 am.  I believe it was the royal library.

4. GPS

+for any business trip where you need to rent a car, a reliable gps is very useful.

+at 1 am, do you really want to fumble for a map?

5. Portable office

+Mine is a refurbished MacBook Air and a used Fujitsu S1100.

+This combo has been immensely useful for taxes and tracking deductions.

6. A great pen

+In Japan, many are too bashful to speak English.  Signs, pictures and maps are universal.

+Keeping a Journal is a great way to be sane.

+in a pinch, they can be used for personal defense.  

7. Sense of Humor

+this is probably the most important thing for a traveler.

+Delays?  Layovers?  Fodder for jokes or bonding

Ps. If I were the model's dentist, I'd be ashamed.  Look at those hyperextended incisors!  And the embrasures are excessive!  (Yes, I'm a dental nerd).

The kindness of strangers--SFO

I'm at SFO waiting for flight UA-1536 to Vegas.  

At first it's smooth sailings.

At 5:59 PM, I got a call from United airlines warning off possible delays.

I leave for SFO at 7:49 PM (late, I know).

The promised Bart is missing--arrival at 9:00 PM.  No worries...flight at 10 PM.

Then stuff gets messy.  

I get on blue line--wrong way!  At Westfeild, I and a fellow straggler hustle to reverse course: 9:03 PM.  Gate 3 at 9:10.

Meanwhile, UA1536 is noted as on schedule to *leave* at 9:18 PM.

Security check.  Crap!  Nice airplane lady waves me to front--still another row!  9:12 PM.  The couple in front of me graciously lets me pass.  9:14 PM.  Security doesn't body search me (unusual).  9:16 PM.  I barrel to gate 73 and almost knock over a dainty brown haired dude in front of his son.

And the flight is delayed to 10 PM.

Thanks to all the gracious strangers.

I really appreciate your consideration.

I love my job

Some days are awesome--like today.

There's a young lady from LA.  She's a new patient.  It's first time to the dentist by herself.  She says she needs a root canal, and shows me this: 

The dentist in LA lopped off half her tooth.  To their credit, all decay was removed.  Sadly, there was no attempt to temporize things--just a grungy cotton pellet with a spot of dried blood.

So I pray.

The tooth is infected, but the nerve is dead.

The tooth is open.  I file the canal.  The apex locator isn't working, so I pray and feel for the apex.

And God answers.

This is *exactly* what I want.  I finish cleaning and shaping.   Irrigate with my special mix, and fill the canal:

Gracias a Deus!

The rest was fun: build up core with Fuji iiLC.  Reinforce with A2 composite.  Create a layered buildup that looks like God intended:

The tongue side is uglier.  I wanted to make sure that this tooth doesn't get fractured.  (The stain is blood under the composite overlayer--no worries.  It didn't interfere with the core Fuji buildup.

Uurgh.  Ugly.

Anyways, I have to thank God that my patient is out of pain and can smile.

FEMA training--aargh!

As part of my job with the San Mateo Medical Center (great team), I am required to have all sorts of non-dental related training.

Some of it is good (emergency codes, first responder protocols), some useful but boring (hospital safety, OSHA, sexual harassment), and some are hard to apply outside the public sector (medical billing fraud compliance remediation as a hospital.)

Recently, the whole dental team was assigned FEMA's NIMMS (national emergency medical management system) training due to a mandate by President Obama.

In short--be prepared, and don't trust your government...or at least FEMA.

In long: the NIMMS training has some good principles (watered down versions of classic military standard operations).  However, these principles are needlessly cloaked in jargon--very wordy, poorly presented jargon.  

The instruction is geared towards bureaucratic cratic self preservation and image control instead of actually helping people.  There are moderately useless diagrams that are informationally empty.  There are pointless videos.  The questions are needlessly obtuse, and test based on key words instead of true knowledge.

Base principles (I'm not making this up)

-do not skip chain of command

-do not take initiative 

+before doing anything, it must pass through at least 4 levels of bureaucracy 

+the PR guy is at top

+the logistics guy (who gets stuff done) is at bottom

+resource acquisition must go through at least 3 levels of bureaucracy--but must be sourced/funded locally--then resubmitted to regional--then state--then interstate--then FEMA--then Gov

What I'll be doing in response to training:

- get fit.

       I don't care about getting a bikini body.  Rather, I want to never need FEMA or any government "help" if possible.  Instead, I'll be a first responder.

-get reserves

      I'll be sure to keep 3 weeks supply of food/water.  At the rate FEMA works, 1 month may be better while they (request authorization to distribute.

      I already have emergency shelter/food in the car.

      Maybe I'll put together a "bug out bag"--no guns mind you--food, first aid, navigation, fire, and possibly dental related supplies for field treatment.

-get equipped

       I really want an Aseptico portable op.

I used an Aseptico taskforce portable unit in the jungles of Cambodia, and I can vouch for it's reliability, portability, and good worksmanship.

       In the event of a major emergency, I want to be there for my patients--not some career bureaucrat from FEMA

-get training

       I hope to become fluent in Cantonese and Spanish by 2015.  As of yesterday, I finally have internet.  I hope to make wise use of YouTube and various podcasts.  I see this as a matter of respect for my patients----sorry, no Arabic, Urdu, Mongolian, Russian, Farsi or Hindi is planned at the moment.

        I may look into basic field survival, foraging, bushcraft, and field medic training in the future.  I thought my friend ( and prebably the best gum surgeon IMHO in the east bay) Dr. Karl Ching was nuts for learning man-tracking and extreme wilderness survival.  Now I think he's wise...

Sheesh!  I sound like an alarmist!

    

CPR training--déjà vu?

Reminds me of a classic transition to the judo scarf hold--Kesa-gatame.

Note: new standard is 30 chest compressions to / breaths--aim for 100 bpm.

Sonicare. Haight Ashury. Street

Random find.

No, I didn't use it.

Lying on the side of the road near Skates on Haight.

Do good vs. look good

For the past three weeks, I've been working for a dentist in Livermore.

At first, it seemed great. He had good systems, well trained staff, and cable TV in every room.

Three weeks later, I've found myself in hot water for doing good instead of looking good.

For example, there was a crown where the buildup came out in the temporary--meaning that the crown would be unsupported. He was furious that I built up a new buildup, took another impression, and reappointed the patient.

He told me that he would have simply cemented it in place.

Why I want my own practice

Over the past couple days, I've been thinking why I want a practice.

Why do I want one?

Pro's:
Quality control - I can use good labs, good equipment, and train great people.
I want things at top quality.
Creative control - I can dedicate the practice to the very best dentistry available.
Better tax write offs - my biggest "optional expense" is training and equipment for my patients. My second expense is cool stuff to show my appreciation for people.
It's be nice to deduct this from my overinflated taxes.

Why it's a bother:
Labor costs - wages get higher; benefits cost more, especially health coverage; sick pay. The Bay Area is a very expensive place.
Taxes - Obamacare medical device tax 2.7% on everything we buy. Business tax. Payroll tax. City tax. State tax.
Liability, lawsuits - California has some of the highest number of lawyers. There are hundreds of opportunities to get sued over stuff like a kid slipping in front of your office.
Marketing/Competition - the SF Bay Area is a super saturated market full of tons of dentists. Frankly, it'd be easier to compete anywhere else (except LA).
Staff issues - the new assistant is hungover and the front desk decided to ditch work for a new boyfriend. These issues happen more often than you think.
Paycheck - as boss, I'm the last one paid. Frankly, some days I'll be paying money to keep the place open.

I'm probably crazy, but I still feel that the end goal is worth it.

Some days are crazy...

If you've never read it, "Kill as Few Patients as Possible: And 56 Other Essays on How to Be the World's Best Doctor" sounds like a joke.

Instead, it's a funny, insightful book.

Today felt like the chapter "death by appointment book."

Crazy patients, we all have them. Generally, we can survive one or two of them without a sedative.


However, today I had a bunch. I had the lady that wants a denture to look 20 years younger, a highly dental phobic principle, a surly, self-absorbed assistant, and no real power to do anything.

The patients would come 10 min late with a thirty minute variance. Some came early by 15 minutes. Some came late by 30 minutes.

Additionally, my setup would be missing something critical. For my extraction, the assistant had no periosteal elevator, no scalpel, no forceps. For the bridge prep, my handpiece stalled midway, and the assistant didn't have the right impression tip. During my prep, she would disappear to chat with the girls. This was frustrating to say the least.

This really highlights the value of a good system, good staff, and patient management.

Personally, I can't understand healthcare workers who see work as a just a 9-5 job. I see patient care as a sacred trust where I will do no harm. If they are accommodating, I will happily bust my ass to serve them.

Man, crazy.
Tired.

Finishing implant training with Misch

I'm finishing S5 with Dr. Carl Misch, the world's best implant guy.

It'll be a while before I see him again, as well as friends I've met during the continuum.

I hope to spread some of this information to counter a lot of misinformation spread by unscrupulous people.

How will I celebrate?
A glass of wine with Misch!

CEREC- faster, cheaper, but is it better?

Today, I'm taking Dr. James Klim's CEREC class.

For me CEREC is a mixed bag.

Likes:
1. It's fast.
No temps. I hate temporary restorations! They break. They fall off. It takes a lot of work to make them look good.
2. It's quickly replaceable.
If it breaks, I can replace it in under an hour. Try that with anything else.
3. It's fun.
CEREC lets me control the margins and occlusal at chair side. I can look at my preps at 3000x.

What I don't like:
1. It doesn't last.
Gold is king. Gold lasts forever. Gold is the only material that offers the level of accuracy and fit that lasts a lifetime.
2. It's not great esthetically.
Hand stacked porcelain with multiple cutbacks are beautiful and stay that way. CEREC crowns lost chroma as the glaze wears off.
3. It's oversold.
CEREC and Invisalign are often sold as the answer to everything. This is because buyers (especially big dental corps) often need to recoup the costs of investment.
With CEREC, costs start at around $150,000 to get the technology.

How to get good service--what not to do...

Today, I have a case of what *not* to do.

A patient called insisting that we see his kid. He was an HMO patient. We essentially didn't cover the procedure that he insisted on.

He wanted it for free.
He threatened to sue.

He spent over an hour trying to cow us into submission. He threatened a lawsuit. He threatened to get Delta involved. He insulted every member on the staff. He called us unethical elitists who are against the poor. He was condescending as all hell.

For the record, DON'T do this.

For the past two years, I was involved with the Berkeley Free Clinic, Random Access Missions, Missions of Mercy, the Sacramento Continued Education Committee, Give Kids a Smile, and the board of a study group.

I would have done the fillings for free if he showed up on time, and had some respect for my staff.

I'm going for a run after work.

Going back to posting

I'm going back to posting.

Previously, this would be a bit involved. Sit at computer. Turn it on. Go online. Find blogger website. Log on. Find small button. Type stuff. Agonize. Delete. Retype.

I'm not doing this anymore.
Instead, I've got an app!

Expect more posts.

Working on the road

I'm writing this from a drive-by Starbucks in Stockton.

For this week, I'll be doing some temp work for one of the corporate chains in California.

It's a pretty busy schedule with quasi-borderline treatment planning.
A lot of the work is subpar. A lot of it is rushed.
It'll be things like 4 quadrants of scaling and root planing and a crown in one hour.

In the mornings, there is a "huddle" that consists of assigning each dentist a production number.
We're expected to make that amount of money.

The assistants don't really know what's going on.
It's fun for them, because they do more than the usual suctioning.

However, for us dentists, it's pretty gruelling.
We're expected to do quadruple the usual private clinic production at HMO rates.
We're expected to do it to the minimum standard of care.

It's a numbers game. We are supposed to make at least 4 times what we cost to the company.
Otherwise, it's a loss.

I'm glad that I'm just a temp, an I intend to stay that way...
Because here, you get what you pay for.

Faking it

At the place where I'm renting space, I've been helping out with billing when I'm not seeing patients.

Its a test of patience. I've been learning that insurance seriously screws us over more than I thought. On the patient's side, there are always additional costs: increasing % responsible, increasing deductable limits, and the same coverage cap since the 1970's. On our end, we doctors get paid way less each year.

I'm not going to get myself in trouble by stating the actual amounts in question ("confidential" according to the insurance companies), but it's sometimes as stupid as 30% reimbursement or nothing.

Moreover, the music is driving me nuts!

I really, really can't stand the muzak that is playing down here. As a jazz, R and B, rock, indie, (anything but muzak), it's pure torture to listen to the Chipmunks Christmas carol play every five songs. It's pure smaltz with a double dose high fructose syrup.

While I can't do too much about the ripoff known as insurance, I will try to have music that doesn't suck.