Episode #576: The recall Renewal Exam, with Debra Engelhardt-Nash

For the same reasons people renew their wedding vows, you should renew your commitment to your existing patients. Their recall renewal exam is the perfect opportunity to review your progress, reaffirm your philosophy, and strengthen your relationship. So, how do you get more patients to show up? To share advice for communicating the value of recall exams, Kirk Behrendt brings back Debra Engelhardt-Nash, practice management expert and co-founder of The Nash Institute. Remember — it’s not “just” a recall exam! To learn how to reengage, reignite, and reinspire patients with a recall exam, listen to Episode 576 of The Best Practices Show!

Episode Resources:

• Debra’s email: [email protected] 
• Debra’s website: https://debraengelhardtnash.com
• Debra’s cell phone number: (704) 904-3459
• Debra’s social media: @debralnash
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Links Mentioned in This Episode:

Debra’s courses at The Nash Institute: https://www.thenashinstitute.com/about-the-nash-institute/meet-debra-engelhardt-nash

Debra’s other programs: https://debraengelhardtnash.com/programs

Pearl: https://www.hellopearl.com

Dental Intel: https://www.dentalintel.com

BlueIQ: https://getblueiq.com

Main Takeaways:

Recare treatment acceptance is between 25% and 35%.

Run a report to know your unscheduled treatment rate.

Understand why your patients don't accept treatment.

Be engaged and intentional in your conversations.

Exhibit proper body language in conversations.

Use artificial intelligence to educate patients.

Quotes:

“It’s one thing to know how to do the dentistry. It’s another thing to know how to talk about it and get your patients to say yes to it. Those are different skillsets. And sometimes, you have a great clinician who’s not a great communicator. And sometimes, you have a great communicator who’s not a great clinician. If you can marry the two and have a hybrid, that's the best of all worlds.” (4:17—4:38)

“The average treatment acceptance rate for new patients is between 70% and 78%. When dentists say they get 100% treatment acceptance, they're fooling themselves. That's not true. If you want to dummy down — if you want to talk about your phase treatment plan or modified treatment plan, and if you want to inflate your statistics to make yourself feel good — but if you're presenting comprehensive treatment plans, you're not going to get 100%. So, there's that statistic. But here was the statistic that really caught my ear, and it was that the treatment acceptance rate for recare patients is between 25% and 35%. That's when you go, ‘Uh-huh. Why is that?’” (6:26—7:18)

“We’re not spending enough time talking to our patients of record about treatment. We’re just not doing it . . . Familiarity sometimes breeds apathy. Familiarity breeds apathy. So, Kirk, if you were my patient, I say, ‘Oh, I know Kirk. He’s not interested. His insurance won't cover it. We’ve talked about those two crowns before. He doesn't want it. I don't want to offend him.’ So, that's one reason that we say, ‘Oh, Kirk’s not interested. Kirk doesn't want it. I've already spoken to Kirk.’ Seventeen years ago, I told Kirk, ‘You need those two crowns.’ And every time he comes in, I say, ‘You know, Kirk, you need those crowns.’ And you go, ‘I know.’ And I go, ‘Okay. I need to clean your teeth.’” (7:27—8:11)

“The other piece of that is, we don't give hygienists enough time to have conversations with their patients. So, timing is everything. Sometimes, doctors — and I say this lovingly and half in jest — brag about how little time their hygienists need to be effective. And I go, ‘Wait a minute. How are you determining effectiveness? Is it their production per day, or is it not only what is their production per day, but what additional treatment was diagnosed and accepted out of their treatment room, out of their operatory?’ So, we have to take a look at both of those things. I could have a great perio hygienist, and maybe he or she is not getting a whole lot of treatment acceptance out of their operatory because that's not what they were designed to do. But if I have a hygienist who’s seeing general care patients, then I want to take a look at, what additional treatment is being accepted out of that room?” (8:11—9:05)

“I go into some offices, and doctors will say, ‘My hygienist can see 12 patients in a nine-hour day! And they're not children.’ And I say, ‘Great. But what's your treatment acceptance from those nine people?’ And there was a hygienist who said to me, she sort of crossed her hands and she said, ‘I am not hired to sell dentistry. I am hired to clean teeth.’ We have a problem. We have a problem.” (9:07—9:33)

“Any strength taken to excess becomes a weakness.” (10:35—10:38)

“We don't intend to be apathetic. But, once again, I may look at your record — hopefully, in the morning huddle. I'm looking at Kirk’s information. And if I'm using Pearl, I'm seeing what radiographs are due for my patients coming in. So, I'm ready for you to come in. But I also can say, ‘I know Kirk. He’s not interested. He doesn’t want it. He’s not going to do it. So, we’re not going to talk about those crowns.’ And sometimes, we even coach the new hygienists coming in, we say, ‘Don't talk to Kirk about flossing. He doesn't want to talk about flossing. Don't ever talk to him about flossing. He hates talking about flossing. Don't talk to him about home care. He doesn't like to have that conversation about home care.’ So, now we train our successor, possibly, some of our bad habits.” (13:02—13:43)

“I think it’s timing as well. You talked about some of the other factors. Sometimes, we ask the patient [about treatment] at the end of the visit. So, first of all, if you already had to wait for the doctor for the exam for 20 minutes, and then you're going to sit and listen to the doctor and the hygienist talking about unscheduled treatment, or treatment that has just been diagnosed, or treatment that has been previously diagnosed — I need to get my kid to the soccer game. I need to get out of here. So, timing is also really important.” (13:47—14:14)

“We talk about new patients being VIPs, and we talk about how we’re going to razzle and dazzle them. What about our patients of record? What about those patients who've been true, blue, loyal to your practice for 15 years? So, that is when I came up with what I call the recall renewal exam. A lot of my friends heard me say it years ago. I remember Cathy Jameson hearing me say it at an ADA meeting in Seattle in 1995, and said, ‘Oh my gosh, I'm using that,’ which is great. And I think, once again, if we sit down — the most important question that a hygienist will ask a patient, and when she or he asks it, that's critical. And also, if we start doing some math on what this could look like, even if we had 10% of our patients of record move forward with some level of treatment, what that would do to our practice productivity.” (14:17—15:18)

“We need to be renewing our relationship with our patients of record. So, if you were my patient, Kirk, for 10 years, I am assuming that the relationship or the new patient experience you had 10 years ago is probably different than the new patient experience that I'm providing today. There are probably things we talked about 10 years ago that we don't talk about now. And I don't want to see you as just Kirk. I don't want to see you as just another recall, just another cleaning. I want to reinvigorate my relationship with you. I want to reengage. I want to reignite. I want to reinspire you to be a part of my practice.” (17:15—17:52)

“We really need to go back with you, my patient, and I might say, ‘You know, Kirk, you have been a patient in my practice for 12 years.’ ‘Wow. Has it been that long?’ ‘It has. Here’s where we were when you were a new patient, and here’s what we’ve done so far. Here’s where we are now. Let's talk about where we are now. Let's talk about your dental future. Let's talk about where we’re going, where we want to be.’ I also want to remind you of our treatment philosophy. I want to remind you of our culture. I want to remind you of the quality of care that you have received in the past. So, it’s not “just” a recall. In fact, sometimes we use that term. ‘Hi, Kirk. This is Debra from Dr. Smedley’s office. I'm just calling because it’s time for your recall. It’s just a recall.’ And sometimes, patients will call and say, ‘I'm calling to cancel my appointment. It’s okay. It’s just a recall. It’s just my recall.’” (18:25—19:22)

“One of the things that I might say to my elderly patients, my older patients — I'm one of those. I'm an older patient — I might say, ‘Your dental care is even more important than it was when you were younger. There are so many systemic causes that we’re discovering with dental health that it’s going to be even more critical for you to be on a more frequent appointment with us. We want to make sure that your oral health is part of your systemic health, and that's critical as we age.” (20:29—21:02)

“Don't wait until the end of the appointment, number one. So, if I looked at your record and I see that we have treatment that we planned that you have yet to complete, that's what I need to bring up first. And my body language has to be — I'm not looking at a computer. My head isn't turned. I'm not putting down my instruments. I'm not giving you the ugly — I'm not glaring at you, but I'm looking you in the eye and saying, ‘Kirk, I see that we have treatment that we have planned for you that is yet to be completed. Tell me what's prevented you from having it done.’ Because now, you're going to say a couple things: it doesn't hurt. Expensive. I don't have time. I really don't see the value. People used to say there are three things. There are four things. I think there are four things.” (22:00—22:59)

“Let's say you said [the reason you haven't accepted treatment is] cost. It’s expensive. I say, ‘You know, Kirk. Exceptional dentistry is expensive, you're right, because it needs to last. But think about this. Think about what it would have cost you five years ago when doctor originally treatment planned that for you. Think about what it might cost you five years from now. It will never cost you less than now. So, we could find a way to make that work for you, to factor that into your budget. What other concerns do you have?’” (23:29—24:02)

“I have my two questions. And my two questions work for almost everything. Number one, if we enhance our communication skills and commit our patients of record to treatment, is it good for them that we’re doing that, or is this a bad thing? Is it a good thing or a bad thing? . . . It’s a good thing. Okay. Then, the next question is, is this a good thing for our practice? . . . Then, why aren't we doing it? So, if you have to answer no, ‘Is this good for our patient?’ ‘No. It’s terrible.’ Then, don't do it. Sometimes, when we talk about allowing patients to make small payments over a long period of time in-house, is that good for the patient? No, because it’s going to prevent them from wanting to come back. It’s going to make them reluctant to return for care. There are all kinds of reasons why it’s not good for them. So, don't do it. If it’s not going to be good for the patient, don't do it.” (25:00—25:51)

“Let's say we have two hygienists working, and they see eight patients a day, and they work 200 days a year. That means we’re going to have 3,200 visits per year, and we divide that. We can say that would be about 1,600 active patients, possibly. But let's say we have the capacity for 3,200. See, that's the other thing we have to know, what's our capacity? But we have the capacity for 3,200 visits. Let's say that 10% of those patients are going to move forward with some level of treatment, and let's say it’s the equivalent of $800. That's another $128,000 per year. So, we want to know where my additional compensation is going to come from. It’s going to come from that. And it’s less expensive to market to patients I already have!” (27:12—28:09)

“We sometimes make assumptions based on age, based on what we’ve talked about, based on what I know about this person, based on insurance restrictions.” (28:25—28:34)

“Pearl is what is called second opinion. It is artificial intelligence that's actually reading the radiographs, not with your naked, subjective eye, but with an analytical, technological eye. So, it becomes a second opinion for the patient. It’s also a great visual for the patient. And knowing that patients, 50% of the population are visual learners, for them to be able to see — because sometimes we put those radiographs up, and for all they know, they're looking at an ink blot. They don't know what we’re looking at. They don't see what we’re looking at. But when you bring Pearl up and Pearl says, ‘We see decay here,’ and it colors it, and it circles it, and it says, ‘This is 35% into the dentin,’ it actually gives percentages, ‘This is 25%. You've got calculus, and calculus is into the tissue by X percent,’ man, it is hard to dispute that. A patient could dispute, ‘It doesn't hurt.’ A patient could dispute, ‘My gums don't bleed.’ But when you're looking at that visual chart that artificial intelligence has picked up, it’s pretty hard to dispute.” (32:19—33:28)

“One of the things we say to the patient during the recall renewal exam is, ‘It is time for us to gather new baseline data.’ If you've ever had a colonoscopy, or a mammogram, or an MRI measuring things, they want your baseline, and then they want to measure your current against the baseline radiograph, the baseline images that they have. So, we say to the patient, ‘It’s time for us to gather new baseline data.’” (35:39—36:03)

“The doctors, when you take a look at how to increase their revenue, one of the ways of doing that is you look at what I call your HPA, your highly productive activities. What are your highly productive activities that yield the most productivity in your office? I'm white-labeled for another consulting company, and I go in and I lecture. And they always ask the young doctors, ‘What do you think your highest paid activities are in your office?’ And they say new patient exams. And it’s not. The patient exams aren't your highly productive activities. What's it going to be? Now, if we want to talk about lab, it’d be crown and bridge. The other thing we talk about, if you're doing CEREC and if you're doing in-office crowns, it could be a highly productive activity. Quadrant dentistry, highly productive activity. Single-unit restorations, not a highly productive activity. Ross just did four direct restorations on a patient. It’s a highly productive activity at $1,200 a tooth. That's a highly productive activity. So, what are my highly productive activities, and are we doing them? What's your service mix?” (36:39—37:55)

“So many doctors are concerned about, ‘Do I raise my hygiene fees? Will my patients turn away?’ Not if you're doing a great service. Once again, if you're charging $125, or $135, $150 for a recare examination, you can't be doing a dine-and-dash exam. In fact, here’s another point. So many times, patients will say, ‘I only want my teeth cleaned. I don't want an exam.’ I would say you need to figure out, if you've got patients saying, ‘I don't want an exam,’ why is that? And I ask audiences, ‘Why do you think that patients say they don't want to have a recall examination?’ Some people say, ‘They don't want you to find anything wrong.’ And some people say, ‘Because they don't want to pay for it.’ Why don't they want to pay for it? They don't want to pay for it because they don't see value.” (38:47—39:40)

“I probably don't want to come in and have an examination because I'm getting the one that John described. We’re going to talk about cats, and TikTok, and we’re talking about construction. We’re not talking teeth, so why am I paying $150 to talk about my cat? Why am I doing that? I don't want to do that. Clean my teeth. If you're not going to have a conversation with me about my teeth, then I want to get out of there. I'll go have a drink with you at the bar and we can talk about our cats.” (39:49—40:18)

“[Start with] one patient a day and ask the magic question. ‘I see that you have treatment that was treatment planned that we have yet to complete. Tell me what has prevented you from having that done.’ And then, your hygienist needs to be comfortable having the answer. ‘Well, that's a lot of money.’ ‘It is a lot of money, isn't it? Think about what it would have cost you five years ago, and what it'll cost you five years from now, and what it would cost you today. It'll never cost you less than right now.’ Let's say it’s fear. ‘Help me understand what you’re fearful of. Are you fearful of the discomfort of the treatment? Are you fearful of the procedure? If you're fearful of the discomfort of the procedure, imagine what it will feel like if you do nothing, and it gets worse, and it starts causing you pain.’ So, we can talk about that fear. ‘It’s not bothering me right now.’ Yeah. So, we could actually solve a number of things. If you're afraid of discomfort, and you're afraid of cost, then the most important thing when we talk about now — that it’s not bothering you — this is when it'll cost you the least, and it'll be the least uncomfortable.” (40:31—41:39)

“You have to be careful that it doesn't sound like you're supersizing. ‘Hey, you want a crown with that cleaning today? Hey, you want whitening?’ You've got to be careful. But here’s the other piece. You've seen that cycle, the belief cycle. You've heard of the belief cycle. So, if I believe the patient doesn't want it, if I believe the patient isn't interested, if I believe the patient can't afford it, I'm going to behave in a way that I believe. So, I'm not going to say anything. My actions are going to perpetuate my belief. My belief is the patient doesn't want it, doesn't care about it. So, my actions are going to perpetuate what I believe, and my results are going to perpetuate my belief. So, ‘I knew they didn't want it. I knew they weren't interested. I knew they couldn't afford it. See? I was right.’” (41:59—42:39)

“People talk about selling dentistry. You know what we’re doing? We’re not selling like we’re selling a bad, used car to people. You know what we’re doing? We’re helping our patients improve their dental health and their dental appearance. We’re helping them improve in terms of periodontal disease. I have to tell you, I met a patient who came in yesterday. She was having her veneers done in another office for less money — big, less money. She was treatment planned to do veneers for $700 in another office. We charge $2,500. She came in here because she said she had a feeling — something about the process. There was something about it. She didn't feel good about it. She Googled us, and she decided that maybe she should go to somebody who’s accredited. But here was the other reality. I hate to say this. That doctor was ready to do veneers, and Dr. Nash said, ‘Debra, she opened her mouth, and her breath was so bad.’ I said, ‘Oh, she had perio.’ He says, ‘Big time. And I told her, I cannot do these veneers for you until we address your disease.’ Someone was ready to do veneers. And he said, ‘It would make this situation worse. Why would I put pretty teeth in a diseased mouth?’” (42:48—44:13)

“What have you got to lose by saying to the patient, ‘Help me understand why we haven't been able to do this for you? What has prevented you from moving forward with your care?’ And you say it with sincerity.” (45:00—45:12)

“Do you want 50 new patients with a value of $400, or would you rather have 30 new patients with a value of $1,400?” (46:00—46:07)

“Don't tell the patient what they need. Say, ‘Would you like me to tell you what I would like to do for you?’ So, ‘We’re going to give you information to help you choose,’ as opposed to, ‘I’m going to tell you what you need, and then Marylin is going to go over what your insurance is going to cover, and she’s going to talk to you about the financial policy,’ all these things, and I'm going, ‘Danger, Will Robinson! Danger, Will Robinson!’ in my head. Those are things you don't say, you don't use. So, say, ‘Kirk, I'm going to give you information to help you make the right choices for your care.’” (46:26—46:54)

“My body must also reflect that I am totally engaged and I'm totally intentional with the question. If it’s a throwaway question while I'm doing something else, if I'm setting up, or I'm on the computer, then it doesn't have the same merit than when I'm sitting there with an engaged, intentional, listening ear. This is an important question. This isn't a throwaway.” (47:17—47:40)

“There are so many things that you can say, ‘That won't work,’ or, ‘Patients are different. We’re different. We don't have enough time.’ You can perpetuate that behavior, or you can be more successful, and you can say, ‘You know what? It’s working somewhere. We can make it work here.’” (51:38—51:55)

Snippets:

0:00 Introduction.

2:34 Debra’s background.

5:58 The real problems with treatment acceptance rates.

15:19 The recall renewal exam, explained.

19:38 Four reasons why patients don't accept treatment.

22:59 Verbal skills to use with patients.

24:04 Two important questions to ask yourself.

25:52 Use your software to market to current patients.

28:10 Don't make assumptions about your patients.

32:04 How artificial intelligence can help treatment acceptance.

36:04 HPA (highly productive activities), explained.

37:56 Why patients don't want recall exams.

40:19 How to get started.

41:40 Change the way you think.

46:10 Be engaged, intentional, and mindful in conversations.

47:41 Last thoughts on the recall renewal exam.

48:53 More about what Debra does.

Debra Engelhardt-Nash Bio: 

Debra is a trainer, author, presenter, and consultant. Having been in dentistry for over 30 years, she engages organizations and study groups nationally and internationally. She is a continual presenter for the American Dental Association, the American Academy of Cosmetic Dentistry, and the Chicago Dental Society Midwinter Meeting. 

Through the Nash Institute for Dental Learning Debra conducts the Dental Business School, an immersive executive training experience designed for EVERYONE in the dental office. Through this program, each member of the team learns the essential elements that make up the management and communication skills of a high-functioning dental office. 

Debra not only teaches and trains groups of dental professionals, but she also works one-on-one consulting personally with doctors and their teams. 

She is married to cosmetic dentist and dental educator, Dr. Ross Nash of the Nash Institute for Dental Learning. Debra continues to work in his busy practice, doing exactly what she preaches. 

Debra is a founding member and three-term President of the National Academy of Dental Management Consultants. She is an active member of the American Dental Assistants Association, the American Academy of Dental Practice Administration, and the Speakers Consulting Network. She has been repeatedly recognized by Dentistry Today as a Leader in Continuing Dental Education and as a Leader in Dental Consulting. Debra is also a member of the American Dental Association’s Dental Practice Management Advisory Board.