Episode 1 of our "Tip Series" begins with Treatment Plan Acceptance. Nearly every practice struggles when it comes to gaining patient commitment but it doesn't have to be that way. Sheena Hindson, RDH and practice coach offers some ideas on how to overcome this common, yet costly, obstacle. Treatment planning is often turned into a session of clinical jargon, the last thing a patient wants to hear. Everyone knows the old saying, "it's all Greek to me". Well, that's what patients hear when a clinician starts rattling off something that is more suited to a room full of dentists getting continuing education. Listen up for some simpler approaches and watch your treatment plans become production.
Episode 1 of our "Tip Series" begins with Treatment Plan Acceptance. Nearly every practice struggles when it comes to gaining patient commitment but it doesn't have to be that way. Sheena Hindson, RDH and practice coach offers some ideas on how to overcome this common, yet costly, obstacle. Treatment planning is often turned into a session of clinical jargon, the last thing a patient wants to hear. Everyone knows the old saying, "it's all Greek to me". Well, that's what patients hear when a clinician starts rattling off something that is more suited to a room full of dentists getting continuing education. Listen up for some simpler approaches and watch your treatment plans become production.
Welcome, You are here at the Beacon! I am your host David Darab…prepare to have your Blind Spots Illuminated!
So…It’s very appropriate, since our Team here at OmniStar Financial and Dental Systems Optimization are Experts in Blind Spots, that we devote this episode to Cognitive Biases which create Blind Spots.
Let’s kick off our discussion with a quote from one of my favorite thinkers, Professor Richard Feynman, A theoretical Physicist, Exceptional Teacher, and Contributor to the Manhattan Project.
> “The first principle is that you must not fool yourself and you are the easiest person to fool.”
> Richard P. Feynman
It is possible for people to be confused or unaware about something rather important. The fact that most people don’t know they are missing it doesn’t make it any less of a problem for them or their practices.
This is the best definition of a Blind Spot!
For those of us that remember the movie City Slickers, you may recall the main character played by Billy Crystal, went out West with his friends to find themselves during a midlife crisis. There he meets his guide, Curly, played by Jack Palance, a rough and leathery cattle rancher that will show them all a thing or two. Curly teaches them about the “one thing”, the secret of life that everyone must figure out for him or herself!
Well, we all have “one thing” that we carry around that is unique to us, and it too is so very important to figure out. This one thing is with us at all times, at every twist and turn life throws at us. Every time we are facing a challenge or problem that requires us to make a decision this one thing is there, hiding silently, but contributing loudly to our choices, direction, and decisions…that one thing is our Cognitive Bias. It is unique to each one of us. If we are not aware of its presence or its powerful influence it creates Blind spots.
A blind spot is something that is critically important even though we are unaware of it. The fact that you don’t know you are missing it doesn’t make it any less important. In fact, because you are unaware it becomes even more important.
Here at OmniStar, it’s our Tag Line “Illuminating Blind Spots”. We consider it Job #1 to help you find, Illuminate and see your Blind Spots! It’s what we do because you can’t see your blind spots alone.
“We see what you are incapable of… that's what we do.” David Darab, DDS, MBA
Cognitive Biases affect how we make everyday decisions, big and small as well as how we think about and invest our money and create our wealth.
A cognitive bias is an error in cognition that arises in a person’s line of reasoning when decision-making is flawed by personal beliefs.
When the Bias is unseen by the individual but seen by others, it is a Blind Spot.
The Cure here is recognizing and acknowledging that they exist. Once you become aware of these Cognitive Biases they are no longer Blind Spots.
I am subject to this, as I bet you are too, in the areas of clinical practice, business decisions as well as finances and investing.
I tend to “cubbyhole” things, giving a lot of weight to my time in the business. I think to myself…I have done this for 30 years, I have seen everything, I should be good to go! But that is not always the case. Just because it looks the same doesn’t make it the same. I can still find myself in “the ditch” when I overlooked a small feature or minor detail that has snuck up and “bit” me.
So let’s dig deeper here.
Let’s Illuminate for you what Cognitive Biases Exist so they will be less likely to create Blind Spots!
Understanding Cognitive Biases first starts with understanding Heuristics.
So what are Heuristics??
Heuristics are mental shortcuts that ease the cognitive load of making a decision, we use them all time. … Examples of heuristics include rules of thumb, an educated guess, or been there and done that!
When considering the term “Cognitive Biases”, it’s important to know that there is an overlap between cognitive biases and heuristics. At times these two terms are used interchangeably but they are not exactly the same.
In his book, *Thinking, Fast and Slow*, Professor Daniel Kahneman defines heuristics as
“a simple procedure that helps find adequate, though often imperfect, answers to difficult questions.”
He also defines the relationship between Cognitive Biases and Heuristics as follows:
“… cognitive biases stem from the reliance on judgmental heuristics.”
Putting this together we see that…
Heuristics are the “shortcuts” we use to reduce complexity in judgment and choice, Cognitive Biases result from the gaps between what “should be” and the Heuristically determined behavior.
According to the Cognitive Bias Codex, there are an estimated 180 cognitive biases. This codex is a useful tool for visually representing all of the known biases that exist to date.
The biases are arranged in a circle and can be divided into four quadrants. Each quadrant is dedicated to a specific group of cognitive biases:
1. What should we remember?
Biases that affect our memory for people, events, and information
2. Too much information
Biases that affect how we perceive certain events and people
3. Not enough meaning
Biases that we use when we have too little information and need to fill in the gaps
4. Need to act fast
Biases that affect how we make decisions
Cognitive biases can have a devastating effect on our business decisions as well as decisions relating to personal finance and wealth. At OmniStar we are experts at Illuminating Blind spots, so let’s take a look at what these Cognitive Biases are.
Because…as it is said…
What has been seen cannot be unseen, what has been learned cannot be unknown.
There are over 40 cognitive biases that negatively impact our ability to make sound financial decisions. I won’t bore you with an exhaustive list, but let’s hit some of the most common ones and see if any of these might ring a bell, and possibly be hindering your decision making ability.
Some of these biases include:
Overconfidence Bias
Is when confidence in our own judgment is greater than the objective accuracy of those judgments. It results from someone’s false sense of their skill, talent, or self-belief. It can be a dangerous bias and is very prolific in finance and business. The most common signs of overconfidence include the illusion of control, timing optimism, and the desirability effect, the belief that something will happen because you want it to.
Self Serving Bias
Self-serving cognitive bias is the propensity to attribute positive outcomes to skill and negative outcomes to luck. In other words, we attribute the cause of something to whatever is in our own best interest. Many of us can recall times that we’ve done something and decided that if everything is going to plan, it’s due to skill, and if things go the other way, then it’s just bad luck.
Herd Mentality
Herd mentality is when you blindly copy and follow what your friends, colleagues, and peers are doing. When you do this, you are being influenced by emotion, rather than by independent analysis.
Loss Aversion
Loss aversion is a tendency for investors to fear losses and avoid them more than they focus on trying to make profits. Many investors would rather not lose $2,000 than earn $3,000. The more losses one experiences, the more loss averse one likely becomes. It is common for both professional and amateur investors to hold on to losing investment positions for too long, whilst selling winners too soon.
> “In human decision-making, losses loom larger than gains.”
> Kahneman and Tversky
Framing Bias
Framing is when someone makes a decision because of the way information is presented to them, rather than based just on the facts. In other words, if someone sees the same facts presented in a different way, they are likely to come to a different conclusion about the information.
You may choose to purchase capital equipment, buy a car, or purchase an investment depending on how the opportunity is presented to you.
Anchoring Bias
Anchoring is the idea that we use pre-existing data as a reference point for all subsequent data, which can skew our decision-making processes. If you see a car that costs $75,000 and then another car that costs $30,000, you could be influenced to think the second car is very cheap. Whereas, if you saw a $5,000 car first and the $30,000 one second, you might think it’s very expensive.
Confirmation Bias
Confirmation bias is the idea that people seek out information and data that confirms their pre-existing ideas. They tend to ignore contrary or conflicting information. This can be a very dangerous cognitive bias in business and investing. Using confirmatory bias, we tend to search for, interpret, and remember information in a way that confirms our existing preconceptions. This unconscious bias makes it possible to miss findings or ignore evidence that could otherwise change our view.
Hindsight Bias
Hindsight bias is the theory that when people predict a correct outcome, they wrongly believe that they “knew it all along”, which falsely inflates their confidence for future decisions.
The Curse of Knowledge Bias
When knowledge of a topic diminishes our ability to think about it from a less-informed, but more neutral, perspective.
I call this…
“You don’t know what you don’t know paradox!”
or, “a little knowledge can be dangerous” bias.
Blind Spot Bias
Demonstrated when we think we’re less prone to cognitive bias than those around us. People see themselves differently from how they see others. They are immersed in their own sensations, emotions, and thoughts while at the same time their experience of others is dominated by what can be observed externally.
Information Bias
Sometimes we tend to seek information even when it does not affect action. Better decisions can often be made with less information – more is not always better.
When we constantly seek more information we are falsely concluding a better decision will result.
More information is not always better.
Better information is better.
Optimism Bias
This is seen when we tend to overestimate the probability of positive outcomes but underestimate the potential for negative ones. 80% of us are prone to this cognitive illusion.
This is the power of positive thinking, but not the best heuristic for the best outcomes.
Mental Accounting Bias
Mental accounting explains how we tend to assign subjective value to our money, usually in ways that violate basic economic principles.
Although money has consistent, objective value, the way we go about spending it is often subject to different rules, depending on how we earned the money, how we intend to use it, and how it makes us feel. In reality, money is fungible and one dollar is worth as much as the next, whatever its source or purpose. This bias affects how we rationalize our spending and investment decisions.
Here is an example…
Imagine you’re walking down the street, and you happen to find a $100 bill lying on the sidewalk. Ordinarily, you’re a pretty frugal person, and you’ve been trying to save some money to put towards buying a car in the future. Today, however, you take your newfound $100 and put it towards an expensive dinner. You tell yourself that this money isn’t “car money” — this is a one-off, special occasion, so why not treat yourself to a nice evening out?
You have just fallen victim to Mental Accounting Bias.
Outcome Bias
The tendency to judge a decision by its eventual outcome, rather than the quality of the decision when it was made. This behavioral tendency leads us to de-emphasize the events preceding an investment outcome, whilst overemphasizing the outcome.
> “The fact that something worked doesn’t mean it was the result of a correct decision, and the fact that something failed doesn’t mean the decision was wrong. This is at least as true in investing as it is in sports.”
> Howard Marks – Inspiration from the World of Sports Memo (2015)
In business, making a good and sound decision does not guarantee a good outcome.
Recency Bias
When people weigh recent events and observations more heavily than those in the past.
With this bias, we tend to base our thinking disproportionately on whatever comes most easily to mind. In an investment context, this can be dangerous because we are likely to lean more heavily on our experience of recent investment performance when considering future returns.
Older people can display marked recency bias, with a focus on positive memories. This has potentially significant implications for the important investment decisions they make as they approach retirement.
> “We look at the most recent evidence, take it too seriously, and expect that things will continue in that way.”
> Dan Ariely – Predictably Irrational (2010)
Regret Aversion
The tendency to avoid making decisions that we fear we could later regret.
Risk Compensation
This suggests that we adjust our behavior according to our perception of the risk level, becoming less careful when we feel safer and more cautious when the perceived risk level increases.
Status Quo Bias
Evident when people resist change and prefer things to stay the same or stick with previous decisions.
Sunk Cost Effect
The tendency to throw good money after bad. Can lead us to continue investing into a project based on our earlier decisions, rather than on its current objective merits or despite new evidence suggesting that the decision was probably wrong.
I think of this as, “What’s past is past!”
The IKEA Effect
This bias explains the tendency for people to place a disproportionately high value on objects that they partially created themselves, regardless of the quality of the end result.
This is especially prevalent in clinical dentistry.
and finally…
Dunning–Kruger effect
Is a cognitive bias in which people with low ability at a task overestimate their ability. It is related to the cognitive bias of illusory superiority and comes from the inability of people to recognize their lack of ability.
[image:3C24884B-4665-43AB-A892-1FAD5A5B4821-9378-000098BBC7F6B8B6/Dunning-Kruger.jpg]
Even with this partial list, you can get a feel for how many Cognitive Biases there are and how influenced by them we can be, distorting our ability to make sound and accurate decisions.
Have you encountered any of these yourself??
I know I have and learn volumes about myself researching for this podcast.
Now that we have some awareness of our Cognitive Biases let’s look at some strategies to overcome them. I’ll outline 5 actions for you to consider…
#1 Separate the Problem from the Decision
Make sure you thoroughly understand the Problem first which requires you to make a decision. Separate the problem from your decision-making, rarely does a decision have to be made immediately or simultaneously.
#2 Reflect on past decisions
If you’ve been in a similar situation before, you can reflect on the outcomes of those previous decisions to learn how to overcome your biases. Learn from your previous decisions, both good and bad. What went well…if so why? What went poorly…if so what would you avoid or do differently?
#3 Include external viewpoints
There is some evidence that we make better decisions when we consult with other people who are more objective, such as advisors, coaches, mentors, and trusted friends and colleagues.
Therefore, before making a decision, talk to other people to consider different viewpoints and have your own views challenged. Importantly, other people might spot your own cognitive Biases, Blind Spots, as we say here at OmniStar!
#4. Challenge your viewpoints
When making a decision, try to see the weaknesses and “poke holes” in your thinking regardless of how small, unlikely, or inconsequential these weaknesses might seem. You can be more confident in your decision if it withstands serious, critical scrutiny.
This “Devil’s Advocate” role and voice are crucial to point out flaws in your thinking. If this alternative view proves stronger, time to rethink your decision.
#5 Delay decisions, do not act when under pressure
A final way to protect yourself from relying on your cognitive biases is to avoid making any decisions under time pressure. Rarely does a significant decision have to be made immediately. If decisions can be delayed, many times the problem that initiated the need for action may resolve, better alternatives may present themself, or additional information can be obtained which aids in the decision process.
A Take-Home Message
We often rely on cognitive heuristics and biases when making decisions.
Heuristics can be useful in certain circumstances; however, heuristics and biases can result in poor decision-making and reinforce unhealthy behavior.
When we are not aware of them, they create Blind Spots which can lead to unpredictable and adverse outcomes.
There are many different types of cognitive biases, and all of us are victims of one or more.
However, being aware of our biases and how they affect our behavior is the first step toward resisting them.
So that wraps things up for this Podcast. We hope this information has created a few "Ah-Ha" moments to help you better understand some of your biases. Once you are aware you can take corrective action and achieve better outcomes. Please share this Podcast if you found it helpful, and leave a review on iTunes too. We welcome your feedback and suggestions for future podcast sessions. You can always find me, your host, David Darab, at my Twitter handle, @ddarab.
Remember our Team here at OmniStar DSO stands ready to help you and your practice with any Blind Spots and questions.
We see what you are incapable of… that's what we do.
Thank you so very much for tuning in and listening. We are very grateful for your time and attention and so delighted to have you in our audience.
https://www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman/dp/0374533555
This episode will take a look at your schedule, most importantly how to make your schedule hum with productivity and not business!
Let’s start with a quote from Stephen Covey…we all know him from his best-selling books, The 7 Habits of Highly Effective People, First Things First, and Principle-Centered Leadership.
Stephen says…
"The key is not to prioritize what's on your schedule, but to schedule your priorities."
I, you, we are constantly bombarded by marketing messages vying for our attention and clicks.
These are commonly presented with email subject lines like the following I received over the past week…
* How to help your practice emerge from the Pandemic…
* Dentists' biggest practice challenges…
* Steps to Take for an All-Star Practice…
* Positioning your practice for Growth…
* How to Turbocharge your Practice…
* Marketing Ideas that will take your practice through the roof…
Our Team here at OmniStar DSO is all about "Simplifying the Complex!"
I can think of no better or more productive area to focus on than your Scheduling Framework or Template.
Our Subject line will be… Scheduling…are you hitting your Target?
Get your scheduling meme right, and everything else will flow.
Yes, there are many essential and critical KPIs to monitor and track; we coach and teach our clients. The beauty of designing a scheduling framework is that it is easy to tell how well your Team is meeting spec. If your block booking is set up correctly, it should be obvious how well your Team is doing just by looking at the scheduling screen on your computer.
Yes, there are other important tasks and goals your practice must monitor and achieve. You must collect patient payments, keep receivables low, manage your employees, control operational and administrative expenses along with clinical supply costs. And last but not least, you must provide exceptional dentistry.
With that said, getting your scheduling dialed in should be a high priority.
For me, “dialed in” means…having all of your chairs full with the optimal mix of ideal procedures, patients, and treatments.
Let's work through some Scheduling Axioms that we use in my practice and coach our clients on.
Remember, get your scheduling meme right, and everything else will flow.
I use the following Axioms as my scheduling foundation.
Axiom 1: Being Busy is NOT the same a being Productive.
Busy people; work at a frantic pace, are rushed, work harder, micro-manage, are fueled by perfectionism, multi-task, prioritize simple and mundane tasks and say "yes" by default.
In contrast, Productive People; prioritize the most important tasks, work at a steady pace, are relaxed, work smarter, are fueled by purpose, focus on essential and complex tasks, delegate the simple, mundane, and repetitive tasks, and can say "no".
Remember, it's ok to say "no." You are not the Coast Guard or US Military; you do not have to go out and rescue everyone. “Stay in your lane, bro…” as the AT&T commercial says.
along with “Just Ok, is not Ok!”
With these ideas in mind, one can begin to see that a jam-packed schedule may or may not be a productive schedule.
So let's get productive…
Axiom 2: Prioritize your Schedule for Productivity
Categorize and colorize your new patient exams, consults, and procedure mix on your schedule. Determine for yourself what your ideal procedure mix is. This will be different for everyone.
What do you enjoy most in your practice? There should be lots of time for these appointments.
What do you enjoy least? There should be very little time, if any, for these procedures on your schedule. As you become busier, these may be procedures you will refer out or cease performing completely. Remember from Axiom #1- it's ok to say "No."
Let's make some business comparisons to help drive home this point.
Your New Patient Exams, Consults and Treatment Presentation appointments are like Inventory in a manufacturing or merchandising business. It is an Asset waiting to be converted into a Product, your Dentistry.
Your Procedure or Treatment Schedule is analogous to your Production Line, where you covert that asset into your dentistry, and in the process generate revenue.
If your Inventory of New Patient Exams, Implant Consultations, and Treatment Presentations is low, your conversion of these assets into Implants, Crowns, and Bridges, or Restorations will be low too.
Put another way…
You can't schedule the production if you don't schedule the patient exam.
So, you need to balance the availability of a precise mix of new patient exams and treatment presentations to keep your treatment schedule full.
It's a balancing act; too many new patients will delay care without sufficient treatment appointments, keeping patients waiting. If patients have taken the time to visit you and your office, they are highly motivated. Please don't make them wait!
A sidebar here…the lag time between diagnosis and treatment is a critical KPI. As this time lengthens, the practice owner may consider expanding hours, expanding the physical plant, or adding a provider.
This can be a Blind Spot for a practice owner.
A Profit Leaks Analysis by our experienced Team at OmniStar DSO can help identify if you have a bottleneck in your practice that needs to be corrected.
Axiom 3: Rocks, Pebbles, and Sand
Time is a finite resource. Use a Block Scheduling Framework to allocate your time and schedule. I like to use the Rock, Pebble, and Sand analogy when designing a maximum productivity schedule.
Rocks are your anchors, your most enjoyable, productive, and profitable procedures. These will tend to be longer appointments. They should be added to your schedule first and always have the highest priority. These treatments should be scheduled at your most productive time of day. Remember, this is unique to you. Your Rocks are the cornerstone of meeting your daily production goals.
After Rocks comes Pebbles, smaller, more limited treatments with shorter appointment times that are used to fill in around your Rocks.
Finally, add the Sand; short appointments, post-op checks, limited emergency exams, and very brief restorative appointments. These are scattered to fill your gaps between the Rocks and Pebbles.
Sometimes it helps to think of Rocks, Pebbles, Sand in reverse. If you start with the Sand, you will never add enough Pebbles and Rocks to make for a productive and profitable schedule. You will have created BUSY, but NOT productive and violated Axiom #1- Being Busy is NOT the same a being Productive.
Next…
Axiom 4: Block Opportunity and Emergency Time into your schedule every day.
I want my schedule to be on autopilot. I do not want to be tracked down in a treatment room or in a hallway, or at my desk and asked what to do with a patient or referring office that is on the phone. After all, I have hired people who should be scheduling for me. I have found that "on the fly", “in the hallway” and "armchair" scheduling is not productive. It is paramount that you empower and train your staff exceeding well, and hold them accountable so that they can make these decisions for you. They will know and should know, more about the schedule than you. Your scheduling staff should be the ones micromanaging this.
When they do make sound decisions and hit the Bull's Eye with a full and productive day, make sure to praise and recognize them for their achievement. After all, it will not happen every day.
The one thing that can throw a monkey wrench into the best schedule is Emergencies and Urgencies, so we must plan for these eventualities. These are excellent sources of new patients and new referrals for your practice and should be accommodated.
To make this easier for all, earmark the best time slots for these patients on a daily basis. This can be determined in your morning huddle, where open slots for emergencies can be identified. Bingo, they no longer have to ask you! Let’s get these patients in and triaged.
A side note here. As a specialist, I recommend that our referring dentists see their emergencies immediately before and/or after lunch. If a referral is needed, there is still time in the day to accomplish that.
The veritable 4 pm emergency slot will unlikely have time to be seen by you, referred, and treated by a specialist that same day. There is nothing more frustrating for everyone; the patient, the referring dentist, and the specialist to have to appoint an emergency patient the next day.
Finally, in addition to emergencies, identify an opportunity slot every day. This can be a highly productive treatment and one that you enjoy. For our oral surgery practice, we will always have time to see a patient with a painful, infected wisdom tooth; that's what we love to do!
And last, but not least…
Axiom 5: Keep Score
If you don't measure it, you can't manage it…especially your schedule.
I know there are countless reports your Practice Management Software can print out to monitor your scheduling. By the nature of reports, they are historical. The schedule is so critically important that I monitor it daily.
I prefer a real-time assessment and visualization of our scheduling efficiency. To accomplish this, I do the following.
Daily, the doctors, and our administrative staff scan the schedule several days ahead, identifying available appointment times at each of our locations. If one location is booked full, they are aware that appointments can be scheduled in the other locations.
Next, I briefly meet with my Treatment Coordinator at the end of every day. I want a summary of every new patient; did they schedule? do they need to check with family? do we need to verify a secondary insurance? do they need to apply for Care Credit?
If they did not schedule and treatment was recommended, there is a follow-up plan for each patient. We start by doing whatever we told them we would do, and reach back out to them once the required information is obtained. If they indicated they would call us back, a reminder is put on the schedule to call them within a three-day window if they have not called us.
Every month, our Scheduling Coordinator assembles a report that tracks every appointment category for each doctor. The doctors monitor and track this report for any changes.
I hope these Axioms, guidelines, and guardrails will help assist you in engineering your "Perfect" schedule. After all, it's like Yogi Berra once said….
"You've got to be very careful if you don't know where you are going because you might not get there."
While working towards your Perfect schedule, you will have numerous "near misses."
Remember, don't panic!
Avoid the temptation to throw your guidelines out the window and fill the schedule with Sand and Pebbles. It is very easy to do. Be patient. Resist being swayed.
At least until 24 hours before an open appointment.
In our practice, we have the "24 Hour Rule". Everyone knows it and quotes it! We keep to the guidelines until the day prior when the "24 Hour Rule" kicks in. Scheduling is easy here. Our motto is "book 'em Danno!" for those of us that remember Hawaii 5-0!! Said another way; schedule patients who can come in today or tomorrow; some work is better than no work. You can never recapture the lost time once your day is done. Those empty slots and lost appointments are gone forever!
Remember the old dental adage…”Consider yourself unemployed for the time that your chairs are empty!"
' Nuff Said.
Excellent…
Time to wrap this up with a quick summary…
Our Axioms are…
Axiom 1: Being Busy is NOT the same a being Productive.
Axiom 2: Prioritize your Schedule for Productivity.
Axiom 3: Rocks, Pebbles, and Sand.
Axiom 4: Block Opportunity and Emergency Time into your schedule every day.
Axiom 5: Keep Score.
I know that if my schedule is kept full, I will meet or exceed my production goals every time with the correct mix of appointment types.
Try it… you'll like it!
Welcome…
You are here at The Beacon…
So glad you found us…
I am David Darab, your host for this episode.
Prepare to have your Blind Spots Illuminated
“To begin, begin.” said William Wordsworth.
Let’s do that and get started.
It’s the New Year, 2021…Happy New Year to You! We are all excited to see 2020 end, and our hopes are that the countless challenges we faced last year will soon come to an end too!
The New Year is a time of reNEWal, time for a fresh start, and a time to reset, recalibrate, and recharge. It is also a time we are constantly reminded about our New Years Resolutions. Seems that we can’t say New Year’s without adding the Resolution part too. Every year we pass this same threshold with the same hopes and desires for the year ahead.
What will you do??…do you have a plan??
Will you offer up some recurring laundry list of New Year’s Resolutions like you may have done many times in the past;
I’ll go first…
- lose weight
- workout more
- eat better
- work less
- spend more time with your family
- save more
- spend less
- read more books
- watch less Netflix
- etc, etc, etc….
I can’t help asking you, “How’s has your plan been working for you?”
You getting things done?
You Moving your needle?
You Accelerating?
Are you Reaching your Goals?
If your response was not a resounding YES, You are not alone. The experts tell us that half of all adults make New Year’s Resolutions, but less than 10% follow through on their goals each year. In reality, by Valentine’s Day, you may find yourself in the same “rut” as before.
Fighting these poor odds and without a better strategy I gave up on New Year’s Resolutions years ago.
The Truth is … Resolutions don’t work. Action does.
I anticipate if you are like me, you know deep down, in your heart of hearts, that you could do better, achieve more, and become a better version of yourself.
During these first weeks of the New Year Social Media and the Internet, heck…even my PodCast here… will have expert after expert share their guidelines, rules, hacks, shortcuts, and strategies for achieving more.
How about, for a change, instead of getting burdened with lists, journals, apps, processes, and other people’s ideas, we just Resolve to do One and only One Thing.
Act…
Let’s make a New Year’s Resolution to Decide to Act this year! Let’s put aside all of our thinking, prioritizing, researching, and list-making and exchange it for one simple task… to Act!
Of course, Simple does Not mean Easy!
We are all very intelligent, with lots of knowledge of the things we know we should do. Just look at the list you create each year.
I hate to break it to you, but Knowledge is the Easy Part…
We all know that to lose weight we should eat better and become more active…
We all know that to grow our Wealth we should spend less and invest more…
But knowing is the easy part…taking Action is the hard part, that’s why it is so challenging to achieve and so easy to come up short year after year.
This point is key and worth repeating…
Knowledge is the Easy Part, Action is the Hard Part.
It is your Action that leads to the Change you wish to make.
The Words “Resolution” and “Goal” are Nouns, not Verbs.
While the Words “Decide” and “Act” are Verbs defining Action.
I like to use the acronym D.A.T.E…D…A…T…E for
D.ecide to
A.ct
T.oday and
E.veryday
So…why is taking Action so very Hard?
Why is it so hard to 1. Decide and 2. Act?
Let’s dig deeper here and go down a rabbit hole, deconstructing this process so you can understand better the challenges and roadblocks to Action.
Once this is understood, it easier for you to conquer.
I’ll take it for granted that those listening here are all high achievers, driven, competitive, and highly successful. We want and demand the very best from ourselves. We are, at most times, our staunchest critic. Failure is not an option, nor something we tolerate or enjoy, after all, we are “Perfectionists”.
But alas, there is no such thing as Perfection. A belief in Perfection is in fact a defense mechanism. Waiting for Perfection gives you a way out, it gives you an excuse. It lets you stall, it requires you to do more research, to think some more, and avoid doing anything that might possibly fail. Because as we just said, failure is not an option…especially for a perfectionist.
But, and here is the kicker…with the risk of failure, comes an even greater reward…the reward of success, of accomplishing something important, of creating the change we so desperately need, want, and desire.
There is an irony here…we want one thing, yet do another…
Does any of this sound familiar…does it sound like Resolutions, Rationalizations or Goals not achieved…??!!
The contradictions never end.
Why is it so difficult to do what we say we’re going to do?
The answer is …as Seth Godin says, our “Lizard Brain”, or as Steven Pressfield calls it, “The Resistance”, our Inner Barrier.
The Resistance is that little voice in the back of our head telling us over and over to back off, be careful, go slow, watch out, this is risky, compromise. The Resistance grows stronger and stronger the closer we get to achieving what we really want, the closer we get to Action. That’s because the Lizard Brain, or amygdala, that pre-historic area of our brain stem, hates change, hates achievement and risk. After all, it is the amygdala that is responsible for our fight or flight response. It is there to protect us, and it acts even without us knowing.
So, we have decided to Act in order to achieve our goals, but for many, just as we are on the verge of action our primitive Lizard Brain, this Resistance, beckons us louder and louder to hold back.
It is much like the effect Krypotite has on Superman…the closer he gets… the weaker he becomes.
So…
How do we Slay and conquer this Resistance, this Lizard Brain, this Inner Barrier, the Amygdala you ask??
We slay it by Turning Pro, as in Professional, and leaving our Amateur ways behind us.
Let’s consider the differences…as described by Steven Pressfield in The War of Art (a great read see the show notes for a link).
An amateur plays for fun, a Pro Plays for keeps.
To the amateur the game is his avocation, to the Pro, it’s his vocation.
The amateur plays part-time, the Pro full-time.
The amateur is a weekend warrior, the Pro is there seven days a week.
The amateur attempts perfection, the Pro achieves something remarkable.
The amateur delays and procrastinates, the Pro Decides and Acts.
The Resistance hates it when we turn Pro.
So…
for this New Year’s Resolution let’s try something different. Let’s show up every day, no matter what, and decide to do act. Because we now know that no matter how small each act might appear, it is facing your Lizard Brain head-on and completing what you started that is most important. Each small act taken together builds on the one before allowing us to achieve our goals and move our needle. With each achievement, we grow stronger and more confident and The Resistance, your Lizard Brain, that Inner Barrier gets weaker and weaker.
Now that you understand better what may have been holding you back, what are you going to do about it?
What new decisions and actions will promote your progress? Are you starting them today?
Too often, we schedule a time to adopt, embrace, and initiate better habits in the future. “I’ll start tomorrow, or next week, or next month, or whenever. We now know those are simply excuses.
Yes, I know, Biology, evolution, and past failures are all conspiring against you. It doesn’t matter. The solution to launching a better way of being is easy. Simply Decide to begin. Decide to Act.
In the final analysis, it comes down to your willingness to decide that today is the day, and now is the time to begin. The time to take your first small step into your potential.
Every day you can decide to do things better, or do things worse. It’s your choice.
So…
Let’s review…
New Year’s Resolutions don’t work…Decisions and Actions do!
You now know that biology and evolution, create an Inner Barrier, a Resistance called your Lizard Brain, powered by your amygdala, which has thwarted your efforts in the past…
You are now armed with a strategy to conquer this force…Action!
The more you Act the easier the next Action becomes…
And finally,
I’ll end with a quote from Walt Disney…
”The best way to get started is to quit talking and begin doing.”
So that wraps things up for this Podcast. We hope that this information has created a few “Ah-Ha” moments to help you make great things happen this year. Please share this podcast if you found it helpful, and leave a review on iTunes too. We welcome your feedback and suggestions for future podcast sessions. You can always find me, your host, David Darab, at my Twitter handle, @ddarab.
Thank you so very much for tuning in and listening. We are very grateful for your time and attention and so very pleased to have you in our audience.
We wish you a happy and healthy New Year.
_______________________________________________________________________
REFERENCES
The Practice; Seth Godin
The Art of War; Steven Pressfield
The topic for today is Air Purification.
During this podcast, we will take a deeper dive into Air Purification Systems. It is our intent to make you more knowledgeable of the choices and technologies available so you can make the best decision for your practice.
By now you have been back in your practice working hard every day to adapt to the new “normal”. We are realizing that we are in this COVID-19 Pandemic for the long haul now and that our work practices today may persist for the foreseeable future…this may, in fact, be the “new normal”.
As concern for the transmission of HIV, AIDS, and Hep B ushered in the OSHA Blood Borne Pathogens Standard in the early 1990s, it is possible we may see an “Airborne Pathogens Standard” emerge from the present COVID-19 Pandemic. Especially since we understand better that infection with COVID-19 comes primarily from breathing air in indoor spaces where people with the coronavirus have been. The greater the exposure, the greater the risk of becoming infected.
After urging steps like handwashing, mask-wearing, and social distancing, researchers say proper ventilation indoors should join the list of necessary measures. Health scientists and mechanical engineers have started issuing recommendations to schools and businesses for how often indoor air needs to be exchanged, as well as guidelines for the fans, filters, and other equipment needed to meet the goals.
We are all concerned about the health of our patients and staff and desire to provide care in the safest worksplace and in the safest manner possible. Dentists maybe thinking about, or have already purchased devices such as air filters, UVC lights, and suction devices to help reduce dental aerosols as well as “clean”, filter, and purify operatory air where aerosols are generated. Products marketed today to sanitize and reduce dental aerosols may lack research to support efficacy claims.
Before you move forward and pull the trigger on “air purification” technology lets spend some time reviewing the terms, vocubulary along some of the pertainant science.
Today, we are at a unique and unexpected intersection of infectious disease transmission, aerosols, filtration, HVAC (heating, ventilation, and air conditioning) and mechanical engineering. Who would have every thought, as dentists, we would be so concerned with HVAC, room layout, air purification, and filtration along with room air exchanges per hour.
We need to remember that the OSHA Gold Standard for High Risk, aerosol generating procedures is an Airborne Infection Isolation Room (AIIR) with proper ventilation. AIIRs are single-patient rooms with negative pressure that provide a minimum of 6 to 12 air exchanges per hour. An AIIR ensures that the room air exhausts directly to unoccupied areas outside of the building, or passes through a HEPA filter if recirculated.
As we look to “hang our hat” on sound science and information we can begin with some facts as we understand them today.
First, transmission…
SARS-CoV-2, the virus that causes COVID-19, is thought to spread primarily between people who are in close contact with one another (within 6 feet) through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne transmission from person-to-person over long distances is unlikely. However, COVID-19 is a new disease, and we are still learning about how the virus spreads and the severity of the illness it causes. The virus has been shown to persist in aerosols for hours, and on some surfaces for days under laboratory conditions. SARS-CoV-2 can also be spread by people who are not showing symptoms.
Second, how do droplets move…
Droplets of all sizes are emitted when a person coughs, talks, or sneezes. How they travel depends on many factors. Some research has found that droplets can be carried by a moist gas cloud, which an MIT researcher has said can travel up to about 26 feet after a sneeze. Some of the droplets will fall as the cloud moves. Others ultimately evaporate, producing aerosols that can linger in the air and travel with airflow patterns.
Scientists emphasize there is no distinct size cut-off between droplets and aerosols. Some disagree about size ranges for each. Researchers are working to better understand the infectiousness of various-sized droplets and aerosols, and how it may change over time.
Here are some facts we know at present…
- Small Aerosols: 3 microns or less, Can linger for hours
- Small Droplets and Large Aerosols: 100 microns or smaller, Can linger in the air for 30 minutes or more
- Large Droplet: 100 microns (diameter) or larger, these heavier droplets fall to the ground within seconds
How about Risks to Dental Health Care Providers…
The practice of dentistry involves the use of rotary dental and surgical instruments, such as handpieces or ultrasonic scalers and air-water syringes. These instruments create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms, and other debris. Surgical masks protect mucous membranes of the mouth and nose from droplet spatter, but they do not provide complete protection against the inhalation of infectious agents. There are currently no data available to assess the risk of SARS-CoV-2 transmission during dental practice.
From these facts, dental professionals concluded that air flow control can help prevent transmission of SARS-CoV-2.
Current recommendatins from
The CDC suggests dentists consider using a portable air filter that meets the high-efficiency particulate air standard while performing aerosol-generating procedures and immediately afterward. The CDC states using a filter will reduce the particle count in the room, including droplets, as well as increase the room air exchanges provided by the existing building HVAC system alone.
There are additional factors dentists need to consider when using air filters, however. These include the direction of the air flow in their operatories and the capacity of the filters.
Ideally, air would flow from a vent behind the head of the patient, where aerosols are produced, down to a filter at the patient’s feet, with dentists and their staff on either side of the patient so they don’t come between the aerosol and the filter. That is easier said than done, however, because in some operatories, air may be flowing from a vent on the ceiling or from other sources, such as windows.
Also, some practices may have portable filters dentists can place in different parts of the operatory, while others may have filters that are part of their ventilation system. Comparing the two is hard to do because both come with their own specifications. While portable filters allow dentists to control their placement, their capacity may not be as large as the ones that are built into the ventilation system.
Just how effective are these filters at trapping the coronavirus??
Filters that meet the high-efficiency particulate air standard (HEPA filters) have a 95% chance of trapping particles that are 0.3 microns or greater. The virus is 0.06 to 0.14 microns in size, but as long as it is traveling on a large enough particle in the aerosol, it would be caught by the filter.
Another array of products dentists may be considering to help sanitize the air in their practices are ultraviolet lights with wavelengths between 200 and 280 nanometers, known as UVC lights. The CDC states dentists may consider using upper-room ultraviolet germicidal irradiation as an adjunct to higher ventilation and air cleaning rates.
While UVC lights are germicidal, many factors can impact their effectiveness, including the amount of organic matter in the air, the intensity and wavelength of the light, the type of aerosol suspension generated by the procedure that is performed, the ambient temperature in the room, the microorganism to be killed, the distance between the light and target and the cleanliness of the light tube.
Safety is another consideration. There are still questions regarding what is the safe UVC wavelength for human exposure.
When it comes to suction devices, the ADA states that dentists should use high-velocity evacuation whenever possible. When using suction devices, dentists should hold high-volume evacuators about 2-5 inches from the instrument being used in the procedure and place extra-oral vacuum aspirators 6-12 inches from the patient.
Overall, research on dental aerosols is lacking. No studies have identified viruses in dental aerosols because researchers weren’t looking for them.
Let’s shift to…
THE ADDITION OF AIR PURIFICATION SYSTEMS
Today, in addition to all of the above recommendations, dental providers that perform aerosol generating procedures should implement an air management plan utilizing a layered application of technology and behavior to minimize the risk of SARS-CoV-2 transmission.
This layered approach could include:
1. Enhancing your Current HVAC system by increasing outdoor air into the building, ventilating indoor air to outside spaces, keep humidity between 40-60 % (lower humidity may favor SARS-CoV-2 viability}, use the highest rated MERV filter compatible with the system, reprogram the system to avoid shut off during occupied hours and leave exhaust fans on in rest rooms.
2. Installing Ultraviolet Light (UV) technology inside the HVAC ducts. Consider Far UVC, which can inactivate the virus. without human health risks in occupied spaces. In occupied spaces consider suspending UVGI lamps from ceilings or upper portion of walls to direct the radiation upward and outward and away from room occupants. Ultraviolet germicidal irradiation (UVGI) has the potential to cause human health diseases, including skin cancer and eye disease. UVGI cannot be used in an occupied space, except when installed in an upper-room fashion.
3. Add Air Scrubbing to the HVAC system: Wet scrubbing uses a damp or wet medium to filter particles and contaminants out of the air. Dry scrubbing utilizes the properties of positive and/or negatively charted ions to destroy certain molecules, disrupt the vitality of airborne organisms and viruses, and cause airborne particles to aggregate, fall, and/or be caught in filters. Though the absolute benefit of air scrubbing for decreasing SARS-CoV-2 transmission in a dental office is unclear, it may still be beneficial to improve the general air quality and reduce the recirculation of contaminants. The ions created through air scrubbing are dispersed. throughout all the air in the workspace extending to areas where UVGI or even some fogged disinfectants may not reach.
4. Finally are HEPA filters: No direct research exists to verify if a HEPA air purifier reduces the transmission of COVID-19. SARS-CoV-2 is generally carried in respiratory droplets, which are much larger than other particles known to be captured by HEPA filters. HEPA filters can be used as an adjunct to the HVAC system to enhance room air exchanges. Portable units can be placed in an operatory where aerosol-generating procedures are performed.
We are at an interesting cross road here, now calling on such diverse professionals as infectious disease experts, mechanical engineers along with HVAC contractors. When doing my research for this podcast I found a wealth of essential information along with the answers to many of my questions, which I anticipate are also your questions, from the documents and specs outlined by ASHRAE, the American Society of Heating, Refigeration, and Air-Conditioning Engineers.
Let’s check it out:
Question: WHAT FILTERS ARE RECOMMENDED FOR HVAC SYSTEMS?
Answer: Our current recommendation is to use a filter with a Minimum Efficiency Reporting Value (MERV) of 13, but a MERV 14 (or better) filter Is preferred. Of course, the ultimate choice needs to take the capabilities of the HVAC systems into consideration. Generally, increasing filter efficiency leads to increased pressure drop which can lead to reduced air flow through the HVAC system, more energy use for the fan to compensate for the increased resistance or both. If a MERV 13 filter cannot be accommodated in the system, then use the highest MERV rating you can.
Question: WHAT IS THE SIZE OF THE SARS-COV-2 VIRUS, AND CAN IT BE CAPTURED BY VENTILATION FILTERS?
Answer: Research has shown that the particle size of the SARS-CoV-2 virus is around 0.1 µm (micrometer). However, the virus does not travel through the air by itself. Since it is human generated, the virus is trapped in respiratory droplets and droplet nuclei (dried respiratory droplets) that are predominantly 1 µm in size and larger.
ASHRAE currently recommends using a minimum MERV 13 filter, which is at least 85% efficient at capturing particles in 1 µm to 3 µm size range. A MERV 14 filter is at least 90% efficient at capturing those same particles. Thus, the recommended filters are significantly more efficient at capturing the particles of concern that a typical MERV 8 filter which is only around 20% efficient in the 1 µm to 3 µm size range. Filters with MERV ratings higher than 14 would capture an even higher percentage of the particles of concern. High-efficiency particulate air (HEPA) filters are even more efficient at filtering human-generated infectious aerosols. By definition, a HEPA filter must be at least 99.97% efficient at capturing particles 0.3 µm in size. This 0.3 µm particle approximates the most penetrating particle size (MPPS) through the filter. HEPA filters are even more efficient at capturing particles larger AND smaller than the MPPS. Thus, HEPA filters are more that 99.97% efficient at capturing airborne viral particles associated with SARS-CoV-2.
Question: IS ULTRAVIOLET ENERGY (UV-C, ULTRAVIOLET GERMICIDAL IRRADIATION, GERMICIDAL ULTRAVIOLET) EFFECTIVE AGAINST THE SARS-COV-2 VIRUS?
Answer: Ultraviolet energy (ultraviolet germicidal irradiation or germicidal ultraviolet) could be a powerful tool in the fight against COVID-19. ASHRAE’s position on UVC is expressed in the UVC air and surface disinfection is used in many different settings – residential, commercial, schools, as well as healthcare. Germicidal light (particularly 254 nm UVC produced by low-pressure mercury vapor lamps, which operate near the most effective wavelength of ~265 nm) has not, to our knowledge, been tested on SARS-CoV-2, but it has been tested on an airborne coronavirus (Walker 2007). The sensitivity of that coronavirus to 254 nm was high enough that it seems like a good candidate for UV disinfection.
Another way to install UV is in an “upper-air” configuration. Specially designed fixtures mounted on the wall create an irradiated zone above the occupant and disinfect the air in the space as air circulates naturally, mechanically, or by means of the HVAC system. This sort of system has been approved for use in the control of tuberculosis by CDC for nearly 20 years and there is a NIOSH guideline on how to design them.
Finally, mobile UV systems are frequently used for terminal cleaning and surface disinfection in healthcare and other spaces. Systems such as these are typically used in unoccupied spaces due to concerns of occupant exposure. All three system types may be relevant, depending on the building type and individual spaces within the building.
The design and sizing of effective ultraviolet disinfection systems can be a complex process because of the need to determine the dose delivered to a moving air stream or to an irradiated region of a room. In-duct systems are further complicated by the air handling unit and ductwork configuration and reflections from surfaces that can help achieve higher irradiance levels. Upper-air systems require adequate air mixing to work properly while paying close attention to reflective surfaces that could result in room occupants being overexposed to the UV energy. Reputable manufacturers and system designers can assist by doing the necessary calculations and designing systems specific to individual spaces.
So, we have covered a lot of ground here, but are still left with the question…
What am I to do?
What’s the take home actionable point?
We know the threat of COVID-19 is significant and it can be transferred via the airborne route through coughing, sneezing, and secretions as well as through aerosols generated during our treatments.
For patients diagnosed with or suspected of COVID-19 infection, the gold standard is a negative pressure isolation room.
However, in our present practice, negative pressure rooms are probably not available or practical. From the above discussion, science, and technology it appears a multi tiered approach may prove the most practical.
Consider the following strategies to enhance the air purfication in your office;
1. Enhance your current HVAC system by running it more frequently, start earlier to allow more time for airflow and filtering before your normal office hours begin.
2. Choose HVAC filters that can remove a large portion of airborne particles, such as a MERV 13. If such a filter is incompatible, choose the most efficient filter.
3. Increase the HVAC system’s supply of outdoor air, to as much as the system can handle, in order to reduce reliance on recirculated air.
4. Consider centrally placed HVAC air treatment. Options here could include UVC germicial irradiation or ionic air scrubbing. Consultation with your HVAC contractor can help recomment the best options for your facility and system.
5. Provide air filtration in operatories where aerosols are generated. Using portable air purifiers with high-efficiency particulate air, or HEPA, filters. Vendors today also integrate UVC chambers, ion generators with HEPA filtration for a powerful viracidal combination.
6. Recirculate room air to achieve the equivalent of 6 to 12 air exchanges per hour. This can be difficult to achieve with your existing HVAC system. The addition of a portable air purifier can greatly improve your room air exchanges. Remember that larger spaces may need multiple units to achieve the recommended air exchanges.
7. Finally, some offices may choose residential and construction-grade air purifiers in patient care areas. Caution must be advised since units can create turbulent outflow in treatment rooms risking spreading aerosols.
Each office facility may use a different combination and method to reach their goal.
One prescriptive method does not exist, so no single strategy can be recommended. We will end with a statement from the ADA…
“When we look at dental aerosols, at this point, there’s nothing that we can nail down and say that this virus or salivary organisms spread through dental aerosols, but again, absence of evidence is not evidence of absence, and therefore, use precautionary prevention protocols,”
REFERENCES:
https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134)
https://www.cdc.gov/coronavirus/2019-ncov/community/office-buildings.html
https://www.cdc.gov/niosh/docs/2009-105/default.html
https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html)
https://www.epa.gov/indoor-air-quality-iaq/what-merv-rating-1
https://www.osha.gov/SLTC/covid-19/dentistry.html
https://www.osha.gov/SLTC/covid-19/healthcare-workers.html)
(https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/air.html
https://www.epa.gov/indoor-air-quality-iaq/what-merv-rating-1
WSJ research; Linsey Marr, Virginia Tech University; Lydia Bourouiba, Massachusetts Institute of Technology
Caitlin McCabe, Alberto Cevantes, Josh Ulick/THE WALL STREET JOURNAL
pd_infectiousaerosols_2020.pdf
Air_Management_For_The_OMS_during_the_COVID-19_Pandemic (1).pdf
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