Demystifying Medicine One Month at a Time

The Doctor & The Orthodontist

My daughter chose purple...

I took my daughter to the orthodontist last week to get braces.

There’s a lot about the process that seems better than when I was a kid. Mostly, it’s that instead of having to slide brackets around each of your teeth (yishk!) the orthodontist just paints a special glue on the enamel and places the brace on the front of each tooth. Kids get to pick the color of their braces now, introducing some degree of choice (and therefore control) into what amounts to a victimization of one’s oral cavity.

What really stunned me, though, was the way that her orthodontist organized his practice.

I’ve written before about the concept of “Patient-Centered Medical Homes,” [PCMH] a high-minded concept in which patients see a doctor or her associates whenever necessary, and all information is seamlessly inside a electronic medical record so any and all providers are able to deliver timely, safe, effective, high-quality care.

It’s an idea that is central to health care reform, and seen as a way in which we can contain costs. [Of course one of the big problems with this concept is that patients often don’t understand the name. Survey data shows that there are loads of misconceptions about what a PCMH actually is. Here is one funny look at this phenomenon.]

My daughter’s orthodontist is part of a three person practice. But for each orthodontist, there are three hygienist/techs and at least one office staff member handling billing, care coordination, and administrative issues like computers.

This sounds pretty personnel-heavy, but let me assure you there was constant motion and therefore constant ‘productivity.’

In the hour that it took for my daughter to have her braces applied, there were four different patients seen in the chair next to her, by three different techs and two of the orthodontists.

The examining suite was arranged with eight chairs in a semicircle, and each chair had a computer screen next to it so that the patient’s parents could see their kids’ xrays, projections of what their jaws/teeth would look like during and after treatment, and get educational material. Of course, the techs and orthodontists used the system for entering patient data as well.

In the center of the circle, tech/hygienists were troubleshooting, preparing trays for subsequent patients, discussing aspects of care, etc.

The orthodontists (two present while I was there) literally sat on office chairs and swiveled from patient to patient–washing up copiously between each encounter, and leaving plenty of time to communicate with parents, and work phone calls in between patients.

It was a tour de force.

I was overwhelmed by the efficiency of it all, the professional nature of the encounter(s), and my daughter entering a rite of passage (and how brave she was!) in no particular order.

How much does it cost?

Well, like health insurance, our employee-benefit dental insurance defrayed a significant portion of the upfront cost. What our insurance didn’t cover, we could have financed. We chose to pay the remainder in a lump sum so as not to incur interest on the debt.

But like a capitation model, we’ve payed for the treatment. Under the contract we’ve signed, our daughter can visit the orthodontist 12 times, 24 times or more, however many it takes to get her teeth straight. I’m certain that at a practice like this one they know their business well enough that even with some unexpected hiccups, they will make money on most patients in the long run.

And I’m O.K. with that. They are providing real value for our money. It goes beyond the “product.” It encompasses the feeling that I got by participating in my daughter’s care and seeing how the operation worked. Literally.

Our experience there made me wonder why medicine can’t be practiced this way.

Medicine is too complicated. Our costs are too variable. Our practice flows are less predictable. We’re not just focusing on one part of the body.

But what’s to stop us from, say, asking our patients with diabetes to come to group visits? They could be seen en masse for education and testing, and see the doctor for quick individual consultations about medication adjustment or the need for further consultation. All the providers (docs, nurses, medical assistants, physician assistants, nurse practitioners, dietitians, etc.) could be ‘practicing at the top of our licenses.’

I never smiled when I had to wear this trap.

At the orthodontist’s office, the hygienists and techs all were involved in lab work, preparation, and direct patient care. No one’s talents were going to waste by locking into one repetitive job description. I spoke with one hygienist, and she told me that she enjoyed the different roles in her job. And she felt empowered to make change or to let the orthodontists know if something wasn’t working well. All in all, it seemed a pleasant work place with a real team atmosphere.

I guess seeing it first hand makes me realize that achieving a medical home model can be done in primary care. We just need our medical homes to be more like our orthodontic homes.

Just ask my daughter. Luckily for her, with modern methods, there’s no need for headgear anymore.


  1. amy

    One of my BIG concerns with this concept in medical or dental settings is privacy. As a patient receiving treatment I can see and hear everything going on around me as well as confirmation about what medications are taken and any changes in health history of other patients. When either I or my children are seen at the dentist or orthodontist we are taken into a private room to discuss the cost but herded like cattle into the treatment center without so much as a curtain for privacy. It may be convent and efficient for the docs but it is intrusive and uncomfortable as a patient.

  2. glasshospital

    Good point re: privacy. Seems like the right thing to do in these settings would be to get the patient’s (or parents, in the case of a minor) consent to be ‘treated in the open.’

    I didn’t see any language about it in the fine print, but I or my wife did sign off that we’d received and acknowledged the office’s privacy policy.

  3. drrjv

    Nice post!

    EMR systems are driving physicians to this model, which in the long run, may be a good thing. Having an assistant handle the EMR system allows me to spend more facetime with the patient, plus I can see more patients.

    The dentists (I know, because my brother is one) are much more efficient and sophisticated in practice management in comparison to most physicians.

  4. Kathy Mcgurn

    I couldn’t resist commenting. Saved as a favorite, I really like your blog!

  5. Mike

    I hate to say it, but I feel like part of what makes this system possible is that that the practice is making money hand over fist (as evidenced by the fact that the amount of money you had to pay after insurance could have been financed. Only expensive things are financed.) They sound extremely efficient because they are probably fully staffed with people who are well compensated for the work that they do. Those are not guarantees of success and you still need excellent processes in place, but they sure give a practice a great head start compared to a place that has to keep “MacGuyver-ing” things together on a hope and a prayer because of decreasing reimbursement. (Very few dentists I know of take Medicaid, I am assuming orthodondists don’t either.)

    That being said, our resident clinic does group well child visits and they are very cool. We start with a cohort of newborns and then they progress through 1-2 years together. It is neat to watch the residents lead the sessions and it is neat to watch the young parents learn from and get support from each other.

  6. Elaine Schattner, MD

    John, I think you’re right about the orthodontist’s model and efficiency. But isn’t the biggest difference that those practices don’t deal with insurance and, by the nature of their business, which it is, don’t have to cover costs of people who can’t pay? It’s a luxury service, not an essential one.

  7. Robert

    The doctor and the orthodontist:

    One gets to balance bill, the other doesn’t. Look at the difference it makes.

  8. Fredrick M

    I think that the dentists (I know, because my brother is one) are much more efficient and sophisticated in practice management in comparison to most physicians.

  9. Anastasia Frodge

    Thanks for this wonderful and informative post. I agree with everything you mentioned, specially the part containing the arguments.

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