More recently, the term “tyranny of the missed diagnosis” has been stuck in my head after spending two days with the incredibly talented Brian Vence, DDS. When we fail to do complete examinations, and take accurate records, including full medical, dental, and social histories that have the capacity to reveal the complexity of the situation about which we are confronted (thank you David McCarty, MD for your brilliant discussions on this topic), we subsequently end up “chasing a black cat around a dark room,” (thank you Rev. Tupper Garden or this useful metaphor). In other words, we don’t really know where we are, how the system is actually working, where it’s highly compromised or adapted (and therefore likely to fail next), and how our well-intentioned interventions might make things worse.

That is, in fact, how many people arrive back at “tooth-centered dentistry” after spending tens (if not hundreds) of thousands of dollars (and years) learning how to do things the right way from the best-of-the-best people and institutions. We arrive back in a tooth-centered world because nothing is making sense 40% of the time, so we conclude, “Why the hell am I torturing myself with all of these interviews, records, analysis, planning, and case presentations, when most people say “no,” and the outcomes aren’t as good as I thought they would be? I think I’ll focus on my golf game instead - at least that feels a little more rewarding.”

Answer to the problem: We don’t know what we don’t know because we aren’t disciplined enough to discover the answers (which might be that we can’t know yet), so a lot of our planning and processes are built upon wrong or incomplete assumptions that predictably render out unpredictable outcomes.

Ok. There you have it.

Success, happiness, and fulfillment in complex, health-centered dentistry are only achievable when we have the mindset that almost every situation is more complex than we know—and will remain so unless we move past our confirmation bias and stick to the pursuit of what David McCarty calls “ground truth.”

This matters in dentistry because so few professions ask a person to make so many irreversible, identity-defining decisions — where to practice, whether to sell, when to retire — using an internal sensor calibrated decades earlier under very different circumstances: dental school hazing, a first associateship that ended badly, a mentor who withheld approval as a management tool, a friend who went bankrupt, a household where money meant safety or its absence meant shame. When this sensor fires, it can do so rather indiscriminately.

THE NEUROPHYSIOLOGY OF “GUT INSTINCTS”

The concept known as predictive coding helps us understand what’s happening in the background. Our nervous system doesn't wait to perceive the present moment before fully responding to it. Instead, it predicts using memory engrams based on everything that has already occurred and only corrects predictions when the mismatch is large enough to cause problems. Interoception, the capacity to sense our own internal state, works the same way. The tightness in our chest when a DSO recruiter calls, the dread before a quarterly partnership meeting, the deflation felt when a patient mentions "I only want to do what my insurance will cover" — these are not pure responses to the present; they are old engrams, thoughtlessly firing fast, and assumed true.

Bob Barkley had a name for a version of this that calcifies within a practice: "slum mentality" — learned helplessness associated with the belief that nothing can be different, a conclusion arrived at through so much repetition that it is never reexamined. This can show up in several different ways: A dentist who was rejected early for confidently setting a fair fee will feel danger whenever the next fee conversation approaches — not because their fee was wrong, but because the engram says “most fee conversations end badly.” The feeling is real, but the story attached to it may be ten or more years out of date.

FOUR VOICES, ONE SENSATION

Carl Jung's taught us that what feels most instinctively "us" is often our persona defending itself, not our true self speaking. Applied here, it means the tightness in our stomach before a big decision could be any of four different things that need to be teased apart before we mindlessly obey them.

There is intuition — quiet, specific, and non-negotiating. It tends to say one clear thing and then go silent, the way we know a hiring decision was wrong within the first day, without needing any additional evidence.

There is anxiety — loud, generalizing, and endlessly running. It doesn't say one thing; it argues, produces catastrophes, and keeps influencing long after the facts have been heard, because its job was never to inform us — it was to protect a much younger version of ourselves from a threat that no longer exists.

There is attachment — repetitive rather than loud. It's the reason a chaotic, unpredictable practice environment can feel more like "home" than a calm, well-run one; the nervous system has learned to associate a certain intensity with belonging, and mistakes recognition for rightness. This is what makes an aggressive DSO acquisition offer feel electric — not because it's good for us, but because urgency and flattery are a familiar combination.

And then there is philosophical incompatibility — the only one of the four that’s related to incongruence. Declining case acceptance across a stable patient base when we are presenting treatment plans that align more with our financial needs than our patient’s desires. A team that keeps turning over regardless of who's hired. Chronic overhead growth that no efficiency improvements seem to touch. Philosophical incompatibility doesn't need our nervous system's help to make its case; it also involves our prefrontal cortex and a concept called moral injury.

The confusion nearly every one of us runs into at a genuine crossroads is treating all four as the same voice.

KNOW YOURSELF, THEN KNOW WHICH ONE OF THESE VOICES IS SPEAKING

Dr. Pankey's Cross puts ‘Know Yourself’ before ‘Know Your Patient’ and ‘Know Your Work’ for a reason: everything a dentist perceives about a person, a case, a fee conversation, or a career decision must first pass through the individual doing the perceiving. CoDiscovery works with patients because it slows down the development of the relationship enough that the patient's true values and priorities have time to surface, rather than allowing engram-driven, reflexive answers to drive the proverbial bus. The same discipline when applied inward — slowing ourselves down long enough to ask ourselves which of the four voices is speaking — is ‘Know Yourself’ applied, and not just happy talk.

Practically speaking, this means treating the feeling and the interpretation as two separate events instead of one. The tightness in the chest is a feeling; the narrative we immediately attach to it —“I always get taken advantage of,” “This will end as the last one did,” “That can’t be done in my town”— is a hypothesis, not a fact. Thus, it should be questioned rather than obeyed upon arrival.

Barkley's remedy for slum-mentality thinking was interruption — get out of the office, take a walk, put a night between the feeling and the decision, and then come back and ask in a calmer, more introspective state, what proper resolution of the situation will truly require.

If the problem persists once the emotion is gone, it’s likely due to philosophical incompatibility, which warrants our full attention and strategic action. If the issue dissolves over time, it was likely associated with anxiety or attachment needs.

THE FUTURE ASKS A DIFFERENT QUESTION THAN THE PAST DID

A young associate deciding whether to sign a restrictive contract, a mid-career owner/operator deciding whether to finally leave insurance contracts behind, a dentist twenty years in staring at a DSO offer that would solve every cash-flow problem overnight — each of them will feel something in their body before they perceive anything in their mind. The mistake is assuming the feeling is a verdict. Wisdom lies in knowing that a feeling it closer to a rough draft, written partly by the present and partly by similar situations our nervous system has already lived through, whether or not they had anything to do with dentistry at all.

Self-trust isn't the same as feeling-trust. Self-trust is being self-calibrated enough to know the difference between our body correctly warning us and a body that’s still protecting a younger version of ourselves from a nonexistent threat. The future doesn't need us to obey every signal our body sends; it needs us to have done enough self-work — Know Yourself — that we are able to tell where a signal is coming from and whether it’s useful information or just more distracting noise.

It’s easy to read the above quote and think it’s possible to build health-centered relationships —or that it should at least be attempted with every person. But such an approach is both ineffective and inefficient. And when we’re ineffective and inefficient over an extended period, we are likely to abandon what we’re doing and revert to the status quo out of frustration and a need for reassurance.

Therein lies the tender trap which easily causes many of us to surrender our efforts and return to following the herd. The reality is that health-centered dentistry is intended for health-centered people, in the same way that Fitness Centers are designed for people who are committed to becoming more fit — it’s not a “one-and-done” process; it’s a long-term commitment.

If I were to say to you, "Fitness Centers are for people with broken arms because people strengthen their arms there,” you’d look at me as if I’d lost my mind. Similarly, are all dental practices for people with broken or damaged teeth just because other people have their teeth repaired there? Unfortunately, the general public's understanding of dentistry isn’t much more sophisticated than this last question —spend fifteen minutes at a cocktail party, and it will easily be confirmed.

Our profession has largely failed to make its case to the public that what we do is health-centered, and therefore we have largely failed to debunk the meme that dentistry's mission of repair and pain relief hasn't changed much since the time of Paul Revere; that it’s only the methods of HOW we do these things that have changed over time.

This is a long-winded way of saying that the biggest challenge for health-centered dentistry is often a marketing one. If the public wants "X" at a certain price and we are selling "Y" at a different price, we have a real problem on our hands. A very well-organized, congruent practice promotion strategy is consequently essential to our success. And it must be strong and consistent enough to draw a sufficient number of health-centered patients to us.*

Along this line of thought, remember LD Pankey said, "People change, but not very much." And therefore, if we think we are in the people-changing business, then we have yet another problem on our hands: Most people don’t want health; they want their tooth fixed, pain to stop, their teeth to feel cleaner, or to find a “provider” who “takes their plan.” If we aren’t good at facilitating change through more effective learning processes with those who are ready to learn, then we likely aren’t doing what we think we are doing.

*Yesterday, I conferenced with a new patient. After exchanging introductions and welcoming her, she said: “I think I’m ready. I know that I have a lot of work to be done. I’m missing several back teeth, and don’t like the way my smile looks.” To which I asked, “Have you explored this with anyone else?” She replied, “No, it has been about four years since I’ve seen a dentist, and I’ve researched you on the internet and decided to start saving up my money. I also have a CareCredit account with no charges on it.”

These represent the moment when we realize that all of the work we have done building up a good reputation, properly designing a website, carefully selecting and developing a care team, and living our philosophy is paying off. Obviously, not everyone who walks through our door is this goal-oriented and committed, and we still have a lot to learn together to determine whether she is truly ready, but this represents about as good a start as we can hope for.

I explained to her our process for collecting information and sharing it in a way that will help her make informed choices — that is my initial goal: to get her to a place where she can confidently choose her preferred dental health future because that’s when dentistry is most enjoyable to me —when I’m collaborating with a person who values the outcome as much as I do and is subsequently willing to work with me so we can optimize the process.

This is worth considering, because our profession tends to watch economic news the way it watches weather: something happening elsewhere, to other people, that occasionally affects us. But a meaningful share of dental practices are no longer owned by solo dentists. They are owned, financed, and leveraged by private equity-backed dental support organizations, and those organizations were built when money was nearly free.

THE ARITHMETIC OF REFINANCING

The mechanism is simple enough to run in your head. Picture a loan of any size issued at three percent, coming due at a time when the market is charging eight or nine percent instead. The loan doesn’t get smaller; it gets more expensive. A company earning what once looked like a comfortable operating margin can find its margin erased by a single refinancing date.

Now apply that same math to real estate, because this is where it turns from an abstraction into something we can see and understand. A commercial building purchased in 2016 at a given valuation, financed at a conservative loan-to-value ratio, can find itself, several years later, worth a fraction of its financed amount once capitalization rates reprice and rents underperform projections. The strip mall’s loan doesn’t fail because a couple of tenants left; it fails because the appraiser showed up, and the number on the appraisal no longer supports the number on the note.

To refinance, the borrower has to bring fresh cash to the table — often an amount that doesn’t exist. This single, unglamorous mechanism, repeated nationwide across office buildings, apartment complexes, hotels, and strip retail, is at the core of the disruption headed our way in 2027.

WHAT WAS BOUGHT WITH CHEAP MONEY

Private equity didn’t invent dental consolidation, but it financed an unusually large amount of it during the years when cheap debt was available. The roll-up model depends on leverage: a sponsor borrows against a portfolio of acquired practices, uses the acquired practices' own cash flow to service that debt, and periodically refinances or recapitalizes the credit facility to extract a dividend or fund the next round of acquisitions. It’s a model built entirely on the assumption that credit would stay cheap and available—an assumption that held for most of the 2010s and into 2021, but it no longer holds.

A DSO's line of credit is not a philosophical commitment to a way of practicing dentistry, it’s a financial instrument with a maturity date, a covenant package, and a lender who will revalue the enterprise the same way an appraiser revalues a building — against current cash flow, current interest rates, and current comparable sales, not against the assumptions that were true when the loan was written. When that revaluation reviews a portfolio of practices whose same-practice growth has slowed, whose associate turnover has risen, and whose patient trust has been eroding for years under production quotas and truncated appointment times, the math doesn’t ignore the situation, it punishes it at the worst possible moment, in the most concentrated way, on a date the practice's dentists and hygienists never thought about because it was never any of their business.

Some of these organizations will manage the refinancing without visible disruption. However, some will not, and those that do won’t fail quietly. Debt-for-equity restructurings, sponsor write-downs, and outright practice sales at distressed multiples are not hypothetical outcomes for this sector; they are already underway in smaller form and are likely to accelerate as more of this debt comes due in 2026 and 2027. An associate dentist within one of these organizations may not see the credit problem; they will see its consequences: shortened supply budgets, frozen hiring, sudden changes in ownership, and leadership whose boss just changed without an announcement.

THE ANCHOR LEAVES

There is a particular vulnerability worth considering, because it’s easy to overlook until we have seen it happen: a dental practice, whether independent or DSO-owned, that leases space inside or adjacent to a shopping mall or a large anchor-dependent retail center.

Mall and anchor-retail leases often include a feature that most tenants never think about until it activates: co-tenancy clauses, which allow remaining tenants to renegotiate rent or leave when an anchor store closes. A single department store closure can cascade through an entire property's occupancy and into the loan on the property itself, because that loan was underwritten against a rent roll that assumed the anchor would remain. Retail occupancy costs are fixed by contract. Retail sales, and increasingly the dental patient flow that depends on retail foot traffic, are not. When one falls and the other cannot, the practice incurs an occupancy cost it did not create and cannot control, within a building whose ownership may itself be approaching a rollover squeeze.

A dental practice in this position holds none of the levers of control that matter. It cannot renegotiate its landlord's loan. It cannot prevent an anchor tenant's closure. It cannot control whether the mall's owner sells the property out of desperation, defaults on the underlying mortgage, or hands the keys to a lender who has no interest in dentistry at all. The practice's continuity of location — the single most durable form of patient trust a practice can build over years — becomes contingent on a stranger's balance sheet.

THE ASSET THAT CANNOT BE APPRAISED

What almost none of this touches on, and what is worth pointing out, is the practice built on a different foundation entirely: independent, health-centered, and fee-for-service, with a dentist who has retained control over both the fees charged and the overhead incurred.

This is not a claim that such a practice is immune to a difficult economy. Patients facing their own version of the rollover squeeze — higher mortgage payments, higher auto loan payments, tighter household budgets — will make harder decisions about elective and even necessary care. That pressure is real and will be felt by every kind of practice, corporate and independent alike. But there is a structural difference between a practice absorbing softer patient demand and one doing so while simultaneously carrying a sponsor's leveraged debt toward a refinancing deadline it does not control. One of these is a hard season; the other is a hard season stacked on top of someone else's maturity schedule.

An independent, fee-for-service practice has no covenant to violate, no credit facility to service, no private equity sponsor whose exit timeline depends on this quarter's EBITDA. It can slow down. It can right-size staffing, reduce hours, renegotiate a supply contract, or run leaner for a season, without triggering a default clause or an involuntary sale. This is not a small advantage —it’s the entire advantage. The practice that can flex its own overhead on its own terms, because no outside lender is watching the same numbers with a very different set of incentives, is the practice built to actually survive a squeeze rather than merely hope to outlast it.

L.D. Pankey's notion of "Know Your Work" was never solely about clinical competence. It included an honest accounting of the whole enterprise a dentist is responsible for — the philosophy, the finances, the structure that either protects the work or exposes it. Bob Barkley wrote about the danger of practicing from what he called a slum mentality, a scarcity-driven posture that erodes judgment and self-respect alike. A practice financialized against its own future cash flow, or leased at a mall that is itself approaching insolvency, is increased exposure with better signage. It looks stable until the appraisal comes due.

OWNING THE SPACE YOU PRACTICE IN

There is one further layer of protection worth mentioning: owning your own building.

Every vulnerability described above — the office landlord facing a rollover squeeze on a building financed at 2016 valuations, the mall owner facing co-tenancy cascades and a defaulted mortgage, the regional bank holding both loans and unable to extend patience indefinitely — is a vulnerability that belongs to someone else's balance sheet. It becomes the tenant's problem the moment that balance sheet breaks. A dentist who owns the building they practice inside is not exposed to a landlord's desperation sale, a landlord's default, or a landlord's decision to hand the keys to a special servicer with no relationship to the community the practice serves. The real estate itself is exposed to the same interest-rate environment as everyone else's. Still, the dentist decides to make, on the dentist's timeline, according to the dentist's own philosophy of practice rather than a stranger's covenant.

This is not a claim that every dentist must own real estate to be safe, nor that ownership is costless or simple. It’s a claim about where control resides. A practice can control its fees, its overhead, and, if it owns the building, its exposure to another party's collapse. What it cannot control is a sponsor's refinancing calendar, an anchor tenant's decision to leave, or a landlord's decade-old assumptions about capitalization rates. The difference between these two positions is not a matter of degree; it’s the difference between a practice that can adapt its way through a hard season and a practice that discovers, on someone else's schedule, that adaptation was never available.

None of this necessitates panic, and none of it requires prediction of exactly when or how severely these maturities will land. What it does require is an honest look at where a practice's stability rests — on trust and clinical judgment built patient by patient over years, which cannot be called, cannot mature, and cannot be repriced by an appraiser, or on someone else's leverage, someone else's lease, someone else's date on a calendar that was never shared with the people who are actually doing the work.

Which one is your practice standing on? And if you are not certain, what would it take to find out before the date arrives rather than after?

 Paul A. Henny, DDS practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

Know Yourself is the foundation Pankey and Barkley placed first for a reason. It has to come before Know Your Patient, but it was never meant to stand alone.

Most of us who grew up in stable, reasonably healthy homes carry an unexamined assumption into adulthood: that other people —for the most part— are like us. We extend the benefit of the doubt automatically, because doubt was rarely required of us. Nobody had to teach us to read a room for danger. Nobody had to teach us that a smile could be a strategy. This is a natural inheritance, and it shouldn’t be apologized for — but it’s also a blind spot, and blind spots are expensive in a small practice.

Some people are simply difficult. Some are harmful. A few are quietly destructive to everyone around them, yet appear entirely reasonable. Learning to recognize the patterns beneath their behavior isn't cynicism — it's the second half of emotional intelligence, the half that keeps the first half from being naïve.

THE JUDGE

The person who is extremely judgmental of others is typically extremely judgmental of themselves. Their running commentary on everyone else's inadequacy is rarely about the other person — it's often a projection of self-loathing. Elevating themselves by diminishing others is the only mechanism they've found to create a tolerable self-regard. Carl Jung would say the disowned parts of the self, exiled from awareness, get relocated onto whoever is standing nearby.

THE LIAR

Frequent liars are not strategic manipulators enjoying the game. They are people unable to bear the truth about themselves, so they construct a persona to hide behind. The lie is a shield — not against being caught, but against the shame of being seen. Every fabrication is a small, exhausting act of self-protection from a self they've already convicted.

THE NEUROTIC

Neurotic individuals experience the world as fundamentally untrustworthy and disordered. Consequently, managing fear becomes their full-time internal occupation. What looks like assertiveness — the need to categorize, to control, to pin every person and situation into a predictable box — is actually a coping mechanism for chaos they feel is always one step from breaking through.

THE BULLY

Bullies climb the social hierarchy by pushing others down. It is a learned behavioral pattern in service of a felt inferiority, and the aggression — physical or verbal — is mostly theater staged to convince an audience — and themselves — of a superiority they do not privately believe. Underneath the performance sits shame, and beneath the shame sits a hunger for validation so old it precedes the behavior by years. The unlovable are the ones who need love the most; it is one of the harder truths to hold onto when we are in the room with them.

THE PERPETUAL VICTIM

Perpetual victims are starved for love, validation, and attention, and lacking a foundation of self-worth, they've learned that sympathy is available when competence or personal accountability doesn’t exist. Victimhood becomes a reliable form of social currency. The tragedy is structural: the strategy used to get attention also guarantees the person stays exactly where they are, because helplessness cannot ask for help without ceasing to be helplessness.

THE CYNIC

Deep cynicism is fear wearing the costume of wisdom. Having decided that risk ends only in failure, the cynic pre-empts disappointment by refusing to want anything in the first place. The negativity isn't really about the world being disappointing — it's a permission structure that justifies a status quo that leaves them unhappy but, crucially, safe.

THE TRIANGULATOR

Triangulators are often quietly empty, and gossip — criticizing a third party to a second party — gives them a fast, cheap hit of superiority. It costs someone else their reputation every time, and it’s one of the most corrosive forces a practice culture can absorb, because it launders cruelty as concern and spreads faster than almost anything else in a small organization.

In general, people hurt others because they are hurting themselves. Understanding that doesn't excuse the behavior — but it does allow us to stop taking it personally.

Their pain belongs to them. It was there before we walked into the room, and it will be there after we leave it. We are not its cause; hence, we are not obligated to be its cure.

What we are responsible for is our practice — its culture, our team, and the mission it was actually built to serve. Compassion for the wounded person’s behavior and tolerance for it are two different things. Health-centered dentistry depends on being able to hold both without confusing them. Recognizing these patterns early is often the difference between hiring well and hiring around a problem we’ll spend years managing. It's frequently the difference between a slow culture erosion we can’t quite name and a team that trusts each other enough to do the actual work of CoDiscovery — because CoDiscovery, like any relational practice, cannot survive being triangulated, bullied, or lied to from the inside.

Know Yourself comes first. But the discipline doesn't end there, and it was never meant to.

Who, in your practice right now, are you extending automatic benefit of the doubt to — and what would you see if you looked a second time?

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

Bob worked with Nathan Kohn, Jr. PhD to apply Peter Drucker's laws of management, which involved a combination of strategic thinking, a patient-centered focus, and effective leadership. Here are some of the ways Bob Barkley applied what he had learned, each starting with a Drucker quote:

“The purpose of business is to create and keep a customer.”

Focus on understanding the wants and needs of each patient, with a mindset that acknowledges that most relationships begin with a person ‘not knowing what that don't know,’ hence, most people are incapable of making values-driven decisions until their understanding of their problem is elevated to a level that the information is meaningful, relevant, and timely. That was achieved through the application of CoDiscovery and CoDiagnosis —processes pioneered by Bob and Nate. This allowed Bob to create solutions to problems that his patients wanted addressed. On this topic Bob famously said, “Dentists accel at recommending solutions to problems that patients do not yet know they have —and that, in and of itself, is a problem.”

CoDiscovery and CoDiagnosis help build strong trustworthy relationships that allow each person to navigate the complexity of their problem(s), better understand their options, and co-create solutions that are effective and durable over time.

“Results are gained by exploiting opportunities, not by solving problems.”

A problem is not a problem unless the person with the problem thinks so — they start to believe that it is what Bob referred to as a ‘personal problem.’ This means the initial task at hand for a truly health-centered care team is to help each person understand the personal relevance of negative clinical findings (short and long-term implications and what they mean to the person). This can take some time, perhaps several visits and several conversations that circle more deeply around the value of pursuing various solutions, particularly when a person’s situation is complex and requires a multidisciplinary approach. Hence, without solid, respectful, caring relationships, none of this is revealed, and more sophisticated decisions are rarely made. Which then leads to frustrated care teams and patients alike —the central psychological problem present in most dental practices today.

“There is nothing so useless as doing efficiently what should not be done at all.”

Dentists are creatures of habit. Consequently, we find a lot of comfort in maintaining the status quo. Yet, what happens when the status quo is too often rendering outcomes we don't want or like? Most dentists and teams respond to this issue by blame-shifting: “He obviously doesn't share our practice values,” “I really don't think she cares whether or not she has teeth in five years —she’s making no effort whatsoever,” “He only wants to do what his insurance covers. Obviously, he doesn't care at all about his long-term dental health.” —we take our values, project them onto others and when they don’t stick —we judge, instead of looking at how the relationship began and whether or not it was appropriately developed.

“Regularly evaluate processes and activities.”

Are we doing the right things at the right times, for the right reasons? These questions are at their core, philosophical questions. So, if a practice isn’t regularly discussing it’s philosophy and application (its Purpose), then it is likely focused on maintaining the status quo —something they don’t particularly like.

“What gets measured gets improved.”

Establish clear key performance indicators (KPIs). Track and analyze metrics regularly.

Use data to inform decision-making and drive improvements.

“The aim of marketing is to know and understand the customer so well the product or service fits him and sells itself.”

Everything we do is marketing —marketing in ways that help us achieve our goals - or not. Marketing is not “selling,” it's much more sophisticated than that, it's an ongoing strategy that needs to be grounded in a philosophy. Therefore, marketing is developmental, whereas selling is an event.

“Culture eats strategy for breakfast.”

It all begins —and ends— with how people feel. That means first how the care team feels about the meaning and value of their work, and then how patients respond to those feelings —hence, that’s how their attitude toward us and the practice evolves. Are we perceived as kind? Helpful? Understanding? Compassionate? Patient? Health-centered? Goal-oriented?

—or—

Cold, transactional, insurance-centered, manipulative, disconnected, unresponsive, and so forth.

How people feel about their work environment and situation creates the practice culture. The practice culture influences patient behavior —hence, their decision-making.

“If you want something new, stop doing something old.”

It's simple, if you want to experience change, you need to change some things, which includes no longer doing things that are undercutting the advancement toward your Vision of an ideal practice.

“Management is doing things right. Leadership is doing the right things.”

Leadership is all about creating disciples —people who buy into our “why,” and subsequently support and advance our practice’s long-term goals. “Management” is something else. Most DSO’s are good at management and weak on leadership. That's our strategic advantage in a nutshell —if we understand and know how to do both.

”Efficiency is concerned with the inside. Effectiveness is concerned with the outside.”

Management is focused on efficiency, leadership is focused on long-term effectiveness. How influential are we with regard to helping others make better decisions? — teammates and patients alike. When we focus on delivering value to our patients (from their perspective) we create more preferred outcomes for everyone over time.

“The best way to predict the future is to create it.”

Discover and develop your vision of an optimal future in dentistry, and then keep your shoulder on it, while remaining open and flexible to the realities of life. Sailboats never sail directly to their final destination, they tack to and fro, working with wind, weather, and physical conditions until they goal is achieved. A philosophically-driven practice is no different.

It is worth asking why we should organize our professional lives around appeasing those least inclined to reciprocate our efforts.

Respect is a basic form of human decency. It costs nothing. Unless someone has intentionally — and we are certain of it — done something genuinely wrong to us, there is no legitimate reason to withhold it. This is not a complicated ethical position; most of us learned it before we learned long division. And yet the failure to extend ordinary respect, when it happens, is never a neutral event —it’s a disclosure. A person's treatment of someone who has done nothing to deserve mistreatment is one of the most reliable windows available into their actual character — far more reliable than what they say about themselves, and considerably more reliable than how they behave toward people they need something from.

When someone chooses to be disrespectful largely without cause, or over something entirely outside our control, they are showing us exactly who they are. The showing is usually involuntary. Healthy, grounded people do not go out of their way to belittle, mock, or diminish others — not even when they are smarter, richer, or hold a higher rung on whatever social ladder is being measured that day. They manage themselves, even when angry, even when frustrated, even when disappointed. The management is not a performance; it’s simply what a person with emotional maturity does under stress. Disrespect, by contrast, is what happens when emotional regulation is absent — and absence of regulation is not a personality trait to admire or a form of honesty to respect. It is a deficit.

Contempt is rarely spontaneous. It is usually a strategy that has been rewarded — repeatedly, and by people who had every reason to hold their ground and did not. Every unwarranted apology extracted through pressure, every concession granted to make the discomfort stop, every time a dentist absorbed an insult rather than risk the review, teaches the same lesson to the person delivering it: this works.

Contempt, deployed skillfully, functions as a power move. Its real target is rarely the specific complaint on the surface. Its real target is our position — an attempt to force an admission, however small, that they stand above us: intellectually, financially, or socially. The complaint is the vehicle, and submission is the goal.

This is where the modern vocabulary of “authenticity” can become problematic. “I'm just being honest — you need to get over it” has become a familiar refusal to be held accountable for cruelty, dressed up as candor. But there is a meaningful difference between honesty and unregulated emotional behavior, and the difference isn’t subtle once we know what to look for: honesty serves the purpose of seeking the truth; unmanaged emotional discharges serve only the person doing the discharging. What gets called authenticity in those moments is usually closer to its opposite — a person who has never done the inner work of examining the motives behind their behavior.

This pattern — emotional immaturity that attempts to outrank another person's basic dignity — is narcissistic; a helpful way to describe a person who is convinced their feelings matter more than anyone else's in the room. When allowed, that tendency raises its voice, hurls insults, and works quite deliberately to undermine another person's sense of self-worth.

Carl Jung said that what a person cannot bear to see in themselves does not disappear — it gets relocated. It shows up projected onto whoever happens to be standing closest, usually someone with less power to push back in the moment: the person at the front desk, the assistant reviewing the treatment plan, the dentist delivering news the patient does not want to hear. The disrespect in these encounters is rarely about us. It’s a person's inner conflict finding somewhere to land because it has nowhere else to go. Understanding this does not obligate us to accept it. If anything, it clarifies exactly why it cannot be tolerated: excusing the behavior does not neutralize the projection; it reinforces the pattern that produces it — for this kind of person, and for the next practice or professional or partner unlucky enough to be standing in the blast radius after us.

Respect that is situational is not respect at all; it is a transaction wrapped in manipulation.

True respect, the kind worth building a practice or a life around, comes from people who value us, our effort, and our intentions — including during the moments when we make a mistake or a misunderstanding occurs, because respect that only exists when everything is going well was never respect in the first place, it was compliance under good conditions.

For a dental practice, this is not an abstraction to be nodded at and set aside — it is an essential operating principle. Setting healthy interpersonal boundaries is the only way to run a healthy culture. That means deliberately building systems and processes designed to protect the practice and the people in it from this particular category of person, rather than leaving each team member to absorb the impact individually without support. It means having the self-respect to say that you and this person disagree, and to walk away from the relationship without needing the other party's approval.

And it means doing it early. The deeper a person like this is allowed into our life or our practice, the more damage accumulates, and the harder — practically, financially, emotionally — the extraction becomes. Waiting for the “right moment” to address consistently antisocial behavior is usually just rationalizing fear. The right moment was the first moment the pattern repeated itself.

This is a simple fact of professional life, even if the culture surrounding reviews and reputation has made it feel complicated. Some people cannot be treated well enough to stop treating us badly. The sooner we learn how to recognize these moments, the less it costs us to take appropriate action.

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

There is a version of this appointment where we give her what she is asking for. We could soften meaning of the numbers, use the word "watch" instead of "treat," tell her we'll "keep an eye on it," and send her home smiling. She would thank us. She would tell her husband we were wonderful. She would come back in six months no wiser than she left, and at some point — not today, but eventually — the bill for our niceness would come due, and she would pay it in a lost molar, or a bone graft, or a diagnosis she should have heard two years earlier.

That is the appointment we did not have. But we have had versions of it, and so has every clinician who has ever felt the small, specific relief of a patient's approval and mistaken it for having done the job well.

THE PERSONA OF NICE

The distinction, stripped to its core, is this: nice is an attempt to please or placate. Kind is a commitment to the pursuit and sharing of truth. Niceness asks, "What can I say right now that will make this person feel good about this moment?" Kindness asks a harder question: "What does this person need to know or see in order to actually become healthier?" The two questions can produce the same sentence. They just as often don't — and when they diverge, those of us who have never separated them in our mind will default to whichever one keeps the room comfortable.

Jung had a word for the face we present to keep social relations smooth: the persona. It is not dishonesty — it is adaptive, a genuine tool for living among other people without friction at every turn. But a persona held too tightly stops being a tool and becomes a hiding place. The nice dentist is, more often than we'd like to admit, a persona in this second sense: pleasant, agreeable, careful never to introduce a feeling the patient didn't ask for; it’s a professional self built to be liked.

The trouble is that being liked and being helpful are only sometimes the same thing. Niceness, in its degraded form, is strategic avoidance. It optimizes for the next ninety seconds of the encounter — the patient's comfort, and our discomfort.

Kindness is a different animal. Kindness is oriented toward the other person's real good, not their momentary comfort, and it is willing to spend some of its own social capital to get there. It will risk the smile. It will say the sentence that makes the room go quiet for a second. The nice thing and the kind thing overlap often enough that it’s easy to forget they are different verbs — until the moment they don't, and only one of them will truly serve the person sitting in the chair.

THE THIRD CONDITION

Carl Rogers, whose work on the therapeutic relationship shaped so much of what health-centered dentistry has learned from psychology, named three conditions necessary for another person to change and grow: empathy, unconditional positive regard, and congruence. The first two get quoted constantly in clinical education, the third gets quietly dropped.

Congruence is genuineness — the dentist’s inner experience and outer expression matching, with no gap between what is seen and what is said. Rogers was explicit that congruence isn't optional, without it, the other two fail. Warmth without honesty is just a very sophisticated form of manipulation. A dentist can radiate empathy and unconditional positive regard while withholding the one thing — the actual clinical truth — that would let the patient exercise any agency at all. That dentist has two of the three conditions and has therefore failed to create the relationship that allows a person to change.

WHAT THE NERVOUS SYSTEM ALREADY KNOWS

Patients are not naive audiences for our performance of niceness. Long before conscious appraisal, their nervous system is running a continuous, largely unconscious calculation about whether we are safe to trust — what polyvagal theory calls neuroception, and what predictive-coding models describe as the brain constantly checking incoming signals against its running model of: “Is this person congruent?” A softened diagnosis delivered with too much cheer doesn't read as reassurance, it reads, on some pre-verbal level, as a mismatch — and mismatches are what the threat-detection system is built to notice.

Patients extend trust to those who are truly recognizable — whose warmth and whose words point in the same direction. A dentist who is nice but incongruent is, without meaning to be, training the patient's nervous system to distrust the practice's warmth generally, because the warmth has already proven it will bend around an uncomfortable truth once. It will do it again.

CODISCOVERY: KINDNESS WITHOUT COERCION

None of this is an argument for bluntness. There is an effective way to tell the truth. This is where CoDiscovery earns its name. It is not the withholding of truth in the name of comfort, and it is not the imposition of truth in the name of honesty. It is the patient seeing the truth themselves — guided, unhurried, through their own eyes via an intraoral camera, their own radiographs, their own words as they describe what they're looking at. The dentist's job is to make the truth visible and let the patient arrive at it, rather than to either soften it into invisibility or hand it over as an accusation. That is what allowing someone to see the truth so they can make a better decision actually looks like in practice: not a lecture, and not a euphemism, but a doorway the patient walks through under their own power.

She did not, in the end, get the reassurance she came in hoping for. What she got instead was someone she could see for herself, a conversation that didn't rush past the parts that mattered, and — eventually, once the quiet had passed — a plan she chose rather than one she was issued. I don't know if she left thinking I was nice. I know she left knowing more than she did an hour before, which was never a promise I could keep to her and be nice about at the same time.

The question worth considering is not whether we are kind people —most of us are. It is which patient today received our niceness when they needed our kindness — and whether we would recognize the difference if we felt it happening in real time.

Paul A. Henny, DDS practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

I have come to think of these as three fields of vision, three different ways of looking that a dentist-leader must learn to move between, almost without noticing the shift. Fail to develop any one of them, and the other two eventually go blurry too. They are not separate disciplines so much as three parts of an essential whole.

INTROSPECTION: SEEING THE SELF

We must regularly step back and look at ourselves and our behavior objectively, then filter what we see through our value system and reference it against our priorities. This is a constructive habit, like a pilot's instrument check. Without it, we become rudderless, too easily pushed around by trends, emotions, misconceptions, and outdated beliefs we absorbed so long ago we mistake them for our own conclusions.

L.D. Pankey called this “Know Yourself,”and placed it first for a reason. A dentist who has not done this work will still show up, still treat patients, still meet production numbers most weeks — but he will be borrowing his direction from whatever pressure happens to be loudest that day: an insurance company's reimbursement schedule, a consultant's script, a competitor's Facebook ad, his own unexamined fear of an empty afternoon. None of these are values. They are just noise wearing the costume of urgency.

Introspection is what lets a person distinguish between what they actually believe and what is easiest to believe today.

Practiced honestly, introspection is not a burden — it is what allows each morning to arrive as a genuinely new creation, rather than a rerun of yesterday's reactivity.

OTHER-CENTERED MINDSET: SEEING THE PATIENT

As health care providers, our primary focus must be on helping others become — and learn how to become — healthier. At its core, this is a philosophy of living and of how we see other people. Without it, we function inside an imaginary world: dualism.

Dualism is the psychological cleavage of a person into two—a reductionist frame that quietly colors everything we believe about health, illness, why people do what they do, and how (or whether) people change over time. Western medicine trains us to consider the body almost in isolation from the mind, and the mind almost in isolation from the environment that shaped it — the relationships, work, love, and loss a person has actually lived inside. We learn to examine a mouth as though it arrived in the operatory unaccompanied by a life.

Most of us absorbed this orthodoxy without ever choosing it. It was simply the water everyone around us was swimming in during training, and it slipped into practice culture unexamined — because that was how everyone we respected thought and behaved. It becomes remarkably easy, inside that water, to think of patients as procedures: “MO composite #2 at 10:00, remember she's a gagger.” As problems to be managed. As pathways toward a production goal. Instead of what they actually are — unique individuals carrying fears, barriers, thoughtless habits, and goals, some of which look nothing like our own.

When we lose the sensitivity to see and feel patients as people rather than objects, we frequently go a little clueless in the interaction itself — and then, almost reflexively, we rationalize that cluelessness after the fact. “He obviously doesn't share our practice values.” “She's only interested in what her insurance covers — don't waste your breath.” These lines feel like clinical judgment. They are usually dualism, finishing the sentence dualism started.

There is no dualism inside a real conversation. The mind and body, the fear and the habit, the goal and the barrier — they all show up in the same sentence, spoken by the same person.

Pankey's second discipline, Know Your Patient, is the corrective — and it is worth noticing that it cannot be practiced from a distance. It requires the kind of unhurried, curious conversation that CoDiscovery is built around: not extracting information from a patient, but discovering, together, who this particular person is and what health would actually mean in the context of the life they are living.

OUTWARD MINDSET: SEEING THE GESTALT

The third field of vision is the ability to see the greater gestalt — a German word meaning “form” or “shape,” the sense of a whole that is more than the sum of its parts. Great leaders look out into their local community and culture, reading its needs and emerging trends. They visualize how their work — their purpose — fits into, and synchronizes with, those needs. Then they synthesize what people are likely to want and desire, and build their business model around that visualization, iteratively, revising as the picture sharpens. Think Steve Jobs, who famously built toward desires people had not yet articulated to themselves.

This is Know Your Work in its fullest sense — not merely technical mastery of dentistry, but mastery of the context dentistry is practiced inside. A gestalt view asks what this community actually needs from health care right now, what it is quietly hungry for, and how a practice's particular philosophy might meet that hunger before the community itself can name it. It is the difference between reacting to whatever walks through the door and building something people did not know to ask for until they encountered it.

Leaders who never develop this outward mindset tend to run a very good version of yesterday's practice. They mistake local for global and today for permanent. The gestalt view is what lets a practice keep its philosophy intact while its form — its systems, its offerings, its language — continues to evolve to meet a world that has not stopped changing since the day the doors opened.

THE INSTRUMENT, NOT THE SETTINGS

Focusing on mastering these three key areas of leadership helps align our future with our desires. And when our desires align with our care team's, we can ride that wave to the top.

But notice what actually holds the three together. Introspection without an other-centered mindset produces a leader who is deeply self-aware and still fairly useless to the person in the chair. An other-centered mindset without introspection produces a leader who means well but keeps unconsciously reenacting whatever unexamined belief is steering them that week. And an outward mindset, without either of the first two, produces something closer to a trend-chaser than a visionary — synchronized with the market, perhaps, but with no stable center from which to meet it.

The three are really one continuous act of attention, aimed in three directions: inward, toward the person across from us, and outward toward the world both of us are standing in. Which direction has your attention been avoiding lately — and what has that avoidance been costing the people who are counting on you to see clearly?

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

EPISTEMIC CONFIDENCE

The first kind is epistemic confidence — certainty. “I know this is true, because I was taught it, and I've seen it work.” It's belief associated with memory and experience, largely a left-hemisphere phenomenon, and notoriously hard to dislodge without new information, new logic, or new experience strong enough to overturn what came before. That stubbornness is a double-edged sword. In a profession changing as fast as ours — materials, imaging, the evidence base on airway and the oral-systemic connection — clinging too long to how things used to work, or what we knew can become a liability disguised as expertise.

SOCIAL CONFIDENCE

The second kind is social confidence — self-assuredness. It's the sense of feeling “comfortable in one's own skin,” of having earned a place in the room, of speaking with a level of composure that makes people want to keep listening. It has almost nothing to do with certainty and almost everything to do with self-regard.

The most effective leaders in dentistry — and in any field for that matter — are high in social confidence. They're educated, experienced, they hold a clear vision of where they're headed, and their belief systems stay adaptable rather than fixed. They're proactive rather than reactive. Listen to the difference:

“I know the numbers were a little off this month, but let me tell you why, and how we're trending in the bigger picture — and where I intend to take this practice over the next five years.”

“The numbers are down this quarter. I'm disappointed in our performance, and it's clear everyone needs to try harder to hit the goals I've set. If we can't, I may need to make some changes.”

The first sentence is leadership: flexible epistemic confidence paired with genuine social confidence. The second is management dressed up as leadership — fear-based, low-trust, command-and-control. It substitutes attempted manipulation for the kind of social confidence that makes people want to follow you because they sense you have their best interests at heart.

Jeff Bezos put it plainly: “People who are right a lot change their minds often.” Great leaders hold the bigger picture in mind even in hard seasons, because they believe in themselves and in the people they've selected and developed. That belief lets them respond with creativity instead of control. They aren't afraid to say “I'm not sure.” And because of that, rather than in spite of it, people actually listen to them — not out of obligation, but because they've built disciples: people who believe in the vision and in the person advancing it.

Social confidence also shows up in how we carry ourselves. Benjamin Franklin is the classic case. He was famously charming, witty, and warm — and he paired all of it with humility, a habit he built deliberately as a young man after noticing that people pushed back harder whenever he used certain words. “Certainly.” “Undoubtedly.” So he retrained himself to say, “I think...” or “If I'm not mistaken...” instead.

WHAT PATIENTS SENSE

This matters for an uncomfortable reason: patients judge us primarily on social confidence, not on our clinical skill, because most have no way to evaluate the latter. That's how a financially successful practice can coexist while producing mediocre dentistry — people can't easily tell the difference between good clinical work and a confident presentation, but they can absolutely feel comfort or discomfort in a room.

Dr. Pankey addressed the danger in that gap directly: “You need to have it on the shelf before you sell it.” It's one thing to project ease and security, it’s quite another to let that ease substitute for the technical competence a patient is trusting you to possess. That's the line between social confidence and manipulation, and it's a line some practices cross without ever noticing they've crossed it.

Dr. Jeff Baggett’s phrase for the honest alternative is that, “practice development should be evolutionary, not revolutionary” — a humbling acknowledgment that confidence has to be built the slow way, skill by skill, so the cart of clinical self-assurance never gets ahead of the horse of actual clinical ability.

None of this means “faking it until you make it,” or manufacturing swagger you haven't earned. Social confidence is buildable without self-deception: how we communicate, how we present ourselves physically in the room. Are we having a potentially life-altering conversation from behind a mask, with loupes dangling around our neck?

THE HONEST WAY TO INSPIRE A DECISION

There's a final piece of this worth examining, especially now, with so much technology mediating how patients form beliefs before they ever sit in the chair. We can inspire people toward better decisions without overpromising. We can paint a vivid, honest picture of the outcome we're offering. We can speak plainly about why we believe it matters. We can share real stories of people similar decisions have helped. None of that requires the false certainty of epistemic overreach — the “this will definitely work for you because it worked for the last patient” trades honesty for a authority.

The most effective communication we have is honest, delivered from the heart, and carried with a real dose of humility — because we’re never the expert on another person's life —they are. The decision in front of them is theirs to make, not ours to make for them, particularly if our philosophy is to improve our patients’ health over the long run.

CoDiscovery works for exactly this reason. It doesn't ask a patient to accept our epistemic confidence on faith, it invites them into a shared, honest look at their own situation, their own life, their own values — and lets whatever confidence we've genuinely earned speak for itself, in a way the patient feels is trustworthy.

Paul A. Henny, DDS practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

EPISTEMIC CONFIDENCE

The first kind is epistemic confidence — certainty. “I know this is true, because I was taught it, and I've seen it work.” It's belief associated with memory and experience, largely a left-hemisphere phenomenon, and notoriously hard to dislodge without new information, new logic, or new experience strong enough to overturn what came before. That stubbornness is a double-edged sword. In a profession changing as fast as ours — materials, imaging, the evidence base on airway and the oral-systemic connection — clinging too long to how things used to work, or what we knew can become a liability disguised as expertise.

SOCIAL CONFIDENCE

The second kind is social confidence — self-assuredness. It's the sense of feeling “comfortable in one's own skin,” of having earned a place in the room, of speaking with a level of composure that makes people want to keep listening. It has almost nothing to do with certainty and almost everything to do with self-assuredness.

The most effective leaders in dentistry — and in any field for that matter — are high in social confidence. They're educated, experienced, they hold a clear vision of where they're headed, and their belief systems stay adaptable rather than fixed. They're proactive rather than reactive. Listen to the difference:

“I know the numbers were a little off this month, but let me tell you why, and how we're trending in the bigger picture — and where I intend to take this practice over the next five years.”

“The numbers are down this quarter. I'm disappointed in our performance, and it's clear everyone needs to try harder to hit the goals I've set. If we can't, I may need to make some changes.”

The first sentence is leadership: flexible epistemic confidence paired with genuine social confidence. The second is management dressed up as leadership — fear-based, low-trust, command-and-control. It substitutes attempted manipulation for the kind of social confidence that makes people want to follow you because they sense you have their best interests at heart.

Jeff Bezos put it plainly: “People who are right a lot change their minds often.” Great leaders hold the bigger picture in mind even in hard seasons, because they believe in themselves and in the people they've selected and developed. That belief lets them respond with creativity instead of control. They aren't afraid to say “I'm not sure.” And because of that, rather than in spite of it, people actually listen to them — not out of obligation, but because they've built disciples: people who believe in the vision and in the person advancing it.

Social confidence also shows up in how we carry ourselves. Benjamin Franklin is the classic case. He was famously charming, witty, and warm — and he paired all of it with humility, a habit he built deliberately as a young man after noticing that people pushed back harder whenever he used certain words. “Certainly.” “Undoubtedly.” So he retrained himself to say, “I think...” or “If I'm not mistaken...” instead.

WHAT PATIENTS SENSE

This matters for an uncomfortable reason: patients judge us primarily on social confidence, not on our clinical skill, because most have no way to evaluate the latter. That's how a financially successful practice can coexist while producing mediocre dentistry — people can't easily tell the difference between good clinical work and a confident presentation, but they can absolutely feel comfort or discomfort in a room.

Dr. Pankey addressed the danger in that gap directly: “You need to have it on the shelf before you sell it.” It's one thing to project ease and security, it’s quite another to let that ease substitute for the technical competence a patient is trusting you to possess. That's the line between social confidence and manipulation, and it's a line some practices cross without ever noticing they've crossed it.

Dr. Jeff Baggett’s phrase for the honest alternative is that, “practice development should be evolutionary, not revolutionary” — a humbling acknowledgment that confidence has to be built the slow way, skill by skill, so the cart of clinical self-assurance never gets ahead of the horse of actual clinical ability.

None of this means “faking it until you make it,” or manufacturing swagger you haven't earned. Social confidence is buildable without self-deception: how we communicate, how we present ourselves physically in the room. Are we having a potentially life-altering conversation from behind a mask, with loupes dangling around our neck?

THE HONEST WAY TO INSPIRE A DECISION

There's a final piece of this worth examining, especially now, with so much technology mediating how patients form beliefs before they ever sit in the chair. We can inspire people toward better decisions without overpromising. We can paint a vivid, honest picture of the outcome we're offering. We can speak plainly about why we believe it matters. We can share real stories of people similar decisions have helped. None of that requires the false certainty of epistemic overreach — the “this will definitely work for you because it worked for the last patient” trades honesty for a authority.

The most effective communication we have is honest, delivered from the heart, and carried with a real dose of humility — because we’re never the expert on another person's life —they are. The decision in front of them is theirs to make, not ours to make for them, particularly if our philosophy is to improve our patients’ health over the long run.

CoDiscovery works for exactly this reason. It doesn't ask a patient to accept our epistemic confidence on faith, it invites them into a shared, honest look at their own situation, their own life, their own values — and lets whatever confidence we've genuinely earned speak for itself, in a way the patient feels is trustworthy.

Paul A. Henny, DDS practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

Staff compensation is higher. Laboratory costs are higher. Supplies are higher. Technology is constantly expanding. Equipment costs are higher. Utilities, rent, insurance, compliance, software subscriptions, and virtually every other expense required to operate a modern dental practice are significantly higher. But one number has not moved nearly as quickly: What many third-party payers are willing to reimburse dentists for providing quality care.

This is no longer merely anecdotal. The American Dental Association's Health Policy Institute is now documenting the phenomenon and has given it an appropriate name: the fiscal squeeze.

Understanding what is happening may be one of the most important issues facing dentists today.

INFLATION CHANGED THE VALUE OF A DOLLAR

Consider what has happened since 2020. According to the U.S. Bureau of Labor Statistics Consumer Price Index, cumulative inflation from January 2020 through mid-2026 has been approximately 29%. In practical terms, something that cost $100 at the beginning of 2020 would require roughly $129 today to purchase the same amount of goods and services. That distinction is important because we tend to think about fees in nominal dollars rather than real purchasing power.

Suppose an insurance company allowed $100 for a particular procedure in 2020. And suppose that allowance eventually increased to $105. On paper, the dentist received a raise —five percent. But in terms of pay, the dentist didn't receive a raise at all. If approximately $129 is now required to purchase what $100 could buy in 2020, then receiving $105 represents a substantial decline in purchasing power.

That's the part of the PPO discussion that’s often missed. The relevant question isn't simply, “Did my fee schedule increase?” The more important question is, “Did my reimbursement increase enough to maintain its economic value?” For many dentists, the answer is clearly “no.”

THE ADA IS NOW DOCUMENTING THE PROBLEM

The ADA Health Policy Institute's State of the U.S. Dental Economy, Q1 2026 states the issue plainly: “Prices for dental equipment and supplies are rising while reimbursement rates are not.” After adjusting for inflation, practice expenses are rising substantially faster than reimbursement.

This isn't simply about supplies. The largest expense in most dental practices is personnel. Dentists are competing for hygienists, assistants, administrators, and other skilled employees in a labor market that has changed dramatically over the past six years.

The ADA reports persistent recruitment problems, particularly in dental hygiene. Its workforce analysis succinctly describes the fundamental problem: “…practice costs are increasing while reimbursement remains comparatively stagnant, producing margin compression and limiting practices' ability to raise wages.”

So, a dentist can easily get caught in the middle. Their hygienist needs a raise. Their assistant needs a raise. Their laboratory raises its fees. Their supply company raised its prices. Their software company increases its subscription fee. Their landlord increased the rent. Their liability insurance went up, and their equipment now costs more to both repair and replace.

Everyone who sells them something is essentially free to adjust their prices to reflect the current economic reality. But they can’t, because they signed a PPO contract that sets fees at nearly the same level as six years ago. That creates an increasingly problematic economic asymmetry.

AND THE PROBLEM IS COMPOUNDING

A small reimbursement gap in one year may not appear particularly threatening; but the difference compounds. Imagine that the economic cost of delivering dental care increases by 4 or 5 percent annually while reimbursement increases by 1 or 2 percent. The practice may absorb the difference initially. Then another year passes, and another. Eventually something has to give. Perhaps the dentist works faster. Perhaps hygiene appointments become shorter. Perhaps more patients need to be seen each day. Perhaps the practice adds more operatories. Perhaps treatment is down delegated wherever legally possible. Perhaps the dentist is forced to focus more intensely on daily production. Perhaps more procedures need to be performed each day to generate the needed economic return.

None of those responses necessarily means the dentist has become less caring. More likely, they represent adaptations to a reimbursement model that increasingly rewards volume, and punishes interpersonal time. And therein lies the deeper problem. Economic systems eventually shape clinical systems and practice philosophies.

THE INVISIBLE CONSEQUENCE: TIME

Dentistry isn't merely a collection of procedures. At its best, dentistry is successful health-centered relationships between human beings. Understanding someone's health history takes time. Listening takes time. Comprehensive diagnosis takes time. Co-discovery takes time. Helping patients understand the implications of their present condition takes time. Discussing alternatives takes time. Allowing patients to determine what matters to them takes time. Building trust takes time.

But time becomes increasingly expensive when reimbursement fails to keep pace with the cost of providing it. Consequently, the financial pressure created by stagnant reimbursement can quietly push practices toward a different model: more patients, more procedures, more speed, more delegation, more production per hour.

The accountants may call this efficiency, but there is a point at which efficiency begins competing with the very things that make healthcare personal, effective, and affective.

DENTISTS ARE BEGINNING TO RESPOND

Our profession appears to recognize this problem. In the ADA's Q4 2025 economic survey, dentists were asked about their biggest challenges heading into 2026.

55.3% identified insurance-related issues — including low reimbursement — as one of their top three concerns. Staffing followed at 54.2%, while increasing overhead and expenses were cited by 41.5%.

These issues aren't independent, they are interconnected. Higher labor costs would be considerably easier to absorb if reimbursement increased proportionately. Higher supply costs would be easier to absorb if reimbursement increased proportionately. Investments in technology would be easier to make if reimbursement increased proportionately. But when costs rise faster than revenue per unit of service, profit margins inevitably thin or disappear entirely.

Dentists then face a relatively limited number of choices. They can reduce expenses. They can increase volume. They can increase the amount of dentistry performed per patient. They can negotiate better reimbursement —if possible. Or, they can reconsider their participation in insurance networks.

That last option appears to be receiving increasing attention. ADA reporting indicates that more than one-third of dentists surveyed planned to drop at least some dental insurance networks going into 2026.

That should tell us something.

THIS ISN'T AN ARGUMENT AGAINST INSURANCE

It is important to make a distinction. Dental insurance has helped millions of people access dental care. Many employers genuinely want to provide meaningful dental benefits to their employees, and many dentists have successfully built practices incorporating PPO participation.

The question isn't whether dental insurance is inherently good or bad. The better question is: Does a particular contractual relationship(s) continue to support the kind of dentistry you want to provide?

That's a very different question.

The ADA itself recommends that dentists periodically review their contracts, negotiate individually where possible, and determine whether participation continues to meet the clinical, financial, and operational needs of their practices.

Clinical. Financial. Operational. Not merely financial — because our practice model and our economic model cannot be separated.

EVERY CONTRACT HAS AN OPPORTUNITY COST

When dentists evaluate PPO participation, they often focus on one number: How many patients will I lose if I leave this network? That's understandable, but it isn't the only relevant question. We should also ask: What does participation cost me? How much dentistry am I writing off annually? How many additional patients do I need to see to compensate for those write-offs? How much additional staff capacity does that require? How much additional administrative work does insurance participation generate? How much clinical time must be compressed to make the math work?

And perhaps most importantly: What kind of practice am I building —what kind of experience am I creating for myself and others —to make this economic model successfully work?

These are strategic questions, not merely accounting questions.

PRODUCTION CAN HIDE THE PROBLEM

One of the most deceptive aspects of the fiscal squeeze is that a practice can appear to be growing even as it loses economic viability. Production increases. Collections increase. The schedule is full. More employees are hired. More operatories are added. And it looks like —on the surface— that the practice is thriving. But gross revenue isn't the same thing as economic health.

The ADA's latest analysis of dentist income illustrates this point. Over a recent five-year period, dental practice revenue increased approximately 1.4% while expenses increased 4.9%, and inflation-adjusted general practitioner income has been declining over the longer term.

A dentist can therefore produce more dentistry, collect more dollars, manage more employees, and carry more organizational complexity — while keeping less of the economic value being created. That's not growth; it’s moving the deck chairs around on the Titanic.

THE QUESTION EVERY PRACTICE OWNER SHOULD ASK

Pull out your PPO contracts. Look at the procedures you perform most frequently. Compare today's allowed fees with what those same plans paid several years ago.

Then compare those increases with changes in staff compensation, laboratory fees, dental supplies, equipment, technology, occupancy costs, professional services, and general inflation. Don't look merely at dollars. Look at purchasing power.

Then ask yourself: if this trend continues for another five or ten years, where does it lead?

That question matters because the easiest time to redesign a practice is before economic circumstances force you to do it.

POSITION OR BE POSITIONED

Every dental practice operates within an economic system. And every economic system creates incentives. If your revenue model requires increasing numbers of patients and procedures to maintain the same purchasing power, eventually that economic structure will influence how you see people, problems, and procedures.

It doesn't happen because dentists suddenly stop caring; it happens because systems shape behavior, and behavior influences outcomes. This is why a practice philosophy and practice economics must align. If your goal is to practice more slowly, more comprehensively, and more relationally —then your financial model must be designed to make that possible every time. Otherwise, economics trumps philosophy, and that means every dentist must decide whether their economic model supports the kind of dentist they want to become.

◆   ◆   ◆

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

But hope becomes something else — something more useful and more influential — when we attach it to situations we do have influence over. And the difference between useful hope and wishful hope isn't the feeling itself; it’s whether there's a plan underneath it, and whether that plan is built on a philosophy we can clearly articulate.

THE HANDOFF

Consider what we do/have done as parents. We spend four or five years preparing a child for the first day of school. We repeatedly teach right from wrong. We teach respect for authority. We teach who and what to avoid, how to ask for help, how to sit still, how to wait for our turn. We potty-train, teach how to put toys away, and what to eat and when. None of that is passive, it’s a deliberate, cumulative, philosophy-driven campaign — our philosophy, about who we want our child to become and how we want them to operate in a complex world.

And then, on a Tuesday morning, we hand them over to strangers. We trust the school, but we can't fully trust it — we’ve never sat in the back of those classrooms. So what's left, once our child walks through the door, is hope: hope that our training was enough, that our child exercises the judgment we spent years trying to build into them, that the school is doing what it says it's doing. And crucially, we retain an option. If the evidence says otherwise — if what's happening in the building drifts too far from our philosophy of child development — we can pull them out and place them somewhere that's in better alignment with what we believe.

Notice the order of events: Preparation first, shaped by our philosophy, then the handoff, then hope. And even after the handoff, we’re still watching for evidence, still ready to act on what we see. Hope isn't a substitute for any of it; it’s what we feel while the strategic plan is being executed.

This lines up with something psychologist Charles Snyder spent much of his career documenting. His research on hope found that it isn't a single warm feeling — it's made of two distinct components. The first is agency: a sense that we are the one who can move toward the goal. The second is pathways: the actual, concrete routes we’ve mapped for getting there, plus a backup route if the first one fails. Take away either piece — the belief that we can act, or the plan for how — and what remains isn't hope —it’s wishing.

That distinction matters more than it appears, because the two states feel almost identical from the inside. Wishing and hoping both produce that same forward-leaning warmth, but one of them is attached to a philosophy-based plan with a course-correction built into it, and the other is attached to nothing at all — a private bet on how things will probably turn out if we don't interfere. That's wishing dressed up as acceptance. It feels calm. But it’s not hope, in Snyder's sense, because there's no agency and no pathway within it — only the feeling, floating free of anything that could make it come true.

WHY WE CAN'T JUST HOPE

A dental practice runs on the same logic as that Tuesday morning first-day-of-school handoff, except most of us never notice the parallel, because nobody hands us our practice in one dramatic moment. It arrives instead as ten thousand small daily decisions, each one either philosophy-based or luck-based, and it's entirely possible to run a practice for twenty years without ever being forced to notice which kind of choices we’ve been making.

We can't just hope that things get better on their own. We can't just hope that a bad hiring decision quietly turns into a good one. We can't just hope that dental insurance companies will someday decide to weigh our patients' interests, or ours, ahead of their own — that has never been the nature of that relationship, and hoping otherwise is wishing against the incentive structures of a massive corporation.

We can't just hope that a tired, dated facility will be perceived by a discriminating new patient as being sophisticated and current — walking through the door, they're forming that judgment in seconds, based on evidence, whether or not we've done anything to shape it. And we can't just hope that patients arrive already understanding our health-centered, comprehensive philosophy of care that took us years to develop ourselves — not without deliberately explaining it in language intended for that purpose.

Each of those is a place where a plan was available, and hope got substituted for it instead. That substitution is comfortable, because it asks nothing of us in the moment. It also, cumulatively, is how a practice drifts.

PHILOSOPHY IS THE PATHWAY

L. D. Pankey’s conception: Know Yourself, Know Your Patient, Know Your Work, apply your knowledge — exists precisely to give hope something to attach itself to besides luck. It's the pathway. CoDiscovery isn't a communication technique bolted onto a philosophy; it's what a philosophy looks like when it's actually being deployed rather than sitting in a mission statement no one's read since it was framed.

This is why “having a philosophy” can't mean simply being able to articulate one when asked. A philosophy that lives only as an answer to an interview question isn't yet a pathway — it's a feeling about ourselves, which is its own quiet form of wishing. The philosophy becomes real, becomes something hope can legitimately attach to, only once it's shaping actual decisions: who gets hired, what the operatory needs to look like, how a treatment plan is developed and explained, what happens when a fee is questioned. Those decisions, made consistently, are the plan. The hope comes after — hope that the cumulative direction of ten thousand philosophy-based decisions evolves into the practice we intend to create.

THE COURSE-CORRECTION

None of this promises a problem-free future. We will misread situations. We will occasionally hire the wrong person. We will get fooled — by a patient, an associate, a vendor, our own blind spot. That's not a flaw in this approach; Bob Barkley never claimed a philosophy-based practice was going to be error-proof, only that it was self-correcting in a way a luck-based practice can't be.

That's the actual payoff. When our actions come from a clarified philosophy, a mistake carries information — we can locate exactly where the decision drifted away from what we believe, and adjust the next decision accordingly. When our actions come from hope alone, a mistake carries nothing but disappointment. There's no map to check it against, so there's nothing to learn and nowhere specific to correct. We hope harder, on the same terms, and wait to see if this time it will work out.

Do you have a clarified practice philosophy — one your team lives out each day, and one you demonstrate via your decisions when nobody's watching? If the honest answer is “not yet,” it's worth considering what that “not yet” is costing you. Hoping you'll get around to it someday won't move the practice forward, it will just maintain the often frustrating status quo —or worse.

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

None of it is bedrock. What feels fixed is simply a story our brain keeps retelling, because nothing has ever interrupted the loop.

THE MYTH OF THE FIXED SELF

This isn’t wishful thinking; it’s neuroscience. The brain is neuroplastic — it physically reorganizes itself every time we think an unfamiliar thought, attempt something for the first time, or hold a vivid image of ourselves living inside a preferred future. The self we experience as permanent is, at the structural level, closer to a current draft than a finished manuscript.

What we call “being stuck” is usually something narrower and more mechanical: we are re-running an old version of ourselves that has been handed over to subconscious autopilot, because we’ve been too busy, too overwhelmed, or too depleted by the daily churn of practice to interrupt the pattern long enough to install a different one.

THE ARCHITECTURE OF BELIEF

Every self-belief we carry into the office is, in the literal, physiological sense, a well-worn neural pathway:

“I’m not good at case presentations.” “I can’t get patients to accept the treatment they need.” “I’m a conflict-avoidant leader.” “I’ll never build the kind of team I need to be successful.” “I can’t get my hygienist to start co-diagnosing.”

Each of these sentences names a pattern, not a fact. And patterns can be reinforced, or they can be rewired, depending entirely on which one gets used.

SEEING BEFORE BECOMING

The process for rewiring is simple to describe and difficult to sustain. It starts with defining, in unusually specific detail, who we intend to become.

Not a goal — a person, seen clearly enough to be a life lived in, now, before the world has offered a shred of evidence that it’s real. We can walk in the front door of the practice we intend to build. We can what’s playing. Ww can see our team’s faces. We can feel the respect we have for ourself for having done the hard, unglamorous work required to become this version of ourselves — the one who no longer flinches at a values-based fee conversations, the one who leads the morning huddle instead of enduring it, the one who trusts the team enough to delegate important responsibilities.

Then — and this is the part we like to skip — we have to think, speak, and act like that person before anyone recognizes it, long before the schedule reflects it, and long before the team believes it. Every decision, however small, gets weighed against one question: Does this move me toward the practice I’ve always wanted to work inside, or does it simply reinforce the pattern I want to outgrow?

REPETITION, NOT REVELATION

Neuroscience settled this a long time ago: neurons that fire together, wire together, which means the future self isn’t produced by insight. The podcast doesn’t produce it, the CE course doesn't, and this essay doesn't. Insight can point at the door, but only repetition walks us through it.

This is precisely how CoDiscovery works. It isn’t a single well-delivered interaction that permanently changes how we relate to patients — it’s the same relational philosophy, repeated with the next patient, and the next, and the one after that, until the old transactional script (diagnose, present, hope for acceptance) weakens from disuse and the relational script (understand, invite discovery, co-decide) becomes the one our brain reaches for automatically, without having to think about it first.

Repetition of the new thought. Repetition of the new conversation. Repetition of the decision that’s aligned with who we’ve decided to become rather than who we’ve historically been. There is no shortcut through this part, and anyone selling one is selling something else.

WHEN ACHIEVEMENT BECOMES ARRIVAL

Over enough repetitions, the old pathway doesn’t just get outvoted — it starts to fade away. The brain, in a very real sense, forgets the earlier version of us, and something shifts in how success feels once that happens.

Early on, growth feels like achievement — a goal reached, a number hit, a hard conversation survived, but somewhere past the point where our new self has become the operating default rather than the effortful exception, achievement stops being the right word for what’s happening. It starts to feel like arrival —not “I did this,” but “this is who I am now.”

This isn’t self-help, self-help implies that there was something wrong with ourselves that needed fixing. This is closer to self-directed evolution — becoming more fully the person underneath the autopilot, by declining, one repetition at a time, to keep rehearsing the old script.

The question worth considering isn’t whether change is possible — neuroplasticity already settled that. The real question is which version of ourselves are we rehearsing today?

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

I want to argue today that this instinct, so deeply trained into professional culture, may be backward more often than we admit. The confusion sits at the boundary between two things we tend to treat as synonyms: goals and systems.

A goal is a destination. A system is an adjustable process that produces outcomes. You cannot hit a goal without first building the system that gets you there — the goal names the place, but it does none of the work of arriving.

A coach's goal is a championship. His system is the daily, unglamorous work of drilling fundamentals and teaching players how to read a situation and respond. No coach has ever won a title by staring harder at the trophy.

Practice management runs on the same logic, though we rarely name it that plainly. Say the goal is fifteen percent more production on twenty percent fewer patients — a more health-centered, less transactional way of practicing. Stated as a number, it feels concrete, measurable, motivating. But the goal itself does not produce the outcome. It cannot see a patient, build trust, or diagnose comprehensively. Only the system can do that. And the system, in our tradition, has a name: CoDiscovery, undergirded by Know Yourself, Know Your Patient, Know Your Work, and Apply Your Knowledge.

If the goal is to practice in a way that is genuinely more health-centered — to become more effective with fewer people rather than more efficient with more of them — the goal itself can actually become an obstacle in the early going. It sets a number before the relational infrastructure exists to reach it honestly, and that gap invites shortcuts.

So let the goal indicate direction. Let the philosophy-centered system lead.

Here is why this matters more than it sounds like it should: goals quietly assume a level of control we don't actually have.

A hygienist's spouse takes a job three states away, and she's gone with six weeks' notice. A derecho knocks out power to half the county for four days during your busiest month. A pandemic reorders patient behavior overnight and your recall schedule, which took a decade to fill intelligently, empties from underneath us. A change in reimbursement policy — decided by people who have never sat chairside — quietly resets what “usual and customary” means for our fee schedule.

None of these were on the goal sheet. All of them will happen to somebody reading this, if they haven't already.

Goals can generate a specific kind of stress in exactly the moments when progress, statistically speaking, is running sideways rather than forward — and that stress is what shuts down the creative problem-solving a sideways season actually requires.

This is the part that gets missed. It isn't that goals are wrong to have; it’s that a goal, gripped too tightly during a season of genuine turbulence, narrows the very cognitive bandwidth needed to navigate the turbulence. The dentist who is white-knuckling a production number during a staffing crisis has less mental room, not more, to solve the staffing crisis creatively. What's needed instead is a wider view — the kind that only comes from stepping back from the number and returning to the process that was supposed to produce it in the first place.

A sailing analogy earns its keep here…

Our philosophy-centered systems are the sails, sewn together out of internal commitments we call values. Collectively, those values are our North Star. They can be re-prioritized as circumstances shift — patient trust may need to outrank production in a hard quarter, or team wellbeing may need to outrank both for a season — but they do not change.

A North Star that moves isn't one.

The wind is everything outside our control: the economy, reimbursement policy, a competitor DSO opening down the street, a global health event, the particular staffing problem of a particular year. Our goal is the harbor we named on the chart before we left the slip.

We get to that harbor only by tacking — sailing sometimes into the wind, sometimes with it, correcting constantly, never in a straight line. We cannot know in advance how long the crossing will take, because we cannot control the weather, and we cannot control when our boat — our team, our equipment, our own health — will need unscheduled repair.

And there will be seasons when we cannot reach the harbor we named. The prevailing wind won't cooperate. The seabed forces a re-route. The satellite navigation — the clean external benchmarks we were relying on, the industry averages, the consultant's formula — goes dark, and we’re left doing something closer to dead reckoning: reading our own compass, our boat, our crew, and trusting the instruments we actually have.

When that happens, the destination has to change at least for now.

Changed to what, though? This is where most of the anxiety in practice ownership actually lives — not in the storm itself, but in the disorientation of not knowing what to aim for once the original harbor is no longer reachable.

The answer is found by returning to the sails, not by staring harder at the water. We revisit the values — the actual, specific commitments that make up our version of health-centered practice — and from there we set a new goal that stays in alignment with them. Only then do we reset the system: recalibrate for the team we have this year, re-teach Know Your Patient to a newly hired assistant, rebuild the recall conversation around whatever trust looks like in this particular economic season.

Philosophy-centered systems facilitate goal attainment. Not the other way around. It is tempting, especially under pressure, to reverse the order — to tighten the goal and hope the system falls in line behind it. But a system built under duress to serve a number rarely holds up once the number changes again, and it always changes again.

Stay flexible. Stay philosophy-centered. The wind is not going to ask our permission before it shifts — this year's version arrived as reimbursement pressure and hiring scarcity; next year's will arrive as something else entirely, unannounced, as it always does.

The dentists who navigate best through these seasons are rarely the ones with the most tightly gripped goals. They are the ones whose sails were sewn from something sturdier than a number — and who trust that the harbor, even when it has to move, is still reachable from wherever the values actually point.

What would your system look like if you let it lead for a season, and let the number follow behind it?

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

I believe we agree, that a dentist who has a business, and gives their time, skills, expertise, and judgment to another person deserves to be appropriately compensated for it. The harder question is who gets to decide what is “fair” or “appropriate.” Should it be the two people present in the relationship — the dentist who provided the services and the patient who received them? Or should it be a third party, sitting somewhere in an actuarial department, who has never seen the situation in question and has a financial interest in the answer being as small as possible?

For fifty years, dentistry has let the third party win that argument —not through force, but through language.

THE WORD THAT GOT AWAY FROM US

Insurance language didn’t drift into its current condition by accident. It was engineered, patiently, word by word, the way every other successful branding campaign was designed — find a word that people know or value, and quietly change what it means.

“Insurance” used to mean something quite specific: a guarantee of compensation for a defined loss, purchased with a premium, in case something goes wrong in a very specific way. Fire insurance pays if our house burns down. It doesn't pay for us to powerwash the outside every two years.

Somewhere in the last half-century, the word insurance got repurposed to describe something entirely different: a capped, employer-subsidized allowance for routine maintenance, repairs, or replacement relative to a narrow list of pre-negotiated procedures at pre-negotiated prices. That’s not insurance in the original sense; it’s a coupon book with an expiration date.

However, by calling it “insurance” they borrowed all the trust and gravity of the real thing — the sense that we are significantly protected, that someone bigger than us has our back in a crisis — and applied it to a product that mostly profits and protects the people selling it.

Next came the phrase that did the real work: “usual and customary.” Three words that quietly installed the third party as the arbiter of value in every transaction it wasn't there to experience. A dentist sets a fee based on training, overhead, the difficulty of the situation, time requirements, and years of pattern-recognition that no algorithm can replicate. The insurer looks at that fee and, with no understanding of any of those variables, pronounces it “unusual” — and by implication, dishonest.

The great enemy of clear language is insincerity. When one’s real and declared aims diverge, one reaches for long words and worn-out phrases, the way a cuttlefish squirts out ink. — George Orwell

“Usual and customary” is ink, as it sounds like a neutral, almost bureaucratic standard. It is, in fact, a value judgment dressed up as an audit finding, built specifically to be unfalsifiable — there is no public schedule, no shared definition, nothing a dentist can point to and say, “by this standard, I am usual.” The standard exists only in the moment it’s invoked against us.

WHAT THE PHRASE DOES TO A PERSON

Here is the part that should concern us more than the reimbursement rates themselves: what happens inside a dentist who sees “unusual and uncustomary” applied to their fees, repeatedly, for years?

Nobody wants to be unfair. That instinct runs deep, and it starts early — long before dental school, back on the playground. So when an institution with the word “insurance” attached to its name tells a dentist, in effect, “you are charging more than a fair person would charge,” it doesn’t just land as a contract dispute; it lands as a character accusation. And most people, faced with a character accusation from an authority-sounding source, don’t argue. They comply, and then they look for evidence that confirms the accusation was deserved.

That’s the mechanism. It isn’t really about money at the moment it happens — it’s about identity. A dentist who has internalized “unusual and uncustomary” doesn’t experience it as “this insurer disagrees with my fee.” They experience it as “maybe I’m asking for too much.” And once that belief takes hold, it doesn’t stay contained to the fee schedule; it shapes how a dentist behaves in case presentations—how apologetically they present a comprehensive case fee—and how quickly they discount it when the patient hesitates.

It is the lack of a pertinent philosophy that limits most dentists. The same is true for most patients. — Bill Strupp

Without a grounded practice philosophy that buttresses perceived value, there’s nothing available to push back against the one that’s projected onto us by the insurance industry. The response of the vast majority of dentists over the past 50 years has been almost uniform: work harder. Strap the loupes back on, tighten up the schedule, optimize the “workflow,” and try to out-produce the discounted fees. It’s an understandable response, yet a losing one, because it treats a language problem as a productivity problem. We cannot out-hustle a definition we never agreed to in the first place.

THE WEIGH-STATIONS

Plenty of dentists have tried to fight back within the system rather than completely absorbing it: Code-mining, up-selling, hiring companies to re-negotiate PPO fee schedules, delegating more, sourcing cheaper materials, outsourcing lab work to the least expensive options.

None of this is dishonorable, and some of it is good business management. But notice what all of it has in common: every one of these decisions tries to optimize a system whose fundamental terms were set by someone else. They are weigh-stations, not destinations — temporary relief on a road that still ends where the money managers designed it to end, which is the full industrialization of clinical judgment. A dentist who becomes extremely good at delegation and code mining inside an insurance-defined fee structure has become extremely good at a game whose rules were written to be won by the house.

It’s evil, it’s malignant, and it speaks fully against health-centered dentistry, which is as much a subjective experience as it is an objective one. — Avrom E. King

That’s not a quote about reimbursement schedules; it’s a quote about which side of the transaction gets to define the word “value.”

THE DRIVEWAY

I recently asked a contractor for an estimate to pave our quarter-mile-long gravel driveway: “Twenty-seven thousand dollars.” When he said it, he didn’t look down and away, kick at the gravel, apologize, or ask if I needed to pre-authorize it. He wrote up a contract, asked me to sign it and mail it back to him if I wanted to proceed.

There is no such thing as paving insurance. Nobody has spent fifty years training paving contractors and their customers to only quote and accept “reasonable” and “customary” fees. So, the free market does what it does: it lets skill, reputation, and the customer’s own judgment about the inherent value of the possible transaction set the price. And subsequently, the contractors who are good at their work and good at making people feel the money will be well spent — thrive. The ones who don’t —don’t. It’s not complicated; it’s just unmediated.

The business of dentistry doesn’t need to be structurally different from the costs, associated benefits, and guarantees of paving a driveway. However, it has been made to feel different, through fifty years of careful word manipulation.

THE METRIC THAT WAS NEVER FOR SALE

Omer Reed used to say that a non-piecework fee schedule isn’t a clever workaround for avoiding insurance company hassle — it’s a philosophically rooted, values-determined way of seeing the world. That distinction matters. If independence from third-party fee control is just a tactic, it will get negotiated away the first time it’s inconvenient, or fear enters the picture. If it’s grounded in a practice philosophy, however, it will hold.

L.D. Pankey offered the clearest alternative metric I know of, and it’s worth remembering because it cannot be manufactured by an actuary: success, he said, is measurable by the number of patients who pay us with appreciation and gratitude. Not merely payment — payment accompanied by the felt sense, on the patient’s side, that they got more than their money’s worth out of the decision, process, and outcome.

That’s a soft metric that resists spreadsheets. It also happens to be the one metric the insurance industry has never figured out how to define for us, price for us, or take away from us — because it isn’t generated in their office. It’s generated in the practice, in every encounter between a dentist and a patient —the two who were actually there at the time.

Whenever one talks about money, there is confusion, emotion, and history involved. — Mike Schuster

Mike is right, and that’s precisely why the confusion has been such an effective tool — it was never an accident that the conversation about fees became so muddled that clear-eyed dentists started doubting their own arithmetic. Clarity is the insurance industry’s natural enemy. It’s our responsibility to take it back, one health-centered relationship at a time.

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

B = f ( P , E )

The equation makes the following statement: Behavior (B) is a function of the Person (P) in their Environment (E).

Known today as "Lewin’s Equation,” this simple concept contains much of what we need to know about helping to facilitate healthier and more health-centered relationships with our patients.

So what drives our patient's behavior? Before Lewin’s Equation became famous, most experts believed that a person’s habits and actions were a result of what type of person they were, and that it had very little to do with the environment in which they were immersed.

And we still find many examples of this belief system still being accepted today. For instance, if a person struggles to stick to a diet we might say, “They just don’t have any willpower.” Or, if a team member seems unable to finish a big re-organizational project at the office, we might say, “They’re great starter, but a lousy finisher.” Or, in the case of new patients: “That person has a real Driver-type personality and I just can't work with Drivers."

These statements imply that habits and actions are almost alway determined by some preexisting set of internal characteristics a person was born with; that habits are rather fixed based upon who a person is on a personality level, and that we need to just accept this as being reality.

Lewin however, proposed something quite different. He said that it’s not just personal characteristics which drive behavior patterns, but rather a person’s behavior is a function of the environment which surrounds them, and as a result, the "Nature vs. Nurture" argument was born.

Relative to health-centered dentistry, our patient's habits, behaviors, and perspectives toward dental health are highly dependent upon past experiences, memories, social / family influences, and current experiences on both a cognitive and emotional level.

And in many cases, if the previous emotional memories and triggers are strongly negative, a re-stimulative office environment will drive the patient's behavior much more than their personality.

When we meet with new patients for the very first time, we don’t know anything about their memories, experiences, mindset, perspective, -or often- even their true reason for being present at that moment.

And that’s why Co-discovery is key to facilitating more health-centered behavior in patients. Bob Barkley was right when he said that we need to "do away with case presentations", and replace them with collaborative, goal-oriented planning sessions which address the whole person - physically and emotionally.” It’s therefore quite likely that Bob and Kurt Lewin would have had some long and interesting conversations had they known each other!

Carl Jung spent decades studying what separated people who aged into calm wisdom from people who aged into bitterness and resentment. And he didn't find the answer in comfort or security; he found it in four capacities, developed or neglected, long before old age arrived to test them. Miss even one, and the final chapter tends to collapse. It's worth walking through all four specifically as they apply to a career in dentistry, because each has a distinct trap built in.

A LIFE LIVED INWARD, NOT JUST OUTWARD

Jung noticed that people who spent every decade chasing external achievement eventually hit a wall — usually somewhere around midlife — that no additional achievement could get them past. The people who aged well had already turned some attention inward before that wall arrived. They had built a relationship with their own internal life, not just their résumé.

Dentistry doesn't make this easy, because dentistry rewards outward attention almost exclusively. Production numbers, case acceptance rates, new patient counts, the next piece of equipment, the next CE course on a technique — all of it is external, measurable, and immediately reinforcing in a way that inner work never is. L.D. Pankey understood this trap, which is exactly why “Know Yourself” is central to his model rather than an afterthought.

A dentist who never asks what they actually believe, what they are afraid of, what they are building their identity on has skipped the one foundation on which everything else was supposed to rest. They can still practice excellent dentistry for thirty years on that missing foundation, but they can't retire from it gracefully.

ACCEPTING YOUR SHADOW — ESPECIALLY THE PARTS THAT AGED WITH YOU

Resentment carried at thirty doesn't soften by age seventy. It calcifies. Jung watched people still fighting, late in life, wars with themselves that could have ended decades earlier — and the ones who found peace had done the unglamorous work of actually looking at what they'd spent a lifetime avoiding.

Every dentist accumulates a shadow specific to the profession: resentment toward an insurance system that dictates fees, toward patients who question a treatment plan built on true expertise, toward associates or staff who don't share the same standards, toward the sheer physical toll the work takes on a body that keeps the same posture for decades. None of that resentment is irrational, but left unexamined, it doesn't disappear — it relocates.

The dentists who age into bitterness are rarely the ones who suffered the most. They're the ones who never metabolized what they suffered.

It shows up as a short temper with a team member who did nothing wrong, as a low-grade cynicism about patients that quietly poisons the relational trust the whole practice depends on. That's the pattern to watch for — not the suffering itself, but where it goes when it's never named.

FINDING MEANING THAT SURVIVES THE LOSS OF THE ROLE

When the career ends — when the handpiece goes down for the last time, when the practice is sold, when “Doctor” stops being the first thing people know about you — who are you without the doing? Jung saw this question destroy people who never asked it while there was still time to answer it slowly, rather than being forced to answer it all at once.

This is arguably the sharpest risk in dentistry specifically, because the identity fusion runs so deep. Ask most dentists who they are and the honest first answer, whether spoken aloud or not, is what they do and how well they do it. That identity works beautifully for thirty or forty years — right up until a practice transition, a health scare, or a hand tremor takes the doing away, sometimes with no warning at all. A dentist who has only ever been a clinician discovers, at exactly the wrong moment, that there was no one standing behind the role. A dentist who has also been a mentor, a teacher, a builder of people, a writer, a student of something outside the operatory, has somewhere else to stand when the role finally goes.

BEFRIENDING DEATH INSTEAD OF RUNNING FROM IT

Jung argued that a life lived in terror of its own ending poisons every stage that precedes it — and that the people who aged with grace had made some peace with mortality well before it arrived at the door. They stopped clinging. They started savoring.

Translate that into a dental career and it looks like something very specific: the willingness to actually plan a transition instead of avoiding the subject indefinitely; the willingness to let a talented associate grow past you instead of quietly undermining them to stay necessary; the willingness to walk into the last chapter of practice with less urgency and more presence, rather than working harder each year to outrun the ending.

A dentist who has made peace with the fact that the career will end is, paradoxically, freer to do his best work in the years he has left.

A dentist clinging to relevance — chasing every new technology, refusing to delegate, unable to imagine an identity after the practice — is running the exact race Jung warned against. He's no longer doing the work to serve it. He's doing it to prove he still exists.

MOST HAVE ONE OF THE FOUR

Very few people, dentists included, have built all four pillars by the time they need them. Most have one, maybe two, and spend the back half of a career discovering the gap the hard way. That's how so many arrive at the end of a long, technically excellent career feeling like strangers inside their own lives — surrounded by everything they built, and unable to say who built it, or why, once the building stopped.

None of this argues against financial success or clinical excellence. It argues against mistaking either one for the whole of a life. A career that is only about fixing teeth and making money will, eventually, run out of teeth to fix and reasons to keep making money — and whatever wasn't built underneath it will have to be built in a hurry, late, under far worse conditions than the ones you have right now.

The work Jung is describing isn't retirement planning. It's the work of making sure there's still someone home when the practice finally goes quiet. That work doesn't wait for a convenient decade to begin. It only waits for you.

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

So the real question was never whether to market. It's what our marketing is quietly teaching people to expect from us — and whether we chose that lesson or backed into it.

WHAT MARKETING ACTUALLY IS

Strip away the jargon and marketing, and it's simply this: every communication, in every direction, between a practice and the people who might someday walk in the door. Some of that communication is trying to build value in the minds of people who don't yet know us. Some of it is about keeping a positive image “top of mind” for people who already do, so that when they're finally ready to decide on their dental care, ours is the name that comes to mind without effort.

That's it. That's the whole discipline. It’s not advertising, or a website, or a mailer, or a Google review strategy — those are only tactics, and often not even the decisive ones. Marketing is the accumulated impression we leave, on purpose or by accident, every time we interact in the world.

And because it accumulates, marketing does something more consequential than generate new phone calls; it positions us. Every practice occupies a place in the mind of its marketplace — bottom, middle, or top — whether or not anyone on the team ever discussed positioning as a strategy. The absence of a decision is itself a decision; it just isn't ours.

THE RISK OF DRIFTING TO THE MIDDLE

Here is where patient-centered, health-centered practices need to pay close attention: If a practice positions itself — intentionally or by sheer inattention — anywhere in the bottom or middle of its market, it has entered a fight it cannot win. That territory increasingly belongs to dentistry sold as a commodity: interchangeable, price-competitive, insurance-centric, convenient in time and place. Corporate dentistry is very good at owning that space, and it is consolidating its hold on it year by year.

You cannot out-commodity the commodity players.

A relationship-centered practice competing on those terms — on price, on proximity, on extended hours, on insurance participation — is competing on the one axis where it cannot win long-term, because it has voluntarily abandoned the one axis where it always could win. This is not a judgment against corporate dentistry's ethics; it’s a simple observation about strategy. If we let the market believe that's the game being played, we’ve already lost the position that made us unique in the first place.

THE THING WE ARE ACTUALLY SELLING

What is the unique selling proposition of a patient-centered practice? It’s not a service. It is not a location, it’s not a time, and it’s certainly not a relationship with an insurance company — because a service, a location, and an insurance company are all, by their nature, incapable of anything but transactional relationships. We cannot have a long-term health-centered relationship with a benefit plan. We cannot be known by a location other than on a very superficial level.

What a patient-centered practice actually offers — the thing no commodity player can replicate at scale — is the opportunity to enter a health-centered, collaborative relationship with a philosophically unique care team. That's the whole proposition. Everything else, every clinical capability and every convenience, is downstream of whether that relationship is real and enduring.

Which means the work of patient-centered marketing is first to understand what a specific relationship-seeking segment of our marketplace actually wants and needs — and then to communicate our USP to that segment, clearly and repeatedly, in whatever form fits our specific market. There is no universal playbook here. What works in one community will fall flat in another. But the underlying task is constant: find the people who are looking for a health-centered relationship, not just a transaction, and make sure they know, again and again, that we’re offering one.

NOTICE WHAT THIS ISN'T

None of this is selling. That distinction matters enormously, and it's worth being explicit about it because the two are constantly confused in dentistry. The entire aim of patient-centered marketing is to make selling unnecessary. Peter Drucker said it best: “Marketing aims to know and understand the customer so well that the product or service fits him and sells itself.”

That's the standard —a depth of understanding so complete that persuasion becomes unnecessary.

It's worth mentioning how Steve Jobs approached this same problem, because it clarifies what “understanding the customer” actually requires. When Jobs was conceptualizing the iPhone, he wasn't trying to build a better phone — faster, cheaper, with more features than what already existed on the market. He was trying to name a desire people hadn't yet articulated to themselves. That is a fundamentally different kind of listening than asking people what they want and giving it to them. It's noticing what they haven't said because they don't yet have words for it, and building the thing that makes those words unnecessary.

Patient-centered dentistry has its own version of this unspoken desire, and it isn't hidden particularly deep. People want to be known. People want to take better care of themselves. They want a place where they are remembered without a chart prompt, where their fears are taken seriously, and where somebody is paying close enough attention to notice when something is off before it becomes a bigger problem. Almost nobody says this out loud when asked what they want from a dentist. They say they want “painless” or “someone who takes their insurance.” But watch what they actually stay loyal to, year after year, and it's rarely the painless procedure, it’s the feeling of being known and felt.

WHAT THEY SAY WHEN WE’RE NOT IN THE ROOM

As fall approaches, it's worth pausing to ask a more important question than “How do we get more new patients?” Ask instead: How is this practice actually perceived, right now, by the people already in it — and by the wider marketplace that hasn't walked through the door yet? Do prospective patients even know we exist? And when our name does come up, what the story?

“She's pretty nice.” “They never hurt me.” “They take my insurance.” “It's close to where I work.” Or, further along the spectrum of significance: “I always feel heard and cared-about.” “They helped me save my teeth — I'll forever be grateful.” “They helped create the smile I've always wanted.”

These are not equivalent statements, even though they might all sound like compliments. The first cluster describes a competent, convenient commodity. The second describes a relationship that changed something. Only one of those narratives protects us from the next decade of commoditization, and only one of them can't be replicated by a practice with lower overhead and a bigger advertising budget.

For any business today — and dentistry is no exception, however much some of us wish it were exempt — these are existential questions. The narrative our patients carry in their minds about us, the story they'd tell a friend without being prompted, is doing more to determine our future than any single clinical skill we possess. Not the story we intend to create, the one that's already circulating, right now, whether or not we’ve ever thought to ask about it.

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.

This isn't cynicism; it's pattern recognition, and it's earned. Behind every discontented new patient is a provider, a salesperson, or an organization that was friendly right up until friendliness stopped serving their interests. The nervous system doesn't forget this. Long before conscious thought catches up, the body is already scanning the new relationship for the tell — the gap between the surface and the intent behind it.

Trust Isn't Given. It's Earned

Real trust doesn't arrive because someone was nice in the first few minutes. It accumulates the way credit does — transaction by transaction. Bob Barkley understood this: technique cannot substitute for trust, and trust cannot be manufactured on demand. It has to be earned — nice, followed by a kept promise; a kept promise, followed by another — until the pattern is strong enough that the patient's internal model quietly shifts from risk to known, safe, entity.

Only then does the patient stop performing for us — the sanitized history, the symptoms they think we want to hear, the story that keeps them safe from further disappointment — and start actually opening. Only then can CoDiscovery happen at all, because it requires two people willing to think together in the open, and no one thinks openly with someone they're still bracing against.

The sequence cannot be skipped: nice, then proof, then trust, then disclosure, then collaboration — outcomes neither party could reach alone. Try to leap straight from nice to co-creation, and the patient's threat-detection system will quietly decline the invitation, often without the patient knowing why.

Nice as Tactic vs. Nice as Character

Here is the distinction that matters: nice deployed as a technique is a mask worn over whatever the practice actually values — production, retention, conversion. Sooner or later, in some unguarded moment, the mask slips, and the patient sees what was underneath it the whole time.

But what flows from an actual philosophy of care has nothing to slip off of. There's no gap between presentation and intention, because the intention is the presentation. It doesn't perform trustworthiness — it simply behaves consistently enough, long enough, that trustworthiness becomes the only reasonable conclusion left for the patient to draw.

This is why it may be the single most powerful marketing strategy a health-centered practice has — more durable than any advertisement, because loyalty built this way doesn't need to be re-purchased. It compounds. It refers. It stays.

The Patient Across From Us

Consider who is actually sitting across from us, or knee to knee, on a given day. Often it isn't someone in search of a fix. It's someone carrying an unresolved history — frustrated by a system that processed them instead of hearing them, hurt by a person who over-promised and under-delivered, deceived by language engineered to close a sale rather than serve a person. Often they arrive holding a complex, tangled problem no one before us was willing to slow down long enough to explore fully.

It's tempting to read this patient as difficult. It's more accurate — and more useful — to read them as an opportunity. Their guardedness isn't an obstacle to a better relationship; it's the raw material of it. Every ounce of skepticism they walk in with is a debt we get the privilege of resolving, slowly and honestly, until our pattern outweighs the pattern of everyone who came before us who didn't follow through. There is no more fertile ground for deep, health-centered care than a person who has already learned, the hard way, what its absence costs.

Step Up and Pay the Price

"For whatsoever ye want, oh discontented man, step up and pay the price."

The line cuts in both directions. Aimed at us: if we want a practice built on trust rather than transactions, there is no discount on the toll. The price is consistency when no one is measuring it, restraint when a shortcut would be easier, and the patience to let proof accumulate on the patient's timeline, not ours.

But it's aimed equally at the patient. Their discontent is real, and often justified. Its resolution isn't free either — it asks them to risk disclosure again, to lower their guard with one more provider after however many times that risk didn't pay off. We can't demand vulnerability from a patient we haven't yet earned it from. And they can't achieve a better outcome without eventually paying their share: the willingness to try trusting again.

This is sacred ground, which is exactly why it can be abused so easily and why it is so rarely talked about in these terms.

Paul A. Henny, DDS, practices in Roanoke, Virginia, and writes on the philosophy and practice of health-centered dentistry in the tradition of L.D. Pankey and Bob Barkley.