When Quality Isn’t the Constant: Part One, the Five Causes

What happens when quality is not the constant? The simple answer is a loss of trust. We lose trust with the key constituencies of our team, our patients/clients, and finally the community. This distrust is significant because it will equate to a loss of business. Why then are quality outcomes not always top of mind in practice or business? I have identified five potential reasons why quality too often wavers.

“our “dumb brain” wants to protect us from the inevitable disappointment and anger that the patient will experience”


Almost every person I know is afraid of something. If you scratch the surface of any area of poor performance you are likely to discover fear. I know I am afraid, but I also know that nine out of ten times running into fear yields better outcomes than running away from fear. Unfortunately, knowledge is not always enough to do those things that we know are the right thing to do. Our bodies are hardwired to avoid danger. Our “dumb brain” the one that is eons older than our “smart brain” does an astonishingly effective job of protecting us from ourselves. Unfortunately, out “dumb brain” isn’t good at seeing long-term consequences of actions. Planning and strategy are part of our smart brain.   In dentistry when we encounter an unexpected poor outcome like an open crown margin at cementation or a broken file in a root canal, our “dumb brain” wants to protect us from the inevitable disappointment and anger that the patient will experience when we explain what happened and what the next step will be. Our “dumb brain” tells us to ignore it, that it isn’t that bad, that things might work out for the best, that the patient will hate you, that she will be mean and abusive, the “dumb brain” tells you to avoid conflict. The “dumb brain” is not smart. Overcoming fear sometimes requires being fearful of something else, something like the loss of trust. Loss of trust is far more harmful than anything that can happen when a well-intentioned action does not work out as well as hoped.

Vince Lombardi used to say “fatigue makes cowards of us all”


Dentistry, Medicine, Nursing, Veterinary Medicine, Dental Hygiene, Chiropractic Medicine, Physical Therapy, it is all hard work. Constantly you are on stage for the client. Being on stage takes energy, commitment, and a positive attitude. If anything is off, the energy can be drained, and suddenly, you are not your best self. Quality outcomes usually take our best self. If we drift into a low power state and begin to feel a little lazy, it becomes easier to lose focus and allow poor outcomes to slip into our work. Of course, it could also be chronic laziness, but that has more in common with ambivalence than laziness due to little energy.   Vince Lombardi used to say “fatigue makes cowards of us all”; this means we have to guard against ambient laziness–the laziness introduced into the system from outside. Guarding yourself against laziness is accomplished through dozens of different techniques. Techniques from surrounding yourself with people who give you energy, to taking better care of yourself physically, to guarding your work schedule so that stress or fatigue is not the natural outcome of running a particular type of template, to even having reliable systems in place.



Ignorance is hard to talk about, but some people don’t know that the results they are delivering are less than ideal. I’m not a psychiatrist, but it almost seems to be delusional. I have seen dentist whose work regularly fails within months to a year or two who don’t think they are part of the problem. It reminds me of the young man who auditions for American Idol who can’t carry a note. If you investigate, it isn’t that they don’t care, or are lazy or any of the other reasons, they think their work is good. Here intervention and education are necessary.



Some providers don’t care that much. Maybe they are working in a job that they think will not be their long-term home, or think the effort to get a great outcome is not worth it for them. Truthfully, there isn’t much anyone from the outside can do about ambivalence especially in a solo practice. There is no legal requirement to care. In a group practice, social accountability “peer-pressure” might have the ability to get someone to care a little bit more, but more often than not the profession has become more of an obligation than a vocation.   These people might feel shackled to dentistry or hygiene due to debt, or lifestyle or even social expectations placed on them from some external source. Ambivalence is an unfortunate reality. These individuals could likely find a way to fill the void in their lives that the profession is not satisfying, but they will likely need help in the search for that path. Until they can find fulfillment in their work quality is an unlikely attribute of their dentistry.

“The consequence of this isolation is that most dentists begin to see their skill set as the standard of care.”

Lack of Skill

In dental school, I learned that not every doctor is smart and not every surgeon has great hand skill. It was an interesting realization, but it makes sense. Like every craft created by human hands and intellect, the ability exists on a continuum from amazing on the positive side, to astonishingly weak on the downside, with most somewhere in the middle. In dentistry, most of the time dentists practice in isolation with no one pushing them to get better and expand their knowledge base. The consequence of this isolation is that most dentists begin to see their skill set as the standard of care. The movement away from solo practice to group practice is changing these isolation phenomena in dentistry, but even in group practices, an intentional effort must be made to expose professionals to what they do not know. The truth is everyone has holes in their knowledge. Not one of us is as good as all of us. The integration of dentists into group practices should improve dentistry as dental practice begins the steady migration from solo practice to group dental practice.

In Part Two we will explore the four pillars necessary to make quality a constant in your practice.

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