House of Delegates Address

IDA President Elect Dr. Steven Holm
May 17, 2014

Dr. Steven Holm's presidential addressSpeaker Platt, President Dimond, Trustee Crowley, Officers, Delegates, IDA Staff, and Distinguished Guests:
NEVER do today what you can put off until tomorrow. This was the credo that Dr. Roberts ran his presidency with and words I’ve never forgotten.  So with that concept ringing in my head, I sat down about a week ago and thought I really should get busy on my speech.
I was at our kitchen table trying desperately to become inspired.  My wife, Lynn, was sitting across from me, intently staring at me.
Finally I looked up and said “WHAT?” Lynn said, “I thought you might like my help.”
“Nope, I’ve got it”, I said.  Now, in retrospect this was the wrong answer.  However, as you know, of the two sexes the male is not the intuitive one.
So I went back to writing and Lynn continued to stare.  After several uncomfortable minutes, I looked up again and said, “OK… I probably could use your help.”  She said, “Are you sure?”  Actually I was sure the first time, but I said “Yes, I really want your advice.”
Lynn said, “I’ve got three suggestions.”  I said, “OK.”  She said, "You probably want to write them down.”  I said, “OK.”
“Number one; don’t tell any of your stupid jokes. I don’t want you to embarrass yourself.” I said, “OK, Lynn, I won’t tell any of my stupid jokes.”
“Number two; make sure your zipper is up. I don’t want you to embarrass me.” I said, “Embarrass YOU? I don’t under…OH! OK, Lynn, I’ll make sure my zipper is up.”
“And number three; Keep it brief. You Know how you tend to go on and on and on.”
I said; “OK Lynn… I’ll make sure my zipper is up.”
Change is painful. For 60 years the Swiss dominated the world in watch manufacturing.  No one else in the industry was even a close second.  They had 65% of the world market and their watches were reputed to be the finest in the world.  Then something happened.  Their market share dropped from 65% to less than 10%.  What happened was the digital watch.
90% of the Swiss workforce lost their jobs.  The Swiss made the most accurate gears in the world.  It was irrelevant.  They made the best bearings. Who cared?  They manufactured the finest mainsprings.  Unneeded.  All the old advantages were worthless.
The irony here is that the digital watch was invented by the Swiss.  They, however, rejected the new invention.  The new invention was picked up by Seiko of Japan.
The story is not unique.  Kodak! How may of you still buy film for your camera?  Borders! Did they miss how customers want to read? Blockbuster!  Who wanted to go out in last winters’ weather to return a video to avoid late fees?
So why didn’t any of these corporate giants see this coming?  Because change is always met with some kind of resistance.
  1. We are unable to literally see the evidence though it is right in front of our eyes. (The evidence does not fit the old framework so it is denied)
  2. We do see the evidence, but rationalize it away.
  3. We see the evidence and distort it to fit our framework. Or..
  4. We see the evidence, but declare it is inaccurate.
The IDA needs to change…to evolve.  We do many things right here in Indiana.  But we live in an age where young people are growing up with instantaneous access to more information than older generations could gather in a lifetime.  An example of change…Pennsylvania got rid of it’s House of delegates.  They are governed by their Trustees and a Council of ten Presidents.  Am I suggesting this…of course not.  But we do need to change.
I am going to give you three examples of where I believe the IDA needs to begin; where we need to change our paradigm of thinking.  Are there only three areas of change needed?  Of course not!  But all journeys begin with a first step.
First I would like everyone on the floor of the HOD to stand up.
  1. Now, if you are not a dentist sit down.
  2. If you are over 60 sit down
  3. If you are over 50 sit down.
  4. If you are over 40 sit down.
  5. If you are between 35 and 40 sit down.
Everyone left standing is our future.  This is our young dentist.  Please, everyone give them a round of applause.  Now you can sit down.
But why aren’t there more of you?
The first thing the IDA needs to change is we need to connect with our younger generation.  The ADA is facing a serious decline in membership. Our membership now is about 60%. We are losing over 1% per year in membership. If the trend continues, by 2025 our market share will be under 50%.  So at what point do we become irrelevant?
We need to make our organization attractive to young people.  My generation, baby boomers, joined out of a sense of loyalty and obligation.  Millenials have a different view of life.  They don’t network at chicken dinners once a month like most of us did.  We need to cater to their view and not judge it as good or bad.
So how do we make the IDA attractive to our new dentists?
First this must be about a partnership not an acquisition.  More members is good for everyone.  But to want to become a member, there must be a mutual trust and a mutual benefit for all stakeholders.  We need to communicate and to listen to understand.  This is why God gave you two ears and one mouth.  We need to make the needs of the dentist our highest goal, no matter where they are in their career.
Membership begins with the member experience.
  1. We need to make joining easy and staying easy.
  2. We need to make joining personal
    • Advocacy is no loner enough
    • Loyalty is not sufficient
  3. We must look at member segments and how they value different things. Young/old, male/female, private practice/faculty, ethnicities, and geography all play into the bias of what members value.
For all of us to thrive and survive in this new age of dentistry we have to change what we are doing.  We have to find ways for members to interact, to make an emotional connection that can’t be broken.  We have to enhance the member experience so young dentists see us as essential to their profession and to their life.
A new approach to member value will require a different set of attributes than those that made us successful in the past.  But we need to act… we can’t outrun this storm.  This is where the courage to make change comes in.
Needed change number two: corporate dentistry.  This one is actually easy.  When it comes to corporate dentistry the IDA needs to “get over itself”.
When I was young, in the black and white days as my children call it, pharmacists had their own pharmacy and optometrists had their own eye clinics.  Now we have Walgreens, CVS, 4 Eyes, and Pearl Vision.  Times have changed.
At the ADA meeting, the President-Elect candidates visit all the districts.  When they came to our district, the Seventh, we asked the candidates the same set of pre-written questions.  This gives us an insight into what they are thinking and how they handle pressure.  One of our questions was, “Be Nostradamus.  Where do you think dentistry will be in 20 years?”  To a person they all had the same answer.  They predicted the dental landscape will be primarily corporate and group practices.  The solo practitioner will slowly go the way of the dinosaur.
So is this movement to corporate dentistry a trend or a passing fad?  To understand why graduates are going into corporate dentistry we first must understand the landscape.
First, dentists’ earnings have not kept up with the growth of gross domestic products.  Simply, dentists are not busy enough.  Average annual revenue is down.  Utilization of dental care has declined among working age adults.  Dental benefits coverage has steadily eroded over the past decade.  More and more adults, in all income groups, are experiencing financial barriers to care.  Total dental spending has been flat since 2008.
A recent government report by Senator Sanders showed that 42% of adults with oral problems did not see a dentist because they lacked insurance coverage or could not afford out of pocket expenses.  Patients are making tough choices in a very fragile economy.
So what about the Affordable Care Act?  It will expand coverage for children, but adults are left with few options.
If you are a new graduate the dental landscape looks bleak.  And you will be entering the profession with alarming levels of educational debt.  In 2013, the average educational debt per graduating dental school senior was $215,145.00.  If you went to a private dental school, your average debt was $283,978.00.
So now lets consider two scenarios:
  1. You bring in an associate and offer him or her 35% of what they produce.
  2.  Corporate dentistry offers them a salary of $100,000.00
In their senior year a dental student produces about $17,000.00. To match the $100,000.00 salary corporate dentistry offers, they would have to produce $300,000.00.  From their senior year in dental school to their first year in practice, they would have to show and increase in production of 176%.  And they have that quarter of a million dollar debt hanging over their head.  So if it was you and you were 25 years old again, and maybe with a wife and kids…what would you do?
Of course there are all the rumors.  Corporate dentistry puts all it’s dentists on a production quota.  I guess no one out there has ever paid their staff a bonus based on production.  Corporate dentistry over diagnoses.  Of course this only happens in corporate dentistry and never in the non-corporate sector.
We need to get over ourselves.  Corporate dentistry is not the “Evil Empire”. What they are is our sons, our daughters and our peers.  It is time we built a united dental front and become the single organization that represents all dentists.
Finally, and mercifully we are at the last point where I feel the IDA needs to change… the dreaded midlevel provider.  If you ask dentists the midlevel provider is Satan incarnate.  If you ask politicians, midlevel providers are the answer to “access to care”.  So to understand the problem, we first have to understand dentists and politicians.
First let’s talk about dentists.  There are two things you need to know about dentists. Number one: we are problem solvers.  We like to fix things.  We want all our solutions tied up in a neat little bow.  And number two; we are “gas bags”.  We don’t know when to quit talking. “Mrs. Jones, you have a space… so we could place an implant which is a piece of metal in the bone which will be restored with a crown…or we could do a bridge where you crown the tooth in front of the space and crown the tooth in back of the space with a false tooth in the middle… or we could do a partial denture which is a metal framework that hooks onto the existing teeth and comes in and out…or we could do a flipper which is a denture tooth on a piece of plastic which is cheap but not very good…or we could do nothing, but your teeth will drift. So, what do you want to do?”  Now apply that scenario when dentists talk with politicians.  I call this the “dope”ler effect.  This is the tendency of stupid ideas to seem smarter when they come at you rapidly.
OK, so lets talk about politicians.  First, they are not problem solvers.  They are vote getters.  How many of you think insurance companies’ main concern is about patients and not their bottom line?  How many of you think politicians are really concerned about access to care and not about re-election?  Plus politicians are surrounded by a layer called the “bozone layer.”  This is a combination of Bozo and ozone.  This is the aura that surrounds politicians that stops bright ideas from penetrating.  As far as I know, science has found nothing to combat this yet.
Politicians feel the answer to access to care is the midlevel provider.  But do they really understand what access to care is?  Is it a geography issue?…maybe in Alaska, but not in Indiana.  Is it a racism issue?  It was on some of the reservation dentistry done on Native Americans.  Is it a money issue?... Are we talking Medicaid, the income level just above Medicaid, or the lawyer who needs an all-on-four denture, but doesn’t have the $25,000.00?
When, and not if, but when midlevels are introduced in Indiana it will be because of the politicians and not the hygienists.  That is how it happened in Alaska, that is how it happened in Minnesota, that is how it happened in Maine, and that is how it will happen in Indiana.  So what do we do?  My good friend, Dr. Schechner told me that the IDA needs a plan for access to care.  The problem is that there is no plan for access to care.  Don’t you think that if there was an access to care plan, that one of the other 49 states would have thought of it by now?  And being the first to do something has never been the way Indiana operated in the past.  We should replace our state nickname.  Change it from “Hoosiers” to “Ice”.  This is not because Indiana is cool under pressure, but that on most things we move at the speed of a glacier.  So what we need is not an “access to care plan”, but an “access to care spin doctor” or a “prevent midlevel provider” plan.
So where does this process start?  In the book Divergent by Veronica Roth, the world was divided into five factions based on your personality.  The Erudite was the smart faction.  This was the faction with your doctors and scientists.  The Erudite faction had this motto:
  1. Ignorance is defined not as stupidity, but lack of knowledge.
  2. Lack of knowledge leads to lack of understanding.
  3. Lack of understanding leads to disconnect among people.
  4. Knowledge is the only logical solution to the problem of disconnect.
So to eliminate the disconnect with us and the politicians we have to make them more knowledgeable.  We don’t begin by telling the politicians everything we know.  We simply need to ask the politicians what do they think ‘access to care’ is and who ‘access to care’ patients are.  And now here is the hard part… we have to listen and shut the hell up.  How can we possibly educate someone if we have no idea where they are coming from or where their knowledge lies?   Once we know this we can begin to educate and hopefully make them understand.  Will this solve ‘access to care’?  Of course not.  But remember, the issue is midlevel providers.  Access to care is merely a political vehicle that politicians drive to promote their agenda and get re-elected.
At this point most of the ‘midlevel provider cards’ are stacked against us.  Politicians can point out the other states where midlevels have been used and so far no casualties.  They will tell us that midlevel provider dentistry will be more affordable than ours.  The FTC, yes the Federal Trade Commission, has already weighed in on the subject of midlevels in a letter to CODA.  They feel that not allowing midlevels is a restraint of trade and that midlevels should be able to diagnose and make treatment plans without any supervision.  They have certainly become the 900 pound gorilla in the room.  And politicians have a vote, “the vote” and we do not.
But to bring anyone over to your point of view, we need to make them understand.  Again as Veronica Roth stated, “Ignorance is not stupidity, but a lack of knowledge”.
So I will leave you with 2 quotes.  Lewis G. Carroll said in the book Alice in Wonderland , “If you don’t know where you’re going, any road will take you there.”  The IDA must have a vision of where it wants to go and the courage to go there.
And finally.. “First rule of leadership:  Everything is your fault.” This was actually said by Hopper in A Bug’s Life.
So I welcome the challenge, I look forward to annoying Dr. Murray for a year, and I am very excited to be your new president.
I would also like to put in a plug for French Lick in 2015.  Bring your family, bring your staff, bring everyone you can think of. 
Thank you!

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