The Millionaire Dentist Podcast

The Psychology of Case Acceptance with Dr. Paul Homoly

Listen to "E21 The Psychology of Case Acceptance with Dr. Paul Homoly" on Spreaker.

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On today's episode, we talk to case acceptance guru Dr. Paul Homoly. Dr. Homoly is a world-class leader in dental education and has written several books paul-homolyincluding what many consider the bible of best practices for case acceptance, "Making it Easy for Patients to Say “Yes.” 

Dr. Homoly gives us several real-world tips you can start using in your practice today. Forget all of those techniques you learned in other CE programs, they don't work; listen to the podcast and find out why they don't and what Dr. Homoly recommends to get your patients to say “yes" to case acceptance. 

Some of the questions we ask him:

  • What are some misunderstandings or limiting beliefs about case acceptance?
  • Is it better for the patient to see you as an advocate or an educator about their dental health?
  • How do you handle a patient who doesn’t have any concerns about their teeth? They have a condition not a disability. 
  • A lot of dentists seem to handle the “bread and butter” type case acceptance ok, but when you get to the higher cost dental work they lose it. Why is that?
  •  How do you present complete care to patients without losing them to sticker shock? And how do you make the patient not feel embarrassed about not being able to afford a needed treatment?
  • Practice management experts might say if the patients aren’t accepting the care you didn’t educate them well enough. Do you agree with that statement? 
  • It’s been well over a decade since you released your iconic book “Making it Easy for Patients to Say “Yes”. If you had to update that book today, what would you add or take out? 

Dr. Homoly's website

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Podcast Transcription:

Speaker 1: Hello everyone. Welcome to the Millionaire Dentist podcast, brought to you by Four Quadrants Advisory. On this podcast we break down the world of dentistry finances and business practices to help you become the millionaire dentist you deserve to be. Please be advised we do speak with an honest tongue and may not be safe for work. Now, here's your host, Alan Berry.

Alan Berry: Hello and welcome back to another episode of the Millionaire Dentist podcast. On today's episode we have Dr. Paul Homoly. Dr. Homoly is a world class leader in dental education. In 1995 after a 20 year career he retired from clinical practice to devote his time to training, coaching, consulting, and authoring. Dr. Homoly has written several books including Making It Easy for Patients to Say "Yes", which many dentists considered to be the Bible of best practices for case acceptance. He also provides seminars, workshops, and consultations on the topics of dental case acceptance, practice development, key opinion leadership, speaking, and practice management. Ladies and gentlemen, we are very fortunate to have this man on the show today. Dr. Paul Homoly. Thank you so much for coming on the show.

Dr. Paul Homoly: I'm sitting on my desk. I've got my [inaudible] sitting next to me, and it's a beautiful sunny day here in Scottsdale Arizona. So I've been looking forward to this conversation for a while, Alan. Looks like you guys are doing a lot of good for dentists.

Alan Berry: I had been looking forward to this conversation as well. Whenever we can get a world class expert and storyteller on the podcast I know it's going to be a good podcast, and at the end our listeners will benefit from that. So thank you so much for coming on. Let's start with what are some misunderstandings or limiting beliefs when it comes to case acceptance?

Dr. Paul Homoly: Well, the biggest limiting belief... and this is especially true for the complex care case. This is the case that's above 3500, 5000, 8000, 10000, I'm talking about the more complex care case. The big limiting belief there is that patient education is the driver, is chief influencer of patients saying yes to care. You see when the patients needs are modest, that is it might be a filling or two, or a [inaudible] or a crown. Typically, when the fees are less than let's say $3500 then the case acceptance process is more of a, "Here's what you need and here's how we're going to do it."

Dr. Paul Homoly: If you are my modest care patient and I looked at you and examined you and I sit the chair up and I say to you, "You know Alan I can see where that tooth on your lower left side is sore. I can see a large crack in it. I also see that you haven't been to the dentist in a while, and I understand that you've been busy with travel. My recommendations are we'll remove that chipped and cracked filling on your lower left side and replace it with a new enamel like material. I also would recommend that you see my hygienist, Rita. You'll love Rita. She's been on practice for years. She'll help you identify areas in your mouth that are prone to infection. We'll clean those areas up, and we don't want the infection spreading to other teeth. Alan, what questions or comments do you have for me?"

Dr. Paul Homoly: You see with a modest care patient, Alan, the conversation is more about here's what you need and here's how we'll do it. Now, that what and how approach stops working in the case fees get up to 5, 8, 10, 12, 15 thousand dollars. You see these patients know they've got dental problems. They may not know every detail with the dental problem, but they do know that they're not happy about something. And because the fees oftentimes far outreach the insurance company benefit plan the driver of the case acceptance process for the complex care patients is not so much about what and how but it's rather about why patients want to get their teeth fixed and when it needs to fit into their life.

Dr. Paul Homoly: You see, we tell patients what we're going to do and how are we going to do it. However, patients need to tell us why they want to get their teeth fixed and when it needs to fit into their life. So the big misconception is that patient education is the secret sauce of the case acceptance. And what I would say there it is the secret sauce for the modest care patient because oftentimes they're not aware of their dental problems.

Dr. Paul Homoly: However, the complex care patient is aware they've got a dental problem. So telling them what and how they've heard that before. They probably heard it many times before. The reason they haven't gotten their teeth fixed is that the dentist who's servicing them didn't understand why they wanted their teeth fixed and didn't get curious about when it was convenient for this patient to fit it into their life.

Alan Berry: When you say when are you also including when they can afford it as well or are you merely saying when as like a time factor?

Dr. Paul Homoly: Oh, no. When is all about affordability. It's all about suitability. You see, the suitability aspect of dental care is the number one reason why complex care patients don't accept care. When, meaning when this dentistry will fit into the issues, into the events of the patient's life. Those events would include their budgets or health issues, their family issues, travel, their work schedules, all of the complexity of a person's life need to be factored into the when issue. So when it's about those issues of fit how do we set the dental care recommendations into what's going on in your life now? Or do we do it later or do we do it a little bit at a time? That way patients get the sense that you're acknowledging their life events.

Dr. Paul Homoly: It's life events that are the obstacles for patients to accept complex care dentistry. It isn't that patients don't understand they need complex care dentistry. It isn't that they don't understand some of the rudimentary processes for fixing their teeth. What patients push back on is that it's not the right time for them. And too often dentists don't acknowledge that and they present complete care with no understanding of what's going on in the patient's life and how their dentistry needs to fit into their life. It's not difficult to discover those things, but you have to be in the right mindset to be curious enough and have the verbal skills enough to ask the questions, the answers to which satisfy the why and the when.

Alan Berry: Do you see yourself as an advocate or an educator, a little bit of both? How do you frame that up?

Dr. Paul Homoly: It's really strong in the terms of advocates. The word advocate means to guide or to lead, and for the complex care patient the mindset providers need to have is that as advocate that is helping patients find a way. Guides help people find a way. For example, Alan, let's say you needed $10000 worth of dentistry, and the reason that you want the dentistry done is because you're a successful financial service provider. You find yourself speaking to audiences and you're not totally comfortable with the appearance of your front teeth and you've got maybe a missing tooth that's kind of shows when you smile, and after a while it begins to kind of prey on your mind.

Dr. Paul Homoly: So you come in. One of the first things I'm going to do is ask you, "What brings you in today, Alan?" And you say, "Well, I'm not happy about these front teeth and I got a tooth missing over here." Now, if I was to put on the hat of patient education at this point I would tell you, "Well, here's what's going on." And I would describe the etiology of tooth loss, periodontal disease. I would talk about maybe different treatment options for the anterior teeth. I would get into a process centered conversation.

Dr. Paul Homoly: Now, if I put on the hat of advocate, that is of a guide after you say, "Well, I don't like the front teeth. I got a tooth missing [inaudible 00:08:37]," I'd say, "Well, Alan, I understand that. Let me ask you something. You've had these problems for a while. Is there anything going on now that makes having a better appearance important to you? Is this something that's related to what's going on with your job or maybe in your personal life? Why now?" And then you respond, "Well, I'm this and that," and then you reveal to me why good appearance is important to you.

Dr. Paul Homoly: You would say, "I'm speaking to groups. I'm in the professional community. I work with other people with good looking teeth, and I'm beginning to get a little self conscious about it." You seen now, Alan, as the guide I understand why you want to get your teeth fixed. Once I understand why now everything that I do is going to relate to your reason why. So I do my new patient interview. When I'm done with the interview I would say to you, "Alan, going back, let me take a look at your teeth. I'll introduce you to my team and let's see if we can get you more confidence in your appearance in front of professional audiences." See, I have linked your behavioral benefits to the processes that I'm doing. So I'm going to put the hat of advocate or guide on when I'm working with the complex care patient and I'm going to wear the hat of educator when I'm dealing with modest care patients. Does that make sense?

Alan Berry: That makes a lot of sense. And it brings... a question to my mind is it seems like a lot of psychology is involved. How did you come about this? Was it just all your experience and you just kind of understood this as you worked these problems or how did you come to this conclusion or this thought process of using the psychology behind how somebody reacts to getting some news that maybe they don't want to hear?

Dr. Paul Homoly: I laugh when I get that question. Here's how I arrived at it. I followed everybody's advice and it didn't work. Very early in my career, Alan, I'm talking about the first year in my practice, I started taking practice management courses. Hey, I was a young dentist. I had a young family. I was in debt. I wanted a decent car. I wanted to give my wife kind of peace of mind. We had two young kids. I basically was living from check to check. And I'm taking these practice management courses and I'm hearing all these wives tales and these cliches about case acceptance, things like patients don't care how much you know until they know how much you care. And I heard that a thousand times and I'm thinking, well, that doesn't do me any good at this. There's no directionality in that statement. It just tells me that I'm not there yet.

Dr. Paul Homoly: And I did the patient education. Understand I'd been through the Pankey Institute. I've been to the Dawson Center. I've been a student of John Kois. I have a lot of high end continuing education in implant and reconstructive dentistry. And don't get me wrong here, the clinical gurus are my heroes. But you got to be careful when they start giving you advice about case presentation and case acceptance. They go down a very strong line on educate, educate, educate. And I did that. I was blowing patients out of the water.

Dr. Paul Homoly: In the beginning I kind of blamed myself. I said, "I got to be doing something wrong. They're saying, "Here's how you do it." Well, I'm doing it like they said to do it, but it's not working. I must be doing something wrong." And it took me about, I don't know, 8, 10 years to finally realize, you know what? I'm losing too many patients to sticker shock. People are hearing... like you said earlier, Alan, I'm giving them bad news and I'm just telling them here is what's wrong and here's what you need and here's how much it will cost. And I wasn't at all visiting the idea of why they wanted to get their teeth fixed.

Dr. Paul Homoly: So I went through a period where I just said, you know what? I am not going to do any of this educate, educate, educate. What I'm going to do is I'm going to get to know people. And I gave them a glimpse of who I was beyond my role of dentist. And when I would talk about my kids, they would talk about their kids. When I would talk about where I went on vacation, they'd talk about when they went on vacation. This process of getting to know people, of discovering how dentistry needs to fit into their life, patients need to fit your dentistry into.

Dr. Paul Homoly: So when I would present care I would present it in context of what was going on in their life. So for example, Alan, in your case where you're not happy with the discolored front teeth and the missing tooth on one of your sides here, but I also know that you've got a young family. I also know that you're modeling your house. I also know that you're taking a trip to Spain to visit your wife's brother. So when I present care it's going to sound something like this. I say, "Alan, you know I've had a chance to look at your teeth and to study your X-rays and your diagnostic material. I feel pretty good about getting you really confident in front of audiences when you speak. You and your wife are planning to go to Spain. You're remodeling your house. You've got a lot going on right now."

Dr. Paul Homoly: The reason that I mentioned that is that all patients, Alan, have got budgets, and we need to decide at some point when is a good time for you to get your care done. "Is this something that you're interested in now or maybe later or maybe we do it a little bit at a time? Allan, help me understand that?" Now, what I've done is I haven't educated this patient to how I'm going to fix their teeth. What I've done here is I told them I feel confident of getting you looking good in front of audiences. See, that's why you're in the chair. So the process that I teach is basically... and your question was how did I learn all of this? Trial and error, that's how I learned it.

Alan Berry: How do you handle the patient who doesn't have any concerns about their teeth? You're talking about me. I have the concerns. I realize that there's an issue there. But if they have a condition and not a disability how do you approach that type of patient?

Dr. Paul Homoly: Yeah. What I do during the examination, Alan, what I do is I first make the patient aware of all the conditions I see. So you're in the chair. You've complained about the front teeth and missing tooth. But you know what? You've got some cracked [inaudible] over here. You've got some gum disease. You've got some asymptomatic periapical abscesses, and you've got a third molar sitting back there that's pushing up against the distal root of the second molar. You don't know about any of that. What you do know is your front teeth and that one missing tooth over there. But you see, so much of your dentistry is unknown. So through the process of patient education I make you aware of everything in your mouth. This is immediately after the exam. This is the post exam conversation.

Dr. Paul Homoly: The second thing I do I give you the consequences of those conditions if left untreated in patients similar to you. For example, let's say you were unaware of your gum infection, your gun disease. I would say, "One of the things you might be unaware of, did you know that you have some gum infection?" Alan, you say, "Well, no I didn't." "[inaudible 00:15:56] many patients have gum infection and not know it. A gum infection, like the kind I see in your mouth, if it's left untreated I've seen in many patients that infection spread to other teeth and in more severe cases the gum disease can lead to tooth loss. Now, does this concern you? Is this something that you'd like to know more about?"

Dr. Paul Homoly: You see what I'm going to do is I'm going to determine your level of concern. I'm going to go through every condition in your mouth. I'm going to make you aware of it. Number two, I'm going to give you a sense of that condition if it's left untreated in patients similar to you, and number three, I'm going to determine whether you're concerned about those consequences. Now, depending on how you answer those questions... You might say, for example, the third molar that's laying up against the root of the second molar, I say, "Alan, are you aware that you had [inaudible] tooth?" "Oh, yeah, I remember Dr. O'Malley. I went home to visit my family and I went to my family dentist, and he mentioned that to me. That was 15 years ago. And he said if it gets to be a problem I should probably have it removed. It's really not bothering me."

Dr. Paul Homoly: Well, you just told me you're not concerned about that third molar. Okay Now, when I get to the point of presenting care to you I have an ethical and legal responsibility of presenting care for all conditions, whether you're concerned about them or not, but you see, there's a smart way and a not as smart way of presenting treatment for conditions patients are concerned about.

Dr. Paul Homoly: So for example, you're concerned conditions, like the front teeth and that missing back tooth, I would say something like, "Alan, I know you're concerned about the appearance of your front teeth. My treatment and recommendation would be... " And then I would give it. And also know, Alan, you mentioned me that you're worried about your parents from that missing tooth over on this side. And then I would give a treatment recommendation. You mentioned to me that you were not concerned about that third molar or that wisdom tooth laying on its side. And I understand it. But I want you to know that I am, and when you're ready my recommendation would be to remove that too. When you're ready, I'll be here.

Dr. Paul Homoly: Now, you notice the way I recommended care for the condition that you weren't concerned about. What I said was I understand you're not concerned. You see, what does that demonstrate to you as a patient? When you've told me that you weren't concerned and then I voiced what you just said back to me, I'm not agreeing with you, I'm just acknowledging to you what you've said. How does that feel to you?

Alan Berry: To me it feels like you're being empathetic. It seems like you're caring for me maybe more than I'm caring for myself and maybe I should be caring for this issue.

Dr. Paul Homoly: Yes, that's exactly right. You see, what I'm doing is I'm giving you permission to feel the way you want to feel. I have a fiduciary responsibility. You as a financial service provider can understand the word fiduciary, that is you put your clients' needs in front of your own. Well, it's the same thing with dentistry. I need to put the patient's needs in front of mine, but you see, I can't close my eyes to a condition that I know that it's not in their best interests. I want to make the recommendation to where I don't start a contest with the patient. If I say to you, "You've got a third molar that needs to come out. It's going to be $450 for the extraction and then another 250 for the conscious sedation. And you need to do this as soon as you can." Well, that's just going to invite a contest.

Dr. Paul Homoly: "Well, Dr. O'Malley told me 15 years ago I didn't need to do anything about it." Now, it's a contest between me, you, and Dr. O'Malley. It doesn't need to be like that. All I need to do is acknowledge, make you aware of the condition, acknowledge the consequences of that condition if it's left untreated, and determine your concern. If I do those three things, Alan, I have met my fiduciary responsibility. And if you're not ready to have that third molar removed you're going to say, "Well, I'm really not concerned." My response to that would be, "I understand. When you are ready, I'll be here."

Alan Berry: Yeah. No, that's powerful because you're interjecting empathy and you're showing concern for the patient by not hard selling them. You're telling them that you understand they're not concerned, but you as a doctor are concerned. And I think that that's powerful. And the fact that by this point you've built up a rapport with them by talking about their kids and your kids and things like that I think your words probably come across stronger to them. Is that fair to say too? Is that part of the rapport part too?

Dr. Paul Homoly: Sure. You see, what I've done with you as the patient I've made an easy for you to succeed in pursuing dental health. You know how I've done that? It's that I've connected with you as a provider. I've talked to you in such a way that you're not going to go shopping for another dentist, not after you have experienced the kind of rapport and the kind of connection that I've created with you. And it might be that you never get the third molar pulled, and that's fine. If there's no condition, if there's no symptom, if there's no negative sequelae to any of it, good for you. But I have met my responsibility. Your responsibility is letting me know if symptoms do arrive. Now, I've already told. It isn't like it's some surprise that I didn't tell you about later on.

Alan Berry: To me, the way you present it you're not presenting it like it's a responsibility of yours. You're talking about it like in a caring way, which I believe you're generally caring too. So to me I don't see it as a... the way the patient views it is that you're not telling them your responsibility. You're being a caring person.

Dr. Paul Homoly: Yeah, I'm being their advocates. It's just like you are an advocate for your clients in financial services. Your clients aren't going to do everything that you say to do. But they may pick out the big pieces, and there might be smaller pieces that they're not ready for but you play them out. They're on the table. It's so year after year after year as you're in relationship with these people when they do become ready to maybe start saving for retirement or change their asset allocation in their investment portfolio they may not be ready to do that the first time they hear it but through your personal connection they're going to hang around, and at some point they may become ready. And everybody wins like that.

Alan Berry: Do you find that sometimes when you're teaching or when you're presenting and you have a couple of dentists that aren't really getting it do you think that you're fighting against years of maybe the way they were brought up or previous relationships? Is there sometimes baggage that dentists bring to the table that are hard to break to get them to this way of thinking?

Dr. Paul Homoly: Oh, God, yes. The easy part, Alan, is to sit back and write a book or make an online program and putting the content out there. Here's what you need to know. If educating people was the key to changing them then we would all have ideal body chemistry, body weight, and fully funded pension plans. It took me 10 years to really figure it out. It won't take my students 10 years. If a dentist really studies my stuff, goes onto the online program and really studies it and works at it and trains his team it's going to him about eight months to a year to really move the needle in their practice, because behavioral change is like a golf swing. I've got a awful golf swing. I take golf lessons about every two weeks, and it's so hard to change that habit of me flipping my wrist through the impact zone.

Dr. Paul Homoly: It's so hard for dentists to change their verbal patterns or their verbal habits when it comes to speaking to patients because they are so bought into dentistry is education based, scientifically based. Well, weight loss is scientifically based. Financial planning is scientifically based. Why isn't everybody rich? And why isn't everybody skinny? Because we're not ready to be skinny and rich. And some dentists like to play the role of victim, "Well, it's the damn insurance company," or something.

Alan Berry: A lot of dentists I understand seem to handle the bread and butter type case acceptance fairly well. But when you get to the higher cost in the work they lose it. Why is that?

Dr. Paul Homoly: Life events, fit issues come into play, and you can't educate a fit issue away. The dentist will educate in the face of a fit issue. And when that happens what it feels like to the patient it feels like sales pressure. And once the patient gets the sense of sale pressure, pow, they're gone. They're gone. And that's when you get the phone call two weeks later, "Alan wants his records transferred to the dentist across the street," and then used the dentist. You think, "Well, low dental IQ." Low dental IQ.

Alan Berry: Blame the patient.

Dr. Paul Homoly: Blame the patient. Yeah. And this is not to downgrade dentist. I love dentists. Don't get me wrong. If a dentist is having challenges with case acceptance they need to stop looking at the patient as the problem and start looking in the mirror. There's where the problem resides.

Alan Berry: No, that's true. And sometimes the dentist, they get bad advice. Practice management might say if the patients aren't accepting the care you didn't educate them well enough. So I imagine that happens.

Dr. Paul Homoly: Oh, man, absolutely. That's what led me astray for the first 8 or 10 years of my practice is I listened to clinical gurus and practice management experts who were driving nicer cars than I did and they were dressing nicer. They were obviously more successful than young Dr. Homoly. And they're saying, "If someone doesn't accept your care it's because you didn't do your job of educating them enough. Now here's how you're going to do it." And then they talked about how to take study models and photographs and face bows and how to talk about pocket reduction. And it just gets beat into their head, and after a while the belief doesn't go away. It doesn't go away. Beliefs are real sticky.

Dr. Paul Homoly: When I was a young catholic boy going to Sunday school the nuns would say, "If you ate meat on Friday and you knew it was Friday and you died afterwards you're going to go straight to hell." And I went to public high schools. They had big cafeterias. And I remember getting the ravioli, the beef ravioli, sitting down at the table. I'm starving. And one of my Catholic friends right across table screams at me just before I'm ready to eat, "It's Friday." And after this Friday do I want to starve or go to hell." Years later one of the popes changed the rules and now it's okay for Catholics to eat meat on Friday except doing lent. But you know what? When I go out to a restaurant and I sit down and look in the menu you know what's one of the first things I think about?

Alan Berry: Is it a Friday?

Dr. Paul Homoly: What day is it? You see, what I'm saying here is that beliefs die hard, and I'm telling you this patient education belief it will never die in some dentist. What I recommend is you kind of put it to the side, just put it to the side and adopt a stronger empowering belief. And that's really at the heart of my work.

Alan Berry: It's been over a decade, well over a decade, since you released your iconic book Making It Easy for The patients to Say "Yes". If you had an update that book today is there something that you would add or take out?

Dr. Paul Homoly: No. No. What I would do is what I've already done. No. The foundational philosophy and practices are the same. What's changed over time is my ability to teach it. And what I have done with that book is I've converted it into an online program to where the content is denser. I've got video, audio, job aids, discovery guides, continuing education credits. If somebody reads the book they don't get CE credits. So I can get CE credits. The technology has allowed thought leadership to be more scalable, meaning that I can reach more people with it. So I have dentists who've got my videos on their smartphone, and before they go into a consultation with a patient they'll play one of my videos. They listen to my verbal pattern. They listen to, "When you're ready I'll be here," those types of praises and they listen to it. They shut it up and they go in there and they do it. You can't do that with a book.

Alan Berry: Hey, how about this, Dr. Homoly, why don't you tell the people at home how they can find you and how they can sign up for your course? What do they got to do?

Dr. Paul Homoly: It's really easy. They go online my website You go into products. You find Making It Easy for Patients to Say "Yes" online program. They click through it. There's a lot of sample videos. You can read all about it. My goal is to enroll as many people as possible on this so we can reach a tipping point to where we can begin to alter the mindset of the profession of dentistry. My goal isn't to sell online program. My goal is to make the profession of dentistry a better place to be. That's the legacy I want to be known for.

Alan Berry: That sounds pretty good to me. Dr. Homoly, you're a big inspiration. I really appreciate you coming on the show today, and I feel that a lot of our listeners probably got a lot of solid wisdom and good advice from you today. So thank you so much.

Dr. Paul Homoly: Well, Alan, and I said this earlier before we turned this recording on, I studied your website to look at what the Four Quadrants are doing for its clients and I've looked at the testimonies and let me say this right back at you, in terms of serving our profession well, helping dentists transition their practices, helping dentists achieve financial freedom, that's a big deal. That is a big deal. When dentists are financially strapped they're afraid that they don't have enough abundance in their life. If you can change that, if you can give dentists the confidence of abundance then my work becomes so much easier because they're not living out of fear anymore. They're living out of how can I grow as opposed to how can I keep from failing. That's a big mind shift. So right back at you, Alan, and the Four Quadrants.

Speaker 1: That's all the time we had today. Thank you to our guests for their insights and for sharing some really great information, and thank you to you, the listener, for tuning in. The Millionaire Dentist podcast is brought to you by Four Quadrants Advisory. To see if they might be a good fit for you and your practice go on over to and see why year after year they retained over 95% of their clients. Thank you again for joining us and we'll see you next time.