Overcoming the Money Taboo

By Dana C. Ackley, Ph.D. (Originally published in Dentistry Today, September 2000)

He was a psychiatrist attending one of my business of practice seminars: “Do I have to talk to patients about money myself?” Psychiatrists are supposed to be able to talk to anybody about anything, right? Yet, the thought of talking to his patients about the financial part of their relationship was just too daunting. He wanted his office staff to handle it. His feelings about money resonate with those of the vast majority of health care professionals, including dentists.

Various rationales are used to avoid noticing the emotional discomfort discussing money creates:

  • “I’m too busy.”

  • “I don’t care about money as much as I do helping my patients.”

  • “That’s what I have staff for.”

  • “My patients would be uncomfortable.”

  • “I would look greedy.”

Each rationale carries enough truth to keep most of us from looking further, into the real sources of uneasiness. Unfortunately, these feelings impact other aspects of the practice as well. Getting straight about money can solve a variety of related practice problems.

Money is an unavoidable part of a dental practice. The resources to provide your services must come from somewhere. When money is not handled well in a practice, everyone suffers. Among other consequences:

  • dentists are underpaid

  • patients develop a dependency attitude that interferes with treatment compliance

  • staff deal with emotional fallout from dentist and patients, creating unnecessary and disruptive office tensions

Are you having trouble, like my psychiatrist friend, in taking charge of the money part of your practice? Ask yourself these questions:

  • At the end of the day, do I feel adequately compensated?

  • Am I spending a large percentage of office resources chasing insurance and/or patient payments?

  • Do my patients complain about my fees or making payments?

  • Are my receivables too high? Do I even know what my receivables are?

  • Have I established clear financial policies that my staff and I then use with patients?

  • Am I having conflicts (hidden or open) with my staff about their compensation?

  • Do I have a sound financial plan for my personal financial future or have I avoided thinking about it?

While money is an emotional topic for everyone, it is especially troublesome in healthcare. As evidence, consider all of the current furor and conflict regarding managed care and other attempts to fund the health care system. All of us have been affected.

There are many factors that can fuel money anxiety. Two of them are personal - how money was handled by our parents and our current financial situations. The others are based in our professional work

Personal Issues: Our parents, wittingly and unwittingly taught us a lot about money. For example, suppose you grew up in a family in which your parents argued a lot about money, a common experience. Children can do little about such disagreements. Yet they understandably get frightened about the emotional intensity such arguments can embody. In self defense, many children learn to pretend arguments about money aren’t happening, an adaptive response. When tension about money arises in their adult lives, they are vulnerable to returning to this default response of avoidance. While the response was helpful to the child, using it as an adult leads to an undirected financial life. Decisions made in childhood often persist into adulthood because we forget to notice and question old habits. The price is that an 8 year old may be running the financial aspects of your dental practice.

Of course, it is not just dentists who grew up in families with various financial traumas. Many of your patients grew up in similar circumstances. Your anxiety, mixed with their anxiety, can create a pretty tense discussion, encouraging you to abandon efforts to discuss money with patients.

In addition to our past, current circumstances have a major impact on your money comfort. Suppose you and your spouse have very different goals and financial strategies. Money may be associated with anxiety or anger. Or suppose that your willingness to “be nice” and work with people’s insurance policies leaves you with a large percentage of under-reimbursed procedures. Add to this that your retirement is underfunded and that you have two high schoolers anxious to go to top universities. Having several of these factors in your life can kindle a lot of anxiety.

Professional Factors: Added to our personal backgrounds are the professional factors that make money a tough subject. The most powerful of these may be the guilt healthcare professionals often experience in asking to be paid for helping. Some of this guilt is fueled by our own beliefs and some is fueled by patients’ expectations of how dentists “should feel” about money.

Do you recall being sick as a child? What happened? For most of us, it was a time to escape from responsibility. No school. No homework. Mom or somebody would take care of us selflessly. It was extremely comforting. Unfortunately, this experience unconsciously becomes the model many of your patients default to when faced with significant dental problems. They forget that you are not their mother and that they are no longer children. They want to be taken care of. In their minds, you have offered to do it, volunteered to be their mother, by being a dentist. When you ask to be paid, their response is often some form of: “I’m in pain. You’re a helper. You want MONEY from ME!? You selfish pig!” Dental insurance feeds this unconscious fantasy that “someone should take care of me.”

There is a part of most health care professionals who, without recognizing it, buy into this notion that we are to be all nurturing. We went into our professions out of a sincere desire to help others. We were taught, by people making a steady salary, that patients always come first. Our mentors’ silence on financial matters suggested that it was a dirty subject and that there was something wrong with professionals who were “too interested” in making money.

Solutions: If the problem with money in professional practice is fueled by anxiety and unrealistic beliefs, then the solutions involve achieving a calm, reality based approach to money. As the professional, it is our job to offer leadership to our patients and to our staff on this difficult topic.

The first step to realistic thinking is to understand what money really is. The meaning of the word is distorted by the many emotional topics money touches, only some of which can be reviewed in a single article. The dictionary is an excellent resource of reason. It reminds us that money is “A commodity . . . that is legally established as an exchangeable equivalent of all other commodities and is used as a measure of their comparative value in the marketplace.” In other words, money is simply a tool people use to trade goods and services. It is neither good nor evil any more than your dentist drill is good or bad. How we use tools can be good or bad, but the tool itself is neither.

The second step is to face whatever anxiety comes from our personal past and present. Assessing our past and current situations can help identify irrational beliefs that guide our behavior and feed anxiety. (See the end of the article for information about a questionnaire that may aid your efforts at self understanding.) Regarding problems from your past, the good news is that, now that you are an adult, you have many more personal resources to use to solve money based anxiety than were available to you as a child. Knowing this can help you to choose to resolve issues anchored either in the past or present.

The third step for many of us is to change how we think of our patients. Because we went into our professions to help people, it is common for us to think of them only in terms of their pain and need. Such thinking leads patients to see themselves that way. Fortunately for everyone, your patients are more than their pain. They are human beings with need but also with strengths, resources, coping techniques, and healing powers (without which we are totally ineffective). We need to think of everyone as a total human being. Charging a person a reasonable fee feels much different than charging someone whose total identity in our minds is a severe toothache.

Another benefit accrues when we remember that our patients are total people. When we only think of someone in terms of their pain, it is difficult to have a genuine relationship with them. You cannot have a real relationship with just part of a person. When we think of a patient as a total person, we are in a much stronger position to create a real relationship with them. Why would we want to? Patients involved in real relationships with dentists are more compliant with treatment needs. They get better results. Further, most dentists enjoy their practice more completely when dealing with real people.

The fourth step is to let go of the unrealistic belief that we should be all nurturing, and help our patients do so as well. Both you and they will benefit. We are not their mothers. The reality is that a professional is a paid helper. It is not helpful to base a professional relationship on a myth. We are one adult working with another adult. (If you have a pediatric practice, then the money part, of course, is conducted with parents.) We do have responsibilities to our patients, but they also have responsibilities to us. This is simply real life. Having realistic expectations leads patients to behave in a more adult fashion, i.e., take care of their part in taking care of their teeth.

Irwin Becker, D.D.S., Director of Education at the Pankey Institute, offered an excellent perspective on this topic. In a recent address to dental school graduates, he defined professionalism as follows: “The use of superior care, skill and judgement to the benefit of the patient, prior to any self reward. Please note that it doesn’t say without self-reward. Just prior to. Thus, as long as we do our very best, with the benefit of the patient first, then we can make a profit.”

Patients make themselves vulnerable to us. We must honor their trust by doing our very best for them. However, we also make ourselves vulnerable to them. In reality, we must make a living. We depend upon our patients to make that possible. This exchange of services for money that we can then use for our wants and needs creates a partnership between equals. Further, well paid dentists are happier dentists. I always prefer a happy dentist in my mouth.

Readers will notice that these four steps all involve changes in the dentist’s thinking. Why? Our feelings and behavior are controlled by how we think. If we change how we think, our feelings and behavior will naturally change. (It may not be as easy as it sounds but the theory is solid.) As your thinking becomes clear, you will be in an excellent position to help your staff think and act appropriately to reality. This will make them feel better. You and they will then be in a good position to do the same for your patients.

Let’s return to our psychiatrist friend’s question: “Do I have to talk to patients about money myself?” The answer is: “Sometimes.” When you and your staff are aligned in your thinking about money, and you have put into place sound financial policies, your staff will be able to handle most financial issues with your patients. However, difficult situations still will arise. Your touch and involvement can make the difference between keeping and losing a patient. It can even keep you out of a lawsuit. (Conflicts over payment are the single most frequent cause of malpractice suits. Lawyers often foster those unrealistic expectations discussed above for their own reasons.)

Further, as leader of your office, it is important that you never ask a staff member to do something with a patient that you are unwilling to do. If you want them to face the anxiety of asking for money and be effective in doing so, you will have to ready to participate sometimes. Staff will respect your leadership. In addition, training staff in this difficult, touchy area can only be as successful as your skills and comfort level.

Money has been a taboo subject in professional offices for too long. We can face our unrealistic beliefs and exchange them for those based on reality. As we do so, we become better professionals and our patients get better results. It is win-win.

For a free copy of a questionnaire designed for health care professionals to assess their own issues about money, both past and present, contact Dr. Ackley.

Dana C. Ackley, Ph.D. is a Consulting Psychologist in Roanoke, Virginia. He has been a guest presenter at the Pankey Institute. He consults regularly to dentists and other health care professionals on organizational issues such as goal setting, team development, communication, and practice building, and emotional intelligence. He can be reached by email at dana.ackley@eqleader.net; by phone at 540-774-1927; and by mail at EQ Leader, Inc., 2840 Electric Rd., Suite 208, Roanoke, Virginia 24018

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