Precision of Persistence: Dr. Nestor Karas on Mastery, Mentorship, & the Mindset of Peak Performance

Persistently trying to level up. There were very few people, I think, that had the drive to work and and I think that's what made the difference for me. It just persistence. The one-size-fits-all approach is absolutely not the right way to do things. Yeah. I mean, that's I I look at myself as an educator. I'm I'm educating them as to what their options are. Having that surgical experience in a broad variety of procedures allows you to do the routine procedures much more predictably with the least risk possible to the patient. I look at how my kids were raised. I look at how I was raised. It's almost like night and day, right? The challenges and the demands are so much greater now with social media and everything that goes on. The level of anxiety and complexity of relationships is so much different. Dr. Nester Carris. Uh, wow. What a what a privilege to have you here, sir. Outstanding opportunity to speak with someone who I admire so greatly. Um, welcome to the show. And as you know in this show we have you pick the charity and the charity that you chose was the Navy Seal Foundation which obviously is uh you know one that we uh we appreciate and and u and think is fantastic. So well thanks for the invitation. It's a pleasure being always with you Jock. And yeah I think given that uh September 11th was just passed I think it's a good idea to honor those who served. Yep. Amen. you have had a incredible career truly when we sit down to talk um it's one of those things where we can really chart Early Life and Education this back and I think the the key thing probably here in order for people to understand just how impactful your career has been is to go all the way back to your origin story. Take us back. Where does it all start? Yeah. Well, I I appreciate that. I'm not I'm not sure I would look at it that way, but I I think what happened with me is I was very fortunate that I had a number of opportunities over the years that came my way and I was either dumb enough or smarter enough to take those opportunities and and see where it took me. I didn't really have any particular plan, but it just worked out. But, uh I I appreciate those comments cuz that's um that's very kind of you. So, it it all started out in Oakland, California. That's where I was born and and raised. I uh went to elementary and junior high there and then my parents moved uh to Contra Costa County to Arinda and went to high school there and and then was um fortunate to go to UP undergraduate and UP dental school in San Francisco and I had a experience uh when I was in high school you know I was your typical high school kid didn't know anything about anything and didn't know what I wanted to do right so uh I went my father had a good friend who was a dentist here in El Discovering Oral Surgery Certo in the Bay Area and he said go go visit Uncle Uncle John and and see what you like. See if you like dentistry. And I didn't really have any particular interest, but I I did. And Uncle John was one of those guys. We called him uncle cuz he was such a good friend of the family. Uh he was one of these guys that everybody loved. His patients loved him. He had absolute command of his practice. It was just a great scenario and situation. He was a great dentist and he sent me to a number of specialists. I went to the orthodontist for a day. I went to the endodonist for a day and then I went to the oral surgeon for the day. And I when I walked into the oral surgery practice, I saw the the buzz that was going around. The the doctor was doing a sedation. I can't remember the the case, but I looked around and I thought, you know, seeing the monitors on one side and the anesthetic assistance and pushing the drugs and getting ready to do the surgery, I thought to myself, this I think I could maybe do. So, you know, I was fortunate. I made that decision early on. So when I got to dental school, I I knew I wanted to be an oral surgeon as opposed to gee, I'm I'm going to kind of decide as I go through. So I was fortunate from that standpoint because of that early positive experience. You knew your track going in. I did. I did. So I I spent a lot of time hanging out oral surgery clinic and dental school. There wasn't a lot of time uh for extracurricular stuff at UOP because it's a three-year program. But I Residency and Training actually did get a chance to go to University of Texas uh to San Antonio and spend a month internship early part of my third year. Um and I spent a month there on the service at uh at UT San Antonio with their service and which was a great experience and and an experience that I would have never been exposed to in dental school. UT Southwest. Uh no that was UT San Antonio. So I was okay, but I was staying with a a classmate from ULOP who had graduated was in the perio program there and and the Parkland program was in Dallas at UC Southwestern and and he said, you know, if you're interested in that program, you should just go visit them for a day. Uh I said, well, I mean, what do you want me to just go there unannounced? He says, no, you know, call them the day before and say you're here in Texas and you want to just visit. So I did do that and you know and they said well you can come but we're not going to really give you any particular tour or any special arrangements because you haven't spent you didn't notify us. So I flew up from San Antonio to Dallas and just walked into the hospital there at Parkland Hospital and was just immediately impressed by the volume of patients and what was going on there that just the mass of of the facility. And then I went up to the to the oral surgery clinic spent you know half a day with the residents there watching them you know basically do exodonial procedures. I went to one of the meetings that evening, it was a Wednesday night meeting. Went to the meeting uh and then I flew back to San Antonio and um although San Antonio was there is is and was a great program. Uh my goal at that point was to try to get into Parkland uh because I just was really impressed with the breath of surgery they had there, the experience there. They had three separate hospitals. They had half a dozen faculty there that were at that time worldrenowned. you know, Bill Bell and Doug Sin and RV Walker and Bruce Eper at Ellis. I mean, you know, those were the the people that everybody wanted to learn from at that time. So, I I was very fortunate. Very fortunate. Yeah. When you drive by it, it's just like Yeah. I recently went back uh cuz my daughter went to TCU, right, for undergraduate and and so I um I called uh my prior chairman, who's now retired, Doug Sin, and we went out with him and his wife Diane to to dinner with my wife, Lillian. And at the end of the dinner, we drove by the new Parkland Hospital. So, they have a new Parkland Hospital. They have a new research facility. And they actually have two brand new university hospitals that are that are um more more private hospitals that are um that are supported by the faculty there. And it's just amazing what they've been able to build there. The resources there just Yeah. It's just it's really impressive. Well, it's kind of like from a dental school dental school standpoint, you look at UOP's new campus and it's just like, you know, I mean, you just go there and you go, "Wow." It's on a whole another level. Parkland is Yeah. It's it's just great to see the progress that's happened there. Yeah. So I think maybe one thing that could be really helpful for people is to Teaching and Professional Experience understand just the disparity in train. I mean like there is a huge gap when we talk about your level of training. of times I think people don't really understand what an oral and maxelo facial surgeon and I emphasize that for effect really means and I think if you could go through and explain what does that training really entail because a lot of you I mean you're not you're not using a lot of it probably on a day-to-day basis but it does play into producing outstanding results in things that you do on a day-to-day basis. Yeah. I mean, I I pretty much do everything that I was ever trained in still today in at at Parkland at University of Texas. The only thing I gave up doing is trauma. So, I did trauma for many years, uh, over 20 years, both at the university when I was teaching and then also when I was in private practice at Charmier Medical Center, Walnut Creek. And although I'm still chair there, the department, I I no longer take trauma call. Um, but I I uh stopped doing that about 5 years ago just because it became difficult to to see patients in the emergency room and stay up all night and then function the next day as I got older. Uh, but beyond that, I I pretty much still do full practice of all the things that I learned at at Parkland. And I think training is, you know, and and when I was teaching and I would tell residents and I would always ask residents, what do you want to do when you go out? Well, Dr. Carris, I want to do this. I want to do implants or I want to just do wisdom teeth. And I would tell him, I'd say, you know what, you may think you know what you want to do, but you have no idea what you want to do because a you don't know whether that's really what you want to focus on, nor do you really realize what kind of community you're going to go into because there may be a community where there are a number of people doing wisdom teeth and there really isn't the demand for that. Maybe they need a traumatologist. Maybe they need someone to focus on orphanathic surgery or TMJ or pathology or combination of all of those things. So why limit yourself? And it's the same thing with training, right? When you're looking, I think for any young person looking at training in oral maxure, as you say, there's a tremendous disparity in not so much curriculum. Curriculum is standardized throughout all programs by KOD, but you know that curriculum varies based on the attendings that are there at that particular time, what their level of expertise is, the resources of the facility, are they connected with the dental school, are they not? What is their level of trauma? You know, trauma is the great equalizer in terms of training for young surgeons, right? So, if you go to a trauma center, you know, you're going to get a tremendous amount of experience, right? When I finished Parkland Hospital after 5 years of residency, I'd done hundreds of facial fractures anywhere from advanced really complicated orbital and midface fractures and and hundreds of mandible fractures. So, it was really second nature and that's really where a young surgeon really learns their surgical skills. Okay. Yeah. And for the viewer that doesn't understand what I mean orbital fractures Challenges and Advancements in Oral Surgery um so around the eye socket cheekbone and then mandible being jaw fractures which you know those are you know those are serious repairs. So when when I think a young person is looking at those residency training programs, you know, it's important to get a breath of experience and once you have that breath of experience, then that will carry on to you throughout your career because you will see cases and you will see patients um that you need to know how to treat and and uh you you can't send them to the university or to other other doctors in the community necessarily, particularly if you live in a in a in a more urban or rural environment, right? So that's the advice I would give to a young surgeon. Well, and the other thing too I think that people maybe don't know is that you have a general surgery portion of what you're doing. I mean that if you could talk about that. Yeah, that's an interesting story. So you know I I went through 13 years of postgraduate education, right? And and I would not I don't say that to scare people away. That's just the way it worked for me because at the time that I was applying for oral surgery programs in in ' 87 86 87 so that was quite a few years ago there weren't many dual degree programs out there. Uh I did interview at one dual degree program and I decided it was not my top choice because you spent so much time in medical school and internal surgery training and very little time I felt very little time in oral surgery. uh the Parkland program that I decided to go to was not a dual degree program when I started and as I was about twothirds of the way through the program uh they created a dual degree program and at the time I I really wanted to go in academics. I wanted to be I was really inspired by my chiefs and my mentors there and I wanted to go into academics which I did and I was told by by the faculty there you know if that's what you want to do then you should really think about going to medical school and getting your medical degree. So I was going to do that. I I applied. There were several medical schools throughout the country that would take people like me that had finished uh dentist dental school and oral surgery training and give them advanced standing as opposed to doing all four years. You would do anywhere from two to three years. And I was going to go to University of Alabama at a good program that was well established uh for people looking to get dual degrees. And I was going to go do a two-year program. As I was getting close to finishing my chief year at Parkland, uh Doug Sin, the chairman at the time, called me up a month or so before finishing. and he said, "Hey, Esther, we have an opening because one of our incoming residents decided not to take the spot because they only had five spots for the University of Texas for Southwestern Medical School. I'll you want that spot? I'll I'll be I'll sponsor you to apply." And I said, "Yeah, absolutely." Because I was married, my wife was working in Dallas, her family was from Dallas, so not having to move, even though I had to do an extra year, it was a three-year program, made a lot of sense. And I'm glad I stayed there because it was a great experience, great medical school. It was interesting to go from chief resident of Parkland where you're basically running a service very busy. I mean Parkland in the summer at that time was probably one of the busiest trauma centers in the world to put it in perspective, right? And and then go a month later be a medical student, you know, a second year medical school and go going to class and and learning how to do blood pressure and take vital signs, you know, but you know, you take it with a grain of salt, right? That's that's part of the process. And so I met a lot of great people and I had a great experience those three years. I was fortunate because I was able to get my my Texas dental license and I was able to practice as an oral surgeon part-time as I was going through medical school. So I kept up my skills and was able to make money to pay for tuition and actually before I finished medical school I was able to get board certified oral max surgery because of that experience. Right. So for me it worked out but after those additional three years you're right I had to do a year of general surgery training. um because I needed to do that in order to qualify for medical license. Every state you need to do a minimum of one year. And so the way it worked out for me, I I applied to Parkland and I knew a lot of the general surgery faculty and staff there to stay another year. But I also applied to other programs too. So I applied to Stanford. I applied to UCSF and I was hoping to not do another internship year. I was hoping to do a second year level training because you're not spending as much time on the floor taking care of patients. second year level, you're spending more time in the operating room, you're spending more time in the emergency room. And uh UCSF came back to me and they said, "Yeah, we would accept you as at a second year level to come and do what we call a PGY2 general surgery training and you'd be working, you know, at the county hospital at at that time was SF General Hospital. Now it's Mark Zuckerberg or Zuckerberg Hospital and then also at Parnasses, right? I mean, that's a heavy duty that's heavy duty hospital. Yeah, it is. And uh so that's what I wound up doing cuz I after 8 years in Dallas, I I I thought if I stayed another year, I'll never leave, right? And I hadn't lived in the Bay Area for 8 years. I didn't know if I really wanted to live in the Bay Area again. And so this gave me an opportunity to come back and check it out. And uh you know, my wife came begrudgingly because she's a Texan and Texans are very proud of their state, but you know, she saw the light after we got here. That's how that worked. Yeah. So, you're at UCSF now and tell us about what's happening as you go. Yeah. Well, that year was um you know, it was I think I did probably five months of trauma service at at at uh San Francisco General Hospital. So, as a second year resident, you're taking care of patients. You're admitting patients out of the emergency room. You're taking them to the O under the telage of your chief resident. You're working a lot in the in the emergency room. Um you're doing triage. um you're you're also doing floor work in the ICU. You're taking care of ICU patients. So, you know, you're doing higher level stuff, certainly higher level care stuff than you would be as an intern. And that's what I really wanted to experience. And to put it all in perspective, how old are you at this age? Oh gosh, I'm I'm in my late 20s, I think, at this point. Yeah, late 20s. So the reason I wanted to point that out is I want to articulate the intensity of this experience. Think about you graduate from high school, you go into you know your your undergraduate uh you know dental school into oral surgery then medical school. That is an int I mean the level it's interesting that you know you your your charity is the is the SEAL foundation because as you know in the SEAL teams uh those guys are always trying to get to another another level. Yeah. Um so it's just interesting the intensity of the work that you did in that in that short period of time. Yeah. You know, it it's interesting and people comment have commented me to me about that over the years and and I would tell you this. I I enjoyed every step of the process, right? I I loved the um the workload and I loved the intensity of it and I I loved working in a tertiary hospital system. It's what I became very familiar with after all those years. Now, there are certain rotations that I didn't love and certainly rotations where I wish I hadn't done. You know, when you're on call every other night when doing cardiac surgery at at Parnasses and you're sleeping in the hospital every other night for a month, that's not particularly fun. I wouldn't want to do it again, but I'm glad I did it because I think it it made me who I am today. But um on the same token, I I enjoyed the process, you know, and and people say, "Would you do it again?" I'd say, "Yeah, I do I would do it again in a heartbeat for sure." And I was just very fortunate that I had all these opportunities. And why? I don't know. Maybe because I'm just stubborn individual and wouldn't say take no for an answer but uh but you know it it was a long process and and it's a lot it can be done a lot shorter today but back in those days um you know I was just trying to go each step of the way trying to get into the best program the best experience that I could and I I figured at the end of the day it would pay off and I think I think for the most part it has you know that's interesting um your pathway to peak performance was persistence Absolutely. Persistently trying to level up. Yeah, exactly. I I can guarantee you I was never the brightest. There were a lot of people uh that were brighter than me, but there were very few people I think that had the drive to um work and and I think that's what made the difference for me. It just persistence. You know, it's so funny. I always say I always have to laugh whenever I hear anybody say that, especially of your caliber, I wasn't the brightest. It's just I always think it's just humility. I mean, yeah, I've been around you enough to know how smart you are and um but yeah. So, okay, now you're in a teaching spot. Yeah. UCSF, correct? And this is a formative I mean, this is a really this is a very important part of your life. Absolutely. I'd love for you to share that. Yeah. I mean, teaching um as again I that's really what my goal was. My goal was not necessarily to go into private practice. I had no no problems going to private pract private practice. But again, I was so much influenced with my mentors mentors at University of Texas that that's what I wanted to be. I wanted to be like them. I I didn't expect to even come close to to their accolades, but I I wanted to try I wanted to I wanted them to be proud of me, I guess, in some ways. Um and I tried I gave it four years and I was I would say that the experience at UCSF was generally positive. Um I I was professionally very fulfilled. I was working in the cranial facial clinic doing advanced cases. I was working I was running the dental facial deformities uh program with the orthodontics and we doing a lot of orthnathic surgery. Uh I was doing a lot of reconstructive. I was doing a lot of advanced implant cases working with the prostidonic uh department for the ectoermal dysplasia kids and the cleft kids and all those are all very challenging cases when it comes to dental implants and bone grafting. So, I I had a tremendous experience there. I would say what I didn't like or jive with was just the politics. I I just I just could not um navigate the the politics of a university system like that. And you know, every every major medical center has its own culture, right? They have their own way of doing things. They have their own focus. Some some are on clinical, some are on research, some are a combination of both. where I came from, University of Texas, it was very much a clinical focused program. Yes, we did research and and a lot of publications were were ca came from that department over the year, collectively more than than most programs, but you know, UCSF it was a different focus. Yes, there was the clinical programs, but the research was the main focus. And quite honestly, that was not my background. That that was not my forte. And that was just not my interest. And it it obviously became it became obvious to me that the only way to really advance in that pro in that system not so much in the department but in the system at large because everybody pretty much has the same path for advancement um that you needed to do basic science research at a very high level. I I just really wasn't a able to come to grips to make that commitment. Yeah. It's funny. Michael Dr. Michael Longinker, you know, his story is one where he was really pushed towards that. Absolutely. Yeah. And and he's I mean he was there when I mean we didn't necessarily cross paths. He was there working with the you know the fetal surgery stuff and and you know quite a pioneer in that extremely impressive individual. Yeah. Great guy. Yeah. Um good friend. Um, so I want to rewind if we can if it's okay with you because there are a lot of terms that um that I think the average person they don't probably really understand. So when we talk about orthonathic surgery, we're talking about moving the maxilla and and the mandible. So the lower jaw and the upper jaw. These are complex surgeries have to be done with such precision. And the reason I want to say that is that when somebody considers like you talk about all the trauma cases that you've done, the orthopathic cases, the cranial facial deformities and cleft pallet cleft lip. I asked um somebody the other day about you know the advancements in closures was at a breakfast and holy smokes. I mean clo closing a pallet then closing the lip and doing it where the repair is uh you know it's that's come so far and these are major cases. What's beautiful about that is when you think about I have a choice and I can pay the same amount of money to go see a general dentist to have my wisdom teeth. General dentists are great. They're great for all sorts of things but there's a nerve that runs down here. Right. Yeah. And I and I'm going to have my wisdom teeth normally, you know, most time the lowers you're going to section them, right? Uh to get them out easier almost always if they're impacted. Yeah. Uh uppers are going to come out pretty easy. But that nerve, you know, that that ability to get a CBCT, so comb beam, like you know, essentially a 3D image and see where they are and and know how to take them out and do it in a way that's with that kind of precision. It's going to produce such a better result for a patient. Yeah. And the same thing holds true for implants. Correct. Correct. Far be it for me to to tell people what they can and can't do. Right. That's not that's not what I'm about. But what I will say is really the difference is as you described, right? Having that surgical experience and a broad variety of procedures allows you to do the routine procedures much more predictably with the least risk possible to the patient. I see a lot of complications in my practice because that's kind of h what we see. We see patients that have had poor outcomes or have difficult cases that, you know, other clinicians may or may not feel comfortable treating. I I mean, I did a lot of that when I was at UCSF cuz that's kind of the way a lot of people wind up that are either had complications or have difficult cases. But in in the local community, I also have seen a lot of those patients. And I can tell you that in hindsight, when I look at those patients, they fall into two categories of mistakes that the non-surgeon has made. One is is failure to diagnose the correct diagnosis and two failure to understand where the pitfalls and increased risks are in terms of surgical positioning, surgical techniques. And then the third thing is how to manage those complications, right? And and you know, when I have people in my community say, "I want to do implants." And they're a non-suronic, I say, "Well, you know, that's great. You can certainly do it. No one can say that you can't do it, but you know, you're going to be held to the same standard as I am when it comes to complications. When I have a complication, I manage it because I know how to manage it." And and and we can get patients where they need to be in terms of result because everybody has complications. There's not a surgeon on this earth that is not going to have one. And the and the question is can they identify it and can they make the correct decision for the patient to rectify it. And what I see a lot of times in the non-surgic educated clinicians either they a they don't recognize the complication or b they don't know how to treat it and c they delay in referral and and so it's kind of the trifecta of problem. And so that's what I've seen in my own personal experience both when I was teaching and also in the last 25 years of private practice. Yeah. I mean so so first things first osteo necrosis I mean trying to understand like hey can you actually get an implant to sit in this do you need a bone graft need ridge augmentation do you need sinus lift to make sure you're not perforating the sinus right um these are all like things that you can just pick off in a heartbeat um and that not everybody can do and then also you know I mean talk about infection I mean sometimes people can wind up in the ER and um the only people that have right you know the ability to um admit somebody to the hospital is going to be an oral and maxlo facial surgeon. So ultimately they're going to have to see anyway. Yeah, that's true. I mean, you know, if you look at the compendium of where we started with implant dentistry. So Implant Dentistry Evolution implant dentistry when I was in dental school, you you heard about implants, right? And they were being done behind closed doors by by just a few people. They weren't the students weren't commonly exposed to that. When I got into residency, University of Texas was one of the first, you know, Brandomark centers. And and so uh Rick Finn who is the the chief at the VA hospital took that on and and and that became you know the center for implants and you know we were working with a prost at that time and our understanding of how implants worked I mean very different than what they are today. Every case was done in the operating room and we weren't using guides we weren't considering restorative uh options or or final restorative plan. uh we were basically just putting implants where the bone was and we were hoping that they would work and that was you know late 80s early 90s and here we are at 2025 implants can be I mean it's like what we're doing today we weren't even thinking ever dreaming of back then right but but along the way we've we've made errors and and we've learned from our mistakes and our complications based on materials and selection and and what have you and now we have amazing materials both from the reconstructive side in terms of bone grafting um as and also from the dental implant side and I think that the mistake that a lot of young clinicians make is that um they don't know where we came from and the mistakes that we were making in the ' 80s 90s and early 2000 and I see a lot of them making the same mistakes now implants in the wrong position implants poorly angulated implants in inadequate bone inadequate soft tissue coverage angulated to the point where they can't be restored it's it's the same mistakes that we were making 20 years ago and we've learned from those mistakes and I think that's what the that's what the novice implant surgeon has to deal with it you can't just go to a weekend course and learn all of those decades of experience and expect to get similar outcomes and and I think that um it takes a tremendous effort and you know for many years even in oral surgery our concept was well you know implant surgery is is easier than orthonathic surgery or trauma reconstruction or bone grafting or cancer, you know, removal of large uh tumors or cysts. But the reality is um sometimes the easiest things are your biggest complication, right? You just never know, right? And um what I like about implants is that in oral surgery, we're often times taking things away. We're taking teeth out. We're taking out jawbone. We're trying to fix a trauma case, but in that process, the patient loses gums and and soft tissue and bone. And with implants, we can actually give things back. So that's that's a huge benefit for patients and it's something that I as I get later in my career particularly enjoy is being able to give give them to structure back because it really is a quality of life issue. Yeah. I think one of the things also people, you know, when we think about um people who have lost some of their dentition, you know, the pressure on the jawbone, missing a tooth in some place, it starts a cascading effect that people don't really often understand. That's correct. can affect the way that you look. Uh eventually if you become a dentilist, it's it's pretty I that's why those those allon X cases or what we call full arch restorations where you're placing whatever the number of implants are that are required and then you put the prostesis on it looks like holy smokes these these people have the best looking teeth you've ever had seen in your entire life. Those procedures can be life-changing for a lot of patients for sure. Yeah. As are the orthonathic. I mean, I think absolutely. You know, when you see somebody who's got a jaw that's just so far forward or recessed and you're able to actually correct that, I mean, I've seen that may be one of the most dramatic. Yeah. I mean, obviously the cleft pallet, cleft lip stuff is Yeah. No, with orthotic surgery, I mean, not every patient gets a huge night and day result difference, but a lot of them do. And it's it's uh it's dramatic and remarkable to see that. And it's really um as a clinician it's it's really great to to to see that for patients. Talk about if you would total joint replacement on TMJ, TMD. So I mean this has been something that's been an issue for people for so many years. It's just so uncomfortable. I remember uh you know Dr. Leonard Caven talking to me about um you know the stuff the failures back in the day that were with the total joint replacements in Alice and those failures were significant. So to the point where I you know fortunately I was I was at a point in my training career where I had missed that that decade prior where total joint replacements were be were very popular and again we were using the clinicians were using the proplast teflon implants and others and unfortunately they all failed uh and they all created um significant problems in terms of bone resorption and and joint fibrosis and almost all of those had to be removed and the patients were reconstructed. Unfortunately, uh the FDA pulled those devices and for many years we had no devices and so we were using ribs um and or a combination of rib and iliac crest bone grafts to reconstruct the joints and and I did more of those in my early career at as a trainee and then also when I was teaching than I actually did any of the prosthetic uh uh joint replacements because again they weren't even they weren't really available for a long period of time. I have done several over the years. I don't do uh many open joints anymore and I certainly don't do uh joint replacements. My partner does those now, but there are better materials now. But what I see is a a resurgence now in in that discussion. And I think that for the right patient, it's great. Um unfortunately, what I see is that often times the idea is well, it's either all or nothing. either we're going to do a joint replacement on this patient or we're not going to do any kind of procedure. And I think that that's probably not the right approach necessarily. That's my opinion because the problem is once you have a joint replacement, that's what you're going to have. So when that joint replacement fails, you're going to have another joint replacement. And the problem is even the ones that we have on the market have really not been on the market long enough for us to do that 10, 15, 20 year study in terms of looking at what the progression is for those patients. So I I think it's a it's an area of caution and and I think that for the right patient it could be a godsend and it's the right operation but what I tend to see is that um maybe it's a little overprescribed at the moment and and there's a resurgence in the interest of doing that. There are certainly benefits to patients that have severe con resorption, have fibers, um have open bites as a result of con resorption. Those types are the patients that's what those those devices were designed for. But your typical patient that has, you know, u some form of early osteoarthritis that has a mal acclusion can be treated, I think, more conservatively with other surgical techniques. That's just my opinion. Yeah. Well, it's a good opinion. Um, I was going to ask you, I'm just curious. If you were going to tell somebody, there are two there are two things I want to ask you, but if you're going to tell there's a mom, we all know that 80% of all healthcare decisions are made or influenced by women, right? At the end of the day, probably in your practice, what you see are like the moms are coming in with their kids and absolutely. Yeah. You know, they've been referred by the general dentist or the pediatric dentist to come see you to have their wisdom teeth extracted or orthodontist, whatever. If you're going to tell um a mom something that you know what's the one thing that they really want to know about wisdom teeth extraction that uh well I I I think there's two things they want to know about the anesthesia and how that's going to be provided you know and then they want to know about recovery and risks and and I think that those are probably the the two most common questions that we get. I I think they they realize that their child needs to have the wisdom teeth out. I think often times the dentists and the orthodontists do a good job of explaining the indications for why. I see very few patients that come in and they say, "I have no idea why I'm here." Right? And and because they've been well educated by the general dentist or the orthodontist or in some cases the periodonist as to why these wisdom teeth need to be removed and at at what age. I think that um anesthesia is a big question mark for them and that's something that we talk a lot about about options because I think it's important for patients to know they do have options. Um and then again recovery and then risks associated with the procedure and you know fortunately the risks are low but they're there. So we we spend quite a bit of time going over those and how those might be managed. Yeah. So when you when you think about the um anesthesia options that's often Anesthesia and Patient Care times don't really know actually general public doesn't know that you're in your residency outside of anesthesiologists oral and maxelo facial surgeons are the only uh uh doctors that are qualified to provide anesthesia that would put you to sleep in an office setting. That's a big deal. I mean, I think the notion of being able to go to sleep rather than I mean, I I don't want to put you on the spot. If you don't want to get into this, don't. But how many times have you had a, you know, general dentist call you and say, "Hey, I've had the kid in the chair for 2 hours and they're local and I can't get the teeth out." Yeah. A number of times. So when we got to think about patient experience and what that means to a patient and um you know um they got to leave that office, they got to come over to you and then you get the uh the luxury of taking out the teeth quickly and then having the patient remember the bad experience was tied to you. Yeah, there's there's no doubt about it. I mean that's that's how I'd want my kids to be treated, you know, and and so I think the addition of being able to provide, you know, a deep conscious sedation or general anesthesia is a huge benefit for patients. And I think it it equates for a quicker recovery too, right? Because with them asleep, I can work faster and I can give less local and I can get the surgery done quicker and less traumatically and therefore there's less pain, less swelling and a quicker recovery as a result of that. Yeah. I once asked I once asked somebody what do you what do you feel is like the the true competitive advantage that an oral max facial surgeon has to and what if that wasn't like an advantage. It was more of like what's the benefit to the patient like hey we can just provide a less traumatic overall experience for the patient that gets a better end result. Yeah. And and what's happened you know over the last 30 years is our our medications that we're using now are much better than than they were 20 30 years ago. So now with with propall we're using very if no if any narcotic anymore. And so with with Probopal and and Versed, we're able to sedate, you know, 95% of patients very very comfortably. And there's 5% of patients that are going to be resistant to those medications. And maybe a general anesthetic like in a hospital is a good option for them. And and that is an option. It's an option to go to the hospital and do those cases. It's even an option for us to bring in an anesthesiologist into our practice to do that for the patient and then we can focus on the surgery. So again, I think it's important that patients know that they do have options now and and and you know, because not one thing fits every patient, right? So it's important to have those options. It's one of the things I really respect about you is that you're not trying you're you're you're trying to inform the patient how to make the best decision for them and recognizing that the one-sizefits-all approach is absolutely not the right way to do things. Yeah. I mean, that's I I look at myself as an educator. I'm I'm educating them as to what their options are. I wouldn't I always tell patients, I'm not going to give you an option that I don't think is going to work, right? I would never tell somebody, let's do it this way, thinking, well, this has a low chance of success, right? I'd only give you options that have similar to equal chances of success, but it's your decision to make that decision and what's best you feel is best for you. I wouldn't give you an option if I wasn't willing to do it and it wasn't best for you. Right. So, yeah, I think it's important. I think what's also interesting about your practice is that Reputation and Practice Philosophy you're in Walnut Creek. So, dental implants in Walnut Creek, California. Right. Right. But you're not just seeing people from Walnut Creek. You're seeing people from all over. I mean, it's conquered Pleasant Hill. uh probably, you know, as far south as people, your reputation's so uh big that you're getting people from, you know, probably down San Raone, Dublin, um all these different areas that people are coming to see you from. And I think that's just really a a a testament to um the reputation, the way that you actually conduct your practice. I remember when I first met you, I was so impressed, you know, after all these years, you you know, you get a sense of who's really great. I I I appreciate that. Those are very kind words. I, as I tell my staff, I try hard every day, right? That's that's the best I can do. Try hard every day and show up and be present and and try to treat patients with respect and try to give them options for surgery. I think is that's my job. And like I said, I've been very fortunate. Um, I had uh excellent training and I had a lot of great mentors that helped me along the way. So, that made a big difference for me. That's kind of just goes back to this story. you know, your pathway to peak performance again is a steady is like a steady climb out. You know, you're one of the more even kill people that I know and you really just kind of keep staying on and you have not compromised. You stay on your your your game all the way through. We talked a lot about practice. I would like to discuss things that I think are important for young people um to think about as they consider a career in healthcare. Yeah. Yeah. What do you see as the future for people in in healthcare today? Yeah, that's a good question. You know, a lot of people both that are in Challenges Facing Young Healthcare Professionals healthcare or out of healthcare, peripherally involved with healthcare are asking that same question. It's tough times right now. There's a lot of changes going on right now. And I think that um as young people come out, sometimes they don't have a choice, which is unfortunate. You know, sometimes things like married, not married kids, loans from school, all those things kind of limit their options in terms of how they can practice or what kind of practice environment they can go to. And that's unfortunate cuz my generation didn't have those necessarily. Well, you know, family, yes, but but large amounts of student loans. We just weren't able to to actually borrow that amount of money, right? Um and and it's unfortunate that that many of them are making decisions based on that which is which is tough and I I feel for them you know beyond Choosing Between Corporate and Private Practice that um I I think that the decision is is how you want to practice right do you want to practice the corporate model or do you want to practice the private practice model or do you want to go into academics and I would tell a young person if they have the ability to at least try academics that's not a bad start for a lot of people. And the reason I say that is that you're going to get a broader experience in surgical techniques. Uh you're going to have a protective environment that you're going to be able to do these things with and you're going to be able to gain confidence in experience that you may not be able to get in private practice. And you'll get your name out in the community, right? And it may stick for you. You may say, you know what, I really enjoy teaching and this is what I want to do. And that's great cuz we need our best and brightest to go into academics. If we don't have that then then training of future generations of surgeons is going to be compromised. So I I I would tell any young person to at least give that a thought and go through the process and see what's available for you. Then the other decision is corporate model versus private practice. And and there's pros and cons of both. Obviously, the problem that I see with the corporate model, and again, I I'm biased because I'm in that private practice area, is that, you know, you're you're getting paid a decent salary, but you're running from location to location to location, and you could be traveling a lot of miles every week, but you're really not creating goodwill in any particular community, right? So when you do decide to go into private practice, uh none of that experience is really going to equate to your community that you set up practice in, right? Yeah, you may have experience. It may be good experience or it may be bad experience. Hard to say. Depends on the situation, but at least if you decide to go into private practice, even if you start small, you're you're creating goodwill within a community. And if you do the right thing, then over time you're going to be able to build that practice up. and then you're going to be able to reach the same goals that you may have in the corporate world in terms of finances. But, you know, it's a tough decision. I don't know if there's any right path for every individual. I think it depends on their circumstances and what their desires are. Right? The problem in private practice is you you've got to be a business owner. You've got to hire and fire people. You've got to do payroll. Uh you've got to run an office, right? You got to run a business. Some people don't want to do that. They're not good at that or they feel they're not good at that. I had no experience in that. But over 25 years learned, you know, from making mistakes and getting good people around me to help me make those decisions, professionals who are in those particular fields. And I think it can be done, but some people just don't want to do it. So I think those are the issues. The the particular issues with the hospital systems is a is a separate concern. Insurance, you know, and and and hospital cases are becoming more and more difficult to do. And that's just as as the health care system gets squeezed. I think you know COVID kind of didn't help that. And even in the postcoid area, the resources available are limited, right? Many clinicians retired. Many people left particularly urban areas to go to to different areas that are maybe a little lower cost of living, less stress, little little more friendly lifestyles. And so therefore there's a shortage of of clinicians, shortage of anesthesiologists for instance in our particular location that put you know constraints on o time and how many cases can be done. And so there's reduced resources for surgeons who want to do cases. So there's a lot of extraneous forces on the market that can affect a practice and can affect a decision by anyone coming into any particular location. And I would tell that person to do their research and and see which one of those three models might fit best for them. Yeah. So, someone that's in residency right now, let's say, is an oral maxel facial surgeon has to make a real decision about whether or not they're going to go the corporate route for a period of time. Yeah. Um and pay off some of the debt that they may have accured. Sure. Um and then try to find their way to a potential partnership. Hopefully, they're getting into a practice where they're getting a great mentor, somebody that can really help them um and learn all those things that you had to learn on your own over 25 years. I think that's the benefit of buying into a practice is that you get to actually get that knowledge. That's why I see you see some of those some of these guys that um stick around. They're not seeing patients anymore, but they're really helping out with the practice still and they're still involved in the practice because guys need them, you know. Yeah. I I think there's a lot to be said about that. I I just think it just depends on the circumstances and the environment and the number of offices and staff and there's a lot of things that have to go into that decision. But the the reality is there's a number of options and I think that the individual has to just, you know, do their research and see what's best for them. I don't I don't think that um either buying or opening a practice is necessarily a bad thing. I think it's probably the right thing. Um because um you know you have control. The problem is in the corporate world you have no control. Perfect example is is what happened to to us at The Impact of Corporate Healthcare Models at Johnir Medical Center. Um for many years there was an anesthesia group there who um was um basically covering John Mir and several hospitals in that 680 corridor. They did a great job. They provided fantastic service for us for for decades. Um they were bought out by a venture capital uh fund and uh that corporation did an analysis of what their anesthesiologists in that location were making uh margin-wise. They didn't think that that was a good bet for them. So they basically gave them pimp slips overnight and fired you know over 120 anesthesiologists overnight. And so John Mir went from a situation where they had full anesthesia care to to now having to scramble to try to hire individuals or bring people in. It really turned into a mess and it dramatically affected um the operating room for for several years. In fact, still has affected that was what four years ago. It's a ripple effect. It's a ripple effect, right? And so that's the risk you take when when you go the corporate route is that um you have really no control over what your future is. And if that venture capital gets bought out by another company and they decide that they want to downsize or liquidate, then you could be on the chopping blocks. So you may lose that job and then again, you haven't really developed any goodwill in the community because you've been working in multiple different offices. So it it becomes it, you know, those are some of the things that I think that uh people need to consider before they make that decision. Yeah, it's funny. I mean, when you talk about private equity coming in and and they're making those, you know, in their world, they have to be blind, their job is to actually return a greatest return for their investor and get more money to get back out in the market and do that. That's right. The downside of that is that a lot of people are affected in a negative way around that. And you hope that there's more of a move to the middle of trying to understand, okay, what is an ethical way to actually approach these types of things? People do great jobs. They deserve to get paid well. And um yeah. Um yeah. So u Okay. Guys in Blackhawk playing uh playing golf, breaks a tooth, goes to Advancements in Dental Implant Technology the general dentist, you need an implant. What's the one thing he needs to know? Well, what he needs to know is is that it's it's very likely that we could potentially remove that tooth and place the implant in the same day. And with the right coordination, it's also possible that he could get a fixed provisional on that implant either that day or within 24 or 48 hours depending on the situation, right? And so, so just just for for those that you know uninitiated, what does that mean? Fixed provisional that means that you can basically it needs a temporary tooth. So, you know, with an implant, you have the implant, then you have an intermediate abutman that connects to the implant, and then you have the tooth that connects to the abupment. And so, for patients that have, let's say, a horizontal fracture or even a vertical fracture of a central incizer, lateral incizer, um, if there's adequate bone, we can remove that tooth a traumatically with, you know, minimal bone and no bone removal. And if there's adequate bone, we can place an implant at the same time. And if that implant is stable in the bone, now we have really great implant systems with high torque initial torque values that we could use uh for those cases. So there's initi good initial bone stability. Uh if there's adequate bone stability, then the patient can have a temporary tooth put on that implant. So they never have to wear something removable and they certainly don't have to go around town without a tooth. That tooth is a looking tooth. It's not a chewing tooth, right? They can't chew on it for at least 6 to 8 weeks, but it it looks like a natural tooth. And for all intents and purposes, no one's really going to know that they're have a tooth that's missing. And then once that implant heals after a couple months, then the general dentist can then go back and make the final restoration. So, some sort of porcelain or porcelain ceramic crown. And that's ideal treatment. And that that immediate placement is going to come down to this the amount of bone that's available and then the size of the implant that you can place properly. That's correct. That's correct. So sometimes you know the trauma has not only broken the tooth but the trauma has also broken the bone right and in particularly if it's the front part of the bone then that's the patient's not a good candidate for that because it's unlikely that we're going to be able to get good stability and we don't really know how that bone's going to react. So in that scenario we would remove the tooth do a bone graft to re regenerate that bone and then after 2 or 3 months of healing we could then come back and place the implant. So the patient can still have an implant. It just means we may have to stage it, but ideally the bone's not affected and ideally there's not a lot of infection around the tooth because this is a traumatic injury as opposed to a paradonal problem. And so for a large percentage of those patients, yeah, they could literally within the day or within 24 48 hours have a temporary toothbrush. Sometimes what we'll do is uh when we place the implant, we will um if if the restorative dentist is ready to make a temporary, great. If they're not, then we could take an I we could take a digital scan of the implant position. We can send that to the laboratory and then within 48 hours, the laboratory can make a lab processed provisional that either can come back to us to put it in or go back to the general dentist. So, it just depends on the scenario, right? The dentist's not available or they're out of town or on vacation, we can still do it. It just means we have to delay it a day or two. One of the things I love about hanging out with you is I learn something new every time over the issues. It's funny. I was just thinking as you were talking about uh the infection side of it. Well, you could have an infection prior to that made the tooth actually fail. Exactly. Um or you can have an infection post uh that could affect its ability. So, when you're managing these cases, having that experience is so so valuable. You know, I think about I go, "Oh, if I was going to have a dental implant, I know exactly where I'm going. And if I'm I do have a daughter that needs to have her wisdom teeth out, I know where I'm going for that, too." Well, we appreciate that. That's very kind of you to say, but but again, it gets back to options, right? And patients have to understand what their options are, what their risk profile is, and and be part of that decision process. But yeah, but we have so many more options nowadays than we had even 10 years ago or 15 years ago, certainly 30 years ago, we didn't have those options. And so the technology, our understanding of how implants heal and our techniques and also our materials are so much better now. what I'm doing today, I wasn't doing three years ago. I just can barely imagine what we're going to be doing in another three, five, 10 years from now. Right? So, it continues to get better and and that process continues to improve patient outcomes and that's really what it's all about. We want the best patient outcomes we could get. All right. So, we've talked about all things clinical. I don't think we can cover anything more unless you can come up with something. I think we've run the gamut on that. Um so let's talk about um fatherhood. Balancing Professional and Personal Life Okay. You know I mean we have a similar situation both boy and a girl. Two totally different uh experiences raising uh just very much so. Yeah. I'm glad I love having the daughter. It was just an interesting experience the son and my kids are in their 20s now. One's almost 30 and and we're still kind of raising them. So you know it never ends, right? It's funny. I was having a conversation with my dad um over the weekend and I realized you know hey I'm 56 years old and I still you know want I mean I'm so grateful to have that of course I have a lot of friends who are older than I am that can give me a lot of insight and there different times I call different people to talk about things but being a dad um best job in the world by the way yeah it's really amazing isn't it? Yeah, it is. It is amazing for the young young father out there. Mhm. What are the things that are most important? Yeah, I mean that's a great question and and you know I feel like I have a good handle of oral maxel facial surgery. Fatherhood questionable, right? So it depends on who you ask. I think what what worked for for our children uh is to be present as much as possible and to be that supportive hand. Whether you wanted to be at that baseball game or that soccer game or not is kind of irrelevant. The fact that you were there and showed up and were present, that's really what matters. And I think that I look at how my kids were raised. I looked at how I was raised, it's almost like night and day, right? The challenges and the demands are so much more greater now with social media and everything that goes on. Um the level of anxiety and complexity of relationships is so much different, right, than than when we grew up. We're I'm a little older than you, but similar similar time frame. Well, we didn't have phones and we didn't have social media. We didn't have any of that. We had the dial phone, right? So So I think that's that's something that every parent needs to take into consideration. You got to make a decision how you're going to hand it ma manage that. Denying it or just saying, "Oh, you know, let them do what they're going to do." that's probably I don't feel is the best option. I think you got to have to manage it some way or the other and you have to kind of reduce their anxiety about situations that arise and refocus on what's important in life. Okay? Whether that be interpersonal relationships, whether that be religion, whether that be, you know, family, uh, whether that be sports, whether that what whatever it is that you can refocus in a positive direction as opposed to what oftenimes works into a very negative direction and creates a lot of anxiety for those kids and and really kind of gets them off path, you know. Um, I think that's that's important. And again, I I'm not saying that we were able to do that all the time, but we tried hard. Well, yeah. I mean, it's it's a process of failing forward, I would imagine, for every parent. Um, listening to you, um, it's clear to me, you know, that you had kids that were looking at a father, uh, and those are big shoes to fill. Did you feel like your kids felt a lot of pressure to live up to the standards that you had set which were so high? Yeah, I mean I think I had pressure with my parents as well and I think every kid that has parents in their life probably feel that pressure one way or the other but you know you try to mitigate it right you try to channel it in a positive thing. Now you know I I brought my both my kids into the office to show them what oral surgery was. Neither one of them were interested and you know I was like yeah okay that's fine. You know, you you got to find your path. You got to find what your what centers you and what gets you out of bed every morning that you want to do. I think that's important, right? I can't tell you what that is. You have to find that on your own, right? Um it's uh it's a work in progress, right? It it it never never ends until someday I guess it will, but you know, it's a work in progress. Uh last uh last thing is to talk about you've been married a long time. Yeah. Yeah, I have been. Yeah. going on 34 years. Yeah. 34 years. That's uh that's quite an accomplishment. That's 10 appreciate that 10 more than me. Yeah. Um and um what's the secret? Yeah, that's a good question. I mean, like I said, I again, I'm no expert in relationships, that's for sure. Um, I think a a lot of it is um respecting that individual and uh uh make making them feel like they're they're part of a team, part of a family and uh giving them space when they need it and being supportive when they need it. I think that goes a long way. Yeah, I think that goes a long way. Beyond that, I I can't give any other advice regarding that. This is something that's happened. 34 years went by very quick. I can tell you that for sure really quick. I was uh talking to somebody yesterday and I was going to uh be in some place that was um you know close to my youth and I almost was like kind of takes your breath away. Yeah. Cuz you know, you know, those days are long gone. Right. Right. And um it's interesting. Yeah. Yeah. I had that experience when my both my kids played high school sports. My son went on to play in college and and the pros, but um when I would go to my old high school, neither one of them went to my old high school, but they were in rival high school. So, we'd go there to watch games and I'm walking around the hallways going, "Wow, this brings back some memories, right?" You know, I remember as a little, you know, kind of as a teenager running through these hallways and it uh yeah, it you pause and think about that, right? So, yeah, it's amazing how fast time flies. Always goes by too fast. And you have the people that tell you that when you're in the middle of it and you go, I can't just can't imagine. Can't imagine. You just have to live to do it. It's like the people used to say to me, "Oh, your kids will be, you know, in college before you know it." I'm like, "Right." I mean, the little kids, right? And now, you know, I guess now you wish you were little kids again, right? Sometimes. I mean, for me it was Yeah. I mean, sometimes I definitely don't think, like you said, I'm not wired. I was just blessed with a wife who was really wired for child care because I, you know, h guy living on airplanes and traveling around doing my thing. Yeah. No, I know. I was a guy spending most of my time in the hospital or on call. So, so yeah, I know I know exactly where you're coming from and you just have to make those times that you do spend with them special. That's the point. Yeah. One clinical thing I didn't ask you. How many dental implants do you think you've placed? Oh gosh, it's it's well in the thousands. Yeah, but it's probably 10 12,000 implants. Yeah. Over the last 30 years, 35 years. It's a lot. Yeah. A lot of implants. Yeah. I mean, and and to think about that, how many how many implants do you think you placed in Walnut Creek in private practice? Oh, the last 25 years. Yeah. I'd say probably eight or nine,000. Probably something like that. Wow. Quite Eight or 9,000 patients. Yeah. When when patients have a dental implant, do they come back of how often do you think you see them? Yeah, so we we see them once we've tested the implant to make sure it's stable and healed and we send them back to the dentist. We'll see them 6 months after the final crown is placed and we'll get a screening X-ray to make sure everything's good, make sure the, you know, the tissues are healthy, make sure the bone's healthy. And then we see them at that point on an as needed basis, right? Because at that point, they're going back to the general dentist. they're being seen every 3 to 6 months for their hygiene appointments and there was any any issues, you know, we have a good referral source, so they would send them back to see us. But we don't we don't really see too many that come back. Um, some of the older implants, when I say older implants, implants that I did, you know, 20 years ago, 25 years ago, are are having some problems. and and there were some implants that hit the market that the the surface topography of that implant uh made it more likely to develop bone loss or what we call perry implant tightness. And again, that's it's not as a technique issue or necessarily a patient healing issue. It's it's a it's a mechanical issue of how that implant was designed. And we've learned a lot from those failures, right? And so I still will see on occasion patients that will come back, but it's it's rare now to see that because we've pretty much, you know, retreated those patients. Yeah. I mean, you look at the how implant technology has, you think about it, you go, "Oh, well, how much could it actually change? How could it get better? How could it actually Well, it's the new the way that it's, you know, mil and the new way that the angle is and the the coatings and all that stuff. It's just and it's beyond that, too. It's it's also the restorative aspect because you know cuz implants typically fail for one of two reasons in the vast majority of cases. Either there's a problem with the bone either the bone's too hard or too soft and the implant just has overloaded or fails as a result of bone loss or if if the restorative aspect is not done correctly. Right? So abutman choice screw choice very important uh material choice very important occlusion very important. So all of those things come into into factors. So, you know, so you'll see failures from two different aspects. And as a surgeon, what I would The Importance of Communication in Dental Practice tell a young surgeon trying to develop an implant practice is often times surgery, we're focused on techniques. We're focused on healing. We're focused on new bone graft materials or new soft tissue grafting procedures or new implants, but we're not as focused on working as a partner with our general dentist or our prostadonist to try to get best restorative outcomes for patients, right? And so that collaboration between surgeon and restorative dentists is really critical if you're going to have a successful implant practice. And I have a study club that I've run for the last 15 years through Sales Club. And it's basically an implant restorative study club that we invite our dentists to participate in and we bring in lecturers and and and we present presentations talking about that implant restorative connection. There's two advantages to that. One is you bring your restorative doctors up to a level that's standard of care and and is very progressive to reduce those failures. And second of all, you create a a ability to communicate. So if there is a problem or failure, you can communicate and figure out what needs to be done as opposed to the surgeon seeing a a patient with a broken screw and say, "Well, you go back to the restorative dentist." The restorative dentist sees the patient, sees the loose crowns, and they say, "Go back to the surgeon." Right? So now the patient is confused. Where's the problem? Who's going to take care of it? That's what they want to know, right? So, so creating that type of connection you with your restorative doctors is important if you're going to be successful at implant surgery. And that's not intuitive because we don't learn that in oral surgery training. We don't learn that in medical school or in dental school necessarily. You got to learn that by reaching out in your community and creating those interpersonal relationships and treat patients collectively. And um that would be probably one of the things I would tell a young surgeon to try to do. Yeah. And that's the foundation of that is education and then being able to speak the same language. Correct. Yeah. Yeah. I mean, if I'm distilling down what you're saying, the pathway to peak performance on that particular portion of it is the ability to have a baseline understanding of what you're working with and then this nomenclature of how you're going to communicate with each other. Correct. So that it's repeatable. Right. Correct. So when I go to lectures and and I still go to lectures, I get more out of watching the restorative lecturers talk about implant restorations and soft tissue management and and implant materials as opposed to necessarily the surgical techniques. It's not that I don't gain pearls and wisdom from watching those lectures on surgery, but I gain much more about how to manage my surgery and how to deal with complications and issues that come up when I see those restorative uh lectures because now I understand what the general dentist is dealing with and where the pitfalls are. And so now I can communicate with them, try to bridge that gap, right? So the idea is to be collaborative. The idea is not to be here you go, here's the implant, it's in bonus yield, good luck. That's not the way you're going to build an implant practice. Yeah, that's so cool. You know, one of Reflecting on a Career in Oral Surgery the things also occurs to me that's so interesting about uh something that we have in common is you went back to where you're from. So did I. Yeah. Right. And what's it like to like be in Arinda Walnut Creek area and and service a patient base there for 25 years? I mean, what's it like? It's great. I mean, it's a very fortunate. is a fantastic community and it's that great mis mix of of educated people that that understand the need for treatment, right? Um and so we're able to do a lot of great things for patients as a result of that. So it's it's been great. But coming home has was a real treat for me cuz again I I lived away for almost a decade and um it was nice to come home and both my parents have passed now uh within the last couple years but it was nice to you know be there as they went through that process and still have a lot of relatives that are very close to and so it's nice there's no doubt about it. You know we're blessed in the uh Bay Area with a lot of sports teams that are just phenomenal. Uh like we can just look at Steph Curry, you know, just like he gets into this flow state of just shooting, you know, three-pointers, three-pointers, three-pointers. When you're when you're doing what you do, uh in a surgical setting, uh very complicated, it's not just you and Steph Curry needs, you know, teammates to set up. Absolutely. But how do you get into that peak performance flow state? That's a really good question. And and I think you know there there are so many different products and ways of doing thing out there. It can almost be overwhelming and confusing, right? And for me, I like predictable. I I like predictable results. When I do a case, I want it to be perfect. Feel like I I strive for that. And I want when that patient goes back to the referral dentist for them to feel the same way because what I want is for them to have an easy experience, right? I don't want them to have to struggle. I don't want to have to have them work more difficult with their uh and increase their costs in doing the care to the patient uh because of a malposition implant or soft tissue problems or whatever. So what I do is I I leverage technology and so for every patient we're doing comb CT. Um for the a lot of patients we're doing CT guides. Not all patients, but for a lot of patients, we're doing CT guides. And um we're doing soft tissue manipulations, we're doing bone grafts, and we're doing connected tissue graphs when they're indicated. And so each case we I identify what needs to be done, and then we execute it. And and that execution is what makes the difference, right? So we're not trying to reinvent things. We're not trying to experiment on patients. we just say we know what works in this particular case in this particular scenario and this is what we're going to do and if you get to that point then it can be very efficient and um you know it it can work out really well but it takes time to get to that point right and and I what I see with a lot of young surgeons is they get you know they go to a class and this person's doing it this way and they read a book person do that way and that's all fine and good but you got to figure out what works for you and and what works for the individual patient you're treating at that That's what we try to do. We we try to make it as efficient as possible and we try to streamline the treatment because we also have to understand that you know patients time is important, right? So you you've got to create a a mechanism for reducing that patient time but getting equal if not better outcomes, right? So material selection, how you stage patients, when you do bone grafts, all of those things make a difference. So I think that that comes with just experience. So, I don't want to put words in your mouth, but it sounds to me like you're getting into a flow state by running through your checklist, knowing that you've got everything that you know you need to do that case the right way lined up before you ever start. Absolutely. And that allows you to have that I think anybody that's doing anything that's important, you have to have a confidence in your capabilities. Uh, and then know what your purpose is, your outcome that you're you're already thinking outcome before you've ever started. That's right. You you got to think where you want to go before you can go there. Right. So, if you don't know what you're trying to achieve and again, that comes down with the communication with your restorative dentist. If if you're not on the same page, how are you going to ever get there? It's hit and miss, right? So, you got to work back or you got to say, what do what are we trying to achieve here? So, let's work back and see what we can do to give that patient the best outcome in the most efficient way possible and the least expense possible, right? I mean, you can throw everything at at every patient and run up their bills, but that doesn't necessarily mean they're going to have better outcomes, right? The way you make that work for you is that patients happy and they come back for additional treatment or they refer their family and friends. That's that's how you do more implants. You don't do more implants, you know, trying to do more implants at at one particular time. Yeah. So that's kind of how you build that practice. And efficiency is very very important. And I'll tell you a funny story. I mean, not really funny, but I in in prior days, you know, when we first started doing implants, we were waiting 8 months, sometimes 12 months before the implant, we would test it to see if it's integrated. Then we went to 6 months. But still, you know, at 6 months, you put an implant in, you see the patient back, you test it, is good. Now the patient has to call the general dentist to make an appointment. Well, that could take a week. It could take a couple of months depending on how busy they are. So now the patient has to wait for that appointment to get an impression that has to go to the lab. So now you're delaying it another week, a month, month and a half. So that whole process is now no matter how much you time you put into it is much longer, right? So I had a female patient come back, I'd say, you know, at when I see him at six months, you know, how do you like your crown? Well, Dr. Caris, I love the crown, but you know what? I had a baby quicker than than I was able to get a tooth back, right? It's like, well, that's not good. So, we got to we got to change our our thought process here, right? So, so how can we get to the point where the implants are healed within two to three months and and how can we then get that information to the general dentist or restorative dentist to start making the crown. So, that's when we integrated the iteros scans and the digital scanning. So when we do second stage procedure for a lot of our restorative dentists, not all because some still wanted to do that, we would take a digital scan at the time we do second stage and then we would send that to their lab of choice, right? And so within a few days that that information is at the lab and so now the lab contacts the dentist and they give them a shay. They let them know what type of abutment and what type of u uh material they want for the crown. And now within 10 days, two weeks, that crown is ready to be placed. Right. So now we've taken that 6 or 8month process now down to two 2 and 1/2 free 3 and 1/2 months somewhere in that frame time time frame. And when you put it in that perspective, patients are like, "Oh yeah, yeah, no, that sounds reasonable. I can I can wait that amount of time." Vastly superior. Vastly superior. Right. And when you tell a patient it's going to take you 6 to 9 months, sometimes 12 to replace a tooth, they look at you like really? I mean, come on. We're in 2025 now. I mean, you know, is that is that really realistic? like, well, you can do it that way. It works. There's nothing wrong with it. It's just maybe it's just not like Curry, you know, he he he's not going to wait to take that that three-pointer. He's going to take it right then and there when he has the opportunity. It's kind of the same situation, right? Yeah. Really interesting to think about like the the going back to what we talked about the level of communication. I mean, this is a master class for anybody that's starting a new practice. Like, I almost want to send this out to the entire oral surgery market just to for them to hear it. But, um, you know, the reality is that, um, that level of communication has to be there in order. I often go back and I I listen to these episodes. Every time I listen to them, I hear a completely different episode. something that I just didn't hear in the first one. I think, you know, it's that whole notion that the brain can't hold two thoughts at once and there's going to be something that comes in you're going to think about as well as something that's being said. It's interesting is I kind of counted out the points of contact that have to happen between um you and a restorative partner to really make that work the right way. And you have definitely mastered that. Um, that's something that, you know, I wonder in the future. Do you ever think that you might teach that? Yeah, I you know, you know, as I'm I'm getting older, you know, I'm starting to think about what, you know, you know, what my path will be, and I haven't quite figured it out yet, but I wouldn't I wouldn't mind going back into teaching. Um, it would just have to be the right situation and it would have to be something that I don't want to be so invested in it like I was before that it it it takes over my life, so to speak. I'm just thinking like the Caris method of like, you know, total total practice management and all that kind of stuff. No, I think there are other people that are probably able to be able to to do that better than me. I I'm not there's that humility again. Yeah. So, I I'm not sure I have much to offer from that standpoint, but you know, anyway, I don't know. We'll see. You know, one of the things I love about talking with you is we could just go on and on. I always feel like that whenever I talk to you, I could talk to you forever. I don't know if you feel the same way about me. And don't tell don't tell me because Absolutely. We always have good conversations. Yeah. It's always a pleasure, man. You're a champion. And um you know what? I just somebody I really admire and I just it's a pleasure and an honor to know you. I'm just want to thank you for coming in to spend some time with us. Yeah, I feel the same way and appreciate uh you know all of your direction over the years and it's been a great relationship. We want to continue that. Closing Thoughts and Farewell Hey, thanks everyone for watching the show. Please remember to like, comment, and subscribe. It really helps us out here at the channel and share the video with someone who might be interested in supporting the charity that our guest uh mentioned in the episode. Thanks again. We'll see you soon.