One of Dr. Pankey's Students Who Changed Dentistry Forever
If you have ever been disillusioned with your practice, especially when you have pursued higher levels of competence, only to diagnose and recommend more treatment, and then to have your patients reject your recommendations, you need to read this story. This is the story of a young dentist from a small, rural, mid-western city who transformed himself, his practice, and his profession through the inspiration of L.D. Pankey. Who was Robert F. Barkley?
This question can be answered in many ways, as I suppose it can for every man. First, in my heart and mind, he was the man most responsible for me becoming a dentist and the teacher I am within our great profession. It was 1968, when as a disillusioned sophomore dental student, I attended a half-day presentation to the faculty and student body of UTDB by a charismatic dentist and visionary teacher from the small town of Macomb, Illinois. I entered the auditorium that day with a heavy heart. The high fear, low trust environment of the first two years of my dental education had me doubting my choice of a life’s vocation. I was having difficulty with the relevance of much of what I was being taught. I waxed small cusps on blocks of precisely trimmed Hydracal slabs, endlessly studied microbiology and histology, neuro-anatomy, the basic sciences, dental materials, etc., while too many of the faculty seemed to relate to me in a demeaning, you cannot be trusted, way. It was that same month, perhaps the same week, I remember taking my first full crown wax-up on a Hanau articulator, to my fixed prosthetics professor to be checked. I had spent probably 15 hours waxing and polishing it. I remember him taking the articulator from me without a word. Rotating it as he examined what I felt was my first masterpiece. He opened the articulator and then slammed it shut, fracturing my crown. He then handed it back to me with the terse remark, “Frazer that was high, do it again!” And I thought we were suppose to become emphatic healers?!
MY PERSONAL EPIPHANY: I sat toward the back of the room as I listened to this passionate man speak of his similar high fear, low-trust dental school experience that he had had in the mid-1950s at Northwestern. Of how filled with hope and expectancy he had been when he received his letter of acceptance. And, how slightly uneasy he had felt when he read the last paragraph about taking mason jars of formaldehyde to local dentists, asking that they save teeth for him. That’s just as I had felt! How difficult it had been for him to understand why, as a freshman, he was learning to set denture teeth (he thought dentists saved teeth) and dissect a cadaver’s leg while a faculty member looking on told him, “Barkley, that is not dissection, that’s destruction! Talking down to Bob from his 4 foot 10 inches (Bob was about 6 foot 3).” Bob said that he was sure they had chosen the most obnoxious professors for the most irrelevant courses. He further stated that he was certain that when some of them went home at night, their mothers crawled out from under the porch and bit them! He said he couldn’t see any relevance to histology. He told us he had learned how to examine a slide of a woman’s breast and tell whether she had ever been pregnant. He noted that in nearly twenty years of practice, he had not used it once! He commented, “You couldn’t even work it into conversations at cocktail parties! And I got a C in histology! Can you imagine the poor guy who just went along like a sheep learning all that stuff he couldn’t use, instead of learning what he needed to learn? How cluttered his mind must be.” Meanwhile Barkley said, “All the while, I was suppose to remain enthusiastic and interested.” These were my thoughts exactly! His point was that the school was teaching us values and style subconsciously. Barkley told us, “What little style we had when we graduated, we had learned in the school clinic. And that style left us with a pretty shaky oar in the boat!”
Although all he said made the greatest sense to me, it was when he said, “You who are training to be dentists will have a greater opportunity to really help people than any in the medical profession because in the absence of pain, bleeding, and swelling, people don’t need to come to you, but they will anyway,” that my epiphany occurred. I had never heard that during my first two years in dental school. I too, like Barkley, had had a very few teachers, who manifested that kind of sense of purpose, mission, and respect. As I write this thinking of those first two years, several names come to mind to whom I am truly grateful. So who was this small town dentist, who had come to our school at the invitation of one of the fathers of preventive dentistry, our school’s Sumter Arnim, and had been so influenced by dentistry’s greatest philosopher, Dr. L.D. Pankey?
BARKLEY’S MISSION: As I said, Bob Barkley practiced in the small western Illinois town of Macomb, with a population of 13,000 people, many of whom he had known growing up. Before his tragic death in 1977 in an airplane crash, he became the most popular speaker in the history of dentistry. He spoke to tens of thousands of dentists throughout North America, Europe, Japan, and Australia. He wrote a book, Successful Preventive Dental Practices, that was eventually translated into Japanese and almost single handedly began the preventive dentistry movement of the 1970s. There never has been a dental box office attraction like Barkley was in his day. Today, only Gordon Christensen would have rivaled him. A master storyteller who wove humor into his poignant stories, he regularly spoke to audiences of 800 to over 2,000. About a month before his death, while speaking at the last meeting of the American Society for Preventive Dentistry in Denver, Bob stated, almost prophetically, that if he were to die tomorrow, he would want his epitaph to read, “The man most responsible for humanizing dental education.” In his short ministry, he worked tirelessly toward that end with dental schools such as USC, Loma Linda, Minnesota, Tufts, Oregon, Washington, Kentucky, Buffalo, and Montreal.
BOB BARKLEY'S JOURNEY BEGINS: Early in his practice, he was disillusioned with the lack of acceptance among his patients of his treatment recommendations. He recounted how shocked his old school chum patients would be when he examined them in the early 1960s, finding a couple of thousand dollars in needed dentistry to be done. They would look at him not as their old friend Bob Barkley, but as a dentist. He said that he didn’t like the way they looked at him. It was about 1965, according to his widow, Willa Jefferson, that Bob attended a three-day course in Miami, Fl., taught by L.D. Pankey. He introduced Bob to the idea of a philosophy of dentistry as the basis for both dental practice and more importantly for life. Bob saw this philosophy as dealing not only with techniques, but also with the dentist-patient relationship. He saw how Dr. Pankey handled patients as people, friends, and not simply as so many dental problems to be solved. L.D.’s approach and his finesse in handling people inspired Bob. Memorizing much of what he heard L.D. say, he returned home and repeated the same things to his patients. Just as I did when I first heard Bob. His results (like mine and perhaps like many of you, after you’ve been inspired by a speaker or your first visit to the Institute) were disastrous! Not only did his patients fail to respond, many of them left Bob altogether, thinking he was trying to sell them something. If you have made it this far in this article, and if you are one who has attempted to practice comprehensive dentistry, I’m sure you, like me, can recount similar stories. One of Bob’s great lines from his later years was, “If you try to copy me or anyone else, the best you will ever be is oleo margarine! You gotta be you!” Much of his work in his last years was centered on experiential learning during which he led his students in deepening their understanding of themselves. He believed as did his teacher, Dr. Pankey, that the first person you had to know was yourself and only then could you really know your patient. And then they would know the authentic you. For it is those we know best that we can then trust and indeed love.
A LESSON LEARNED: Upon his return to Coral Gables to discover what he had missed the first time, he learned how much L.D. knew about human behavior and motivation. He had been trying to copy Dr. Pankey’s style and approach, but it really did not fit his temperament or personality, nor did he understand these critical elements. He realized that each of us have to develop our own style that is comfortable to us. He was so surprised at the success of this honest, southern gentleman dentist with so much humility that he chose L.D. as a mentor. Bob was painfully aware of the fact that philosophy and management was totally lacking from dental schools and that, as stated earlier, the value lessons for the most part were covert and counterproductive. One could graduate from dental school with the skills of a technician or in the best case a craftsman, but be unable to hire well, communicate around expectations or fees, appropriately confront, budget, or establish interdependent relationships with your staff and patients. Sadly, this is still too often the case. Bob Barkley watched Dr. Pankey diagnose, perform treatment, and not even discuss fees. How did L.D. do that so easily?
This small town, Midwest farm boy was blown away by Dr. Pankey’s library. He said it wasn’t the sheer number of books that impressed him, it was that he had actually read them! L.D. had made himself a student of human nature and psychology in order to change the paradigm of his early days, that dentists basically extracted teeth. Dr. Pankey knew that he had to learn more than the technical if he was to raise his patient’s appreciation for what was possible. From that day in L.D.’s library, Bob became a veracious reader. He read widely, as did L.D., for as he recounted to his dental audiences, most dentists, unlike Dr. Pankey, were not truly learned men and woman because we did not read outside of a very narrow frame of reference. He was also in awe seeing the yacht tied behind Dr. Pankey’s home and when L.D. casually mentioned one day while driving through town with Bob, that that was his bank and he didn’t mean that was simply where he kept his money!
THE STUDENT BECOMES THE TEACHER: It has been said that no teacher is well served unless in some ways his student surpasses him or her. In the early days of the Institute, I was privileged to spend all too short a time with Dr. Pankey. But, I clearly remember the sparkle in his eyes when I recounted how I would not have stayed in dentistry had it not been for one of his students, Bob Barkley. I believe the lessons I learned from Bob Barkley are as useful today as when he first expressed them. Perhaps one of Bob’s greatest contributions was what he first learned through L.D., which he expressed as a Barkley truism … “The health of the relationship between you and your patient is always more important than the health of the patient.” We may be the one of finest dentists in our community, but if we fail to establish or worse yet violate the relationship, that person will not let us help them. Bob noted that in his practice it was often the third or fourth year before his patients would elect comprehensive restorative care. He felt it was tragic that dentists would diagnose and recommend comprehensive care on strangers. In one of his letters to a dentist who asked him about his “case presentation procedures,” he writes “I am absolutely opposed to the use of case presentations. I don’t think I will ever outlive the reputation I gained during the years in the early 1960s when I did case presentations. (I can say the same thing for the first three years of my practice.) Case presentations are unsound behaviorally, educationally, and scientifically. They should be replaced with a cooperative problem identification session in which the dentist and patient, as two adults, attempt to discover what is happening in the patient’s mouth and what can be predicted for the years ahead.”
CO-DIAGNOSIS: It was Bob who first coined the term co-diagnosis. What Bob came to understand is that case presentation is about selling, not about understanding. The case presenter is in control with an essentially passive patient. Too often the construct is “we must do this now, Mrs. Smith, so will it be good, better, or best"? Given that urgency of choice, Bob used to say most people choose good or better, but not best. And, sadly, if all you offer them is the best, then they will often leave your practice altogether. Bob pointed out that those of us who go off to places like the Pankey Institute to elevate our diagnostic and treatment skills without elevating our understanding of ourselves and others run the risk of greatly exceeding our patient’s expectations. We are so unlike any dentist they’ve seen before, and we are so ready to do it now that we scare them. They often leave never to come back. Meanwhile they tell their friends, don’t go there, he/she will over diagnose you. Bob was the first I heard say, “We must make quality the constant and time the variable. Not the other way around.” What he believed was that we should begin by establishing a relationship by coming to know each other first as people and then, together collaboratively look at the individual’s dental health, while asking where they will be in the future, if the problems are allowed to persist? Once that is clear, if we then talk about choices for correction, beginning first with controlling the active biology of the problem, most people will ultimately choose our best and finest care.
He admitted that this was hard for a dentist to do since it involved deferred reward, and we don’t deal well with deferred reward, especially those of us who pursue restorative dentistry. Why else would we rush headlong into sales camps that promise us how to close the deal? We want to do it now! Bob Barkley’s last essay before his death entitled, “On Becoming A Humanistic Dentist,” addressed this and much more. When Bob used the word humanist, he was not referring to secular humanism. He had borrowed the word from two works which had been highly instructive to him. The first was Douglas MacGregor’s The Professional Manager and the second was Peter Drucker’s The Age of Discontinuity. I’ll close this essay with a word or two more about what Barkley said about this concept. It seems that in this essay Barkley took what he had learned first from L.D. and expanded on it as he wrote, “We have come to recognize that changing one’s style takes considerably more than lectures and books. The pioneering professionals who have succeeded, know that work, sacrifice, risk, and repeated failure are the price of achievement. Most of all, it takes a change in self-image—how one sees one’s role in the lives of others. Now, during the ebb tide (he was speaking in 1977, as the “born again” wave of preventive dentistry seemed to be dying), most of the profession faces the difficult, but essential task of role clarification. Many individuals an groups have already made great progress. But a substantial number have fallen short. Their dreams have not yet been realized because they approached a philosophical conversion in a mechanical way. They simply added new techniques and tactics without adequately redefining their roles or examining their beliefs about dentistry and its relationships with people. I anticipate that dentistry’s next evolutionary development will be (my words … one in which ...) we must take enough time to obtain badly needed remedial training as human beings.” As Barkley reflected on his own speaking and teaching he said, “If I truly wish to help, I must become more effective in my aid to my colleagues so they can get in touch with their own strengths, values, and beliefs. I must change my lectures to drastically reduce the promotion of new tactics, and I must convince them to stop frantically seeking quick answers in the wrong places.” As I look at today’s dentistry, I believe that these words still ring true for you and for me. All too many of us still rush to the recipes and, although they may work for awhile or in technical dentistry, they do not work long-term with people.
OUR LEGACY: Bob believed that to be truly effective, we had to become more people centered or what he labeled "humanistic." It is fitting to close this paper with his definition of what humanistic meant to him. “To me, it denotes a person whose relationships with others are highly inter-dependent, a person whose purpose is to help others get in touch with their own strengths, and develop their own capacities to become more effective human beings. It draws upon the spiritual, not merely the mortal, resources which are available to all of us.” I, for one, believe this definition could be applied to Dr. L.D. Pankey and to perhaps his most famous student, Dr. Robert F. Barkley. They are both gone now, and it remains for each of us, who were touched by these great men, to carry on and grow the legacy that they gave us!
This article was first published as part of February '02 Texas Dental Association Journal devoted to the legacy of L.D. Pankey. The issue was put together by my friend and colleague, Dr. David Hildebrand of Dallas.