Thoughts on Bob Barkley's article, "On Becoming a Humanistic Dentist" William T Brown DDS I knew Bob Barkley. I studied with him in Macomb, Illinois and in my office in Des Moines, Iowa. He asked me to edit his manuscript of his first book. Bob Barkley was the most powerful, positive and lifechanging person in my professional life. In my opinion, Bob Barkley transformed dentistry in more profound ways than any one individual. Bob is barely remembered by contemporary dentists.

Dr. Bob Barkley

I praise Lynn Carlisle for his undaunted courage and persistence in making *Bob's impact and teachings available on the web. As I read Bob's article, I had a flood of memories that compel me to articulate my impressions of the comments Bob made and the relevance to dentistry, then and now.

The intention of my discussion is to present an historical perspective to Bob's insightful and probing article. Because I worked with Bob and give him the credit for changing my professional and personal life, I hope that I can add a dimension to his remarks that will assist the reader in a deeper and more meaningful understanding of his impact on dentistry and one practitioner.

Brief History At age thirty, I had just opened a new office filled with the finest and most state-of-the-art dental equipment known to man. I had spent two years as an associate in a practice that was CBA (i.e. Chrome, Blood & Alloy). I saw patients six days a week. Four patients an hour plus "squeeze-ins". I told my wife that there must be a better way to make a living. Maybe I should go into another field of endeavor. Instead, I decided that I should try dentistry on my own. It couldn't be worse, I reasoned. My new office helped--but not much. I was a transactional dentist. I was a piece worker. I was putting out fires. My "cures" were alloy, gold, porcelain and the ultimate failure of complete dentures. I felt unfulfilled. I felt depauperate. What was the answer? At the time I made the decision to move into my own office, I visited the new (and only) periodontist in town. He examined me and told me I had gingivitis and recommended that he perform a fullmouth gingivectomy. Needless to say, I was shocked! I was a dentist. I had eight years of college. I used an electric toothbrush. I asked the periodontist what was causing the problem and he gave me the same nebulous etiology I heard in dental school: diet, calculus, missing teeth, etc. I didn't have any calculus or missing teeth (except 3rd molars). I went home and started reading. There was no internet, so I did my research the old-fashioned way. It was apparent that periodontal disease was treated like caries, because dental education was primarily decay oriented. With decay, it was find and fix. With gum disease, it was find and cut.

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Serendipity As I was starting to form a few new ideas on what was causing my problem, a colleague invited me to an informal meeting at his office to meet and hear a dentist my friend had met and wanted me to hear. He was going to tell us about "preventive dentistry". What a concept! I was eager for new information. This was 1965.

Paradigm Shift

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However, after about three hours of listening to him I thought to myself, 'Toto, we aren't in Kansas anymore.

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The dentist was Bob Barkley from Macomb, Illinois. I had never heard of him. However, after about three hours of listening to him I thought to myself, "Toto, we aren't in Kansas anymore." We have all heard of having a paradigm shift, well I had one that afternoon. Barkley struck me with electrifying force. For the first time in my dental career, Bob Barkley gave me hope that I could become the person I was intended to be. I was engaged in an inner struggle. I was a "molar mechanic" and it was apparent that providing therapy would not satisfy me. I wanted to be a diagnostician. I wanted to be a healer. And here was someone who explained that it could be possible. And Bob's message was based upon scrupulous information. I immediately read all of Bass' and Arnim's articles, applied the scientific principles personally and my gums stopped bleeding within two weeks. It was an epiphany. I went to Macomb soon after our meeting and spent two days with Bob and found out he was the real thing. He was highly respected in this small western Illinois town. As we drove around town, all the policeman waved and called him "Doc". Bob also told me how he had been influenced greatly by Dr. Nathan Kohn, Jr., a psychologist and part time lecturer at the Washington University Dental School in St. Louis. Dr. Kohn had completed a study for the Illinois Academy of Dental Practice Administration, to which Bob belonged. The question the IADPA wanted answered was why more people didn't avail themselves for dental care. Dr. Kohn's study found that it was the failure on the part of the dentist to establish a relationship with the patient. Barkley was intrigued with this counter intuitive answer, so he decided to meet Dr. Kohn. Bob said that Nate forced him to start thinking seriously about what he was doing in his practice. Not about margins and contact points, but rather about treating patients as human beings. My retelling of the incident is lacking in the real impact that these sessions with Nate had on Bob, but he felt that his experiences with Nate were the watershed moment for his practice. There were others that had an impact on Bob's development, e.g. Dr. Pankey and others, but Kohn helped with establishment of principles which made all the difference. I was more than mildly interested in meeting Dr. Kohn. Luckily, Bob had scheduled a two-day seminar with Nate in nearby Monmouth in two weeks. I returned with my staff and was able to establish my relationship with Dr. Kohn, which lasted until his untimely death in 1970. His demise was like the felling of a giant tree in the forest.

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The point of her submission was that her boss, Dr. Barkley, was a modern incarnation of Railsplitter, Abraham Lincoln.

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At the meeting in Monmouth, IL, Dr. Kohn was the leader and he had staff members present their thoughts on the practices and people they worked with. One of the most interesting presentations, to me, was made by one of Barkley's dental assistants. She was a mature woman who had worked for him several years. The point of her submission was that her boss, Dr. Barkley, was a modern incarnation of Rail-splitter, Abraham Lincoln. The DA gave a proposal with examples of how Barkley exhibited the

same qualities as Honest Abe, both physically and personality. She made an excellent and sincere delivery. My impression was that Barkley was somewhat embarrassed by her accolades, but he appreciated the thought and comparisons she made.

Doors Opened & Stars Aligned I engaged Dr. Kohn and he started with a careful, in depth study of myself. My attitudes and feelings. My prejudices and desires and other personality attributes. Nate made me realize that I had to understand my self-concept before I could understand others. That dental practices are highly complex and the dentist was cast in new roles not envisaged in dental training. Being a manager was not in the concept I had of dentistry. Nate showed me how a dentist can feel trapped in playing roles they have no training, experience or inclination for. He also felt that every professional person could benefit from a visit with a skilled counselor in behavioral sciences to seek advice with respect to their own personality traits. A few brief sessions in discussion of traits, goals and ambitions could be very beneficial for better service to the patient, better return for the dentist, with less strain. On the basis of the self-appraisal, I could define my practice. This was what I had been looking for. Bob Barkley had been searching for answers, as well. Defining our practices was one of the most important steps for both Bob and me. Nate made us realize that if you are unable to write down a definition of your practice, you won't be able to communicate adequately with patients and staff. Nate had my staff and me complete a Practice Analysis and Understanding Yourself workbook which helped us develop goals, redefine our organization, establish new procedures and define a process of continuous evaluation. The exercise was powerful and revealing on many levels. I soon realized that my self-concept was quite different from those held by my staff. In addition, the staff recognized that the discipline required in the task would help us resolve our performance problems. The application of the results of better understanding ourselves as human beings guided us to mesh as a team. As Bob had done before me, it was obvious that new systems were needed to deal with new information and technology. It was imperative for critical and serious thought about the practice dynamics. The result of this was my development of Comprehensive Oral Health Care (COHC). Obviously, this didn't occur overnight, but took several years to accomplish. COHC was based upon many of the principles that I had received from Bob, but it was organized in a manner that allowed me to apply the concepts I discovered in my activities and training from Nate. With Bob and Nate leading the way, I was able to develop a system the filled my deeply felt needs. The first consideration was humanistic. Bob and Nate made me keenly aware of the necessity of treating patients as total beings. The new information on disease control had made patients responsible for their oral health and therefore it became my charge and obligation to involve patients in a health story. My office needed to be primarily a place of oral health education. The shift was from a case-centered or transactional practice to a relationship based and patient centered one - connecting with patients through empathy, patience and compassion. Moreover, avoiding treating them as objects who came for "cures". Nate helped me realize that the fundamental principles should be open communication, mutual respect, and an emotional connection between my staff, the patients, and me. Nate went so far as to underline the power of Gestalt so that we as a dental team viewed the patient as the "whole person" rather than the "sum of the parts". For example, the staff is indoctrinated with the philosophy of the office, that this office adopts a patient-centered philosophy. This functions primarily by utilizing basic principles of caring for and thinking about the patient's welfare. The education of the patient, the caring for the patient, the serving of the patient are all functions of this approach. By incorporating these principles for

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"learners", it becomes easier to remember a "whole" rather than a "part". Another way of looking at the concept is an athletic team. A team illustrates the principle of "unified wholes". A well-coordinated team that shifts its emphasis as the quarterback or pitcher changes his delivery is more effective than the sum of the individual players. This is why the philosophy of practice is so critical to having an effective dental team. Instead of trying to teach auxiliaries individual "parts" of a practice, we want to see the "wholes", which are much easier to remember and apply to patient care. The Humanistic component was combined with understanding the biology of dental disease and health, the diagnostic elements based upon a comprehensive examination and therapy. The Philosophy of practice was the glue that held the other components together and it was used as a communication and management tool for staff and patients. The philosophical development was the directly related to the serious thought about my practice initiated by Bob and Nate. The concepts of *COHC (* see information at the end of this article) were published in 1971 when I coauthored An Approach To Comprehensive Oral Health The Preventive-Periodontal Concept with Dr. Robert Burns, a periodontist. The book was a direct result of our work with Barkley. The work was based on the premise that the preventive movement was destined to fail because it had been based upon techniques rather than biologic concepts and behavioral science. The gold standard was the normal mouth, treated as an organ system. The establishment of Dental Metrics was essential so the dentist had a benchmark of the patient's initial status as a way to determine progress. Without metrics, there was no reference point. Burns and I discussed this missing link with Barkley and we were rather surprised that he did not acknowledge its importance. I can understand his reaction because he didn't have a periodontal orientation. (Note: Barkley had a very emotional reaction to our suggestion that we should all include the normal periodontal tissues as the basis for our diagnosis and treatment. Any variations from normal. Barkley literally asked us to step outside the lecture room so we could discuss our theory in private.) Bob's training, like mine, had been the traditional dental school caries orientation. I had been fortunate to study with Burns who gave me the education in periodontics that Barkley and I had not received in dental school. My experiences with Bob Barkley and Nate Kohn remind me of the parable of the beggar in Eckhart Tolle's book The Power of Now. In the parable, a poor beggar holds his dirty cap to a passing stranger saying, "Spare some change?" "I have nothing to give." replied the stranger. He said,"What are you sitting on?" The beggar replied, "Nothing-Just an old box I've been sitting on for years." The stranger asked, "Have you ever looked inside?" "No", the beggar replied, "What's the point, there's nothing in there." "Have a look inside." insisted the stranger. With some difficulty, he pried the box open and was amazed to find it filled with gold!

Bob Barkley and Nate Kohn were the strangers. I was the pauper. They told me to look inside. Until you look inside you will never know. The gold was within me, waiting to be discovered. These were gifts I had received without knowing it until these two strangers came into my life and helped me find what I was sitting on. The treasure within fulfilled me and many others. He had a profound sense of responsibility for what he had created.

It became apparent in the 1970's, that Barkley was attempting to explain and expand his message with his exploration of humanism and pedagogy. He had a profound sense of responsibility for what he had created. However, he also recognized that the direction of the movement was proceeding in ways that he had not foreseen. Bob fell back on his family tradition of education. His father was a teacher/farmer in rural Ipava, Illinois and Bob was greatly influenced by the principles of education. I know that Bob turned to many different writers and thinkers to help him expand and develop the concepts he was presenting to the dental profession. Another factor, was that Nate Kohn had passed in 1970, so Dr. Kohn's intellect, orientation, and influence were no longer available to Barkley. Bob's quest was silenced with Kohn's tragic death, but the contributions he made to dentistry and humankind are unmatched. Thanks to Dr. Carlisle and others who are helping these dreams and the treasures within be discovered. Barkley quotes in his article On Becoming a Humanistic Dentist, Peter Drucker's The Age of Discontinuity, which was published in 1968. Dr. Kohn gave me a copy of the book and told me he wanted to discuss it after I had read it. My first reaction to the book was, "This man makes me think." For the younger readers who may not have read this "old" book, Drucker predicts the coming of information technology. That was 13 years before the PC or the world-wide-web. Unlike many of his contemporary economists, Drucker was focused on relationships among human beings rather than crunching numbers about commodities. He made me realize that workers needed to find a sense of community and dignity in the modern workplace and in society. In my young and eager practice, when our team put together our first remedial organizational objectives, we used the goal of establishing a sense of community and ownership for our staff. Another of Drucker's concepts that had important relevance to Barkley's and my activities, was his admonition that there must be a transition from scientific knowledge to technical knowledge, and finally from the technical to a marketable item. The salience of this statement was that the new information on the prevention and control of dental disease and the progression of periodontal disease had been transformed into a technique, but had not been converted into a patient management system. Drucker's concept was the crux of the problem for Barkley and me (and others) who were trying to sell a 5-Day Plaque Control Program instead of a system for interruption of a disease process. Drucker's ideas were a major influence on me in the development of Comprehensive Oral Health Care which was designed to be a complete management and communication system for the dentist, staff, and patient. I told Dr. Kohn that reading Drucker was like drinking from a fire hose. I told Dr. Kohn that reading Drucker was like drinking from a fire hose. Every paragraph needed careful thought because of the gravity of his ideas. Barkley was keenly aware that his message was morphing into a typical dental technique. The first Prevention Convention was held June 6-9, 1971 in Chicago, and even though the ASPD (American Society for Preventive Dentistry) Award Recipients were C.C.Bass, M.D., Sumter Arnim, D.D.S, PhD., and Robert Barkley, D.D.S., there was a carnival-like atmosphere in the Conrad Hilton Hotel. There were rows upon rows of commercial booths hawking floss, polished-bristle toothbrushes, Floxite mirrors, and any manner of tools to use for plaque control. I distinctly remember hearing a serious discussion on how many strands of unwaxed nylon was required in the "right kind" of floss. On the other hand, the convention had high energy. It was definitely "something new" for the dental profession and for all the manufacturers and dental suppliers. It was a market that had been untapped and the industry was there in full force ready to sell whatever it could.

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The Dirty Little Secret In the interest of historical perspective, it is important to note that preventive dentistry hit the dental profession like a ton of bricks. Let me tell you why. Bass published his original research articles on plaque control in the 1940's. It was printed in the Louisiana Medical Journal and was met with a groundswell of apathy by the R.D's (Real Doctors). "What was poor old Dean Bass doing writing about toothbrushes? He must be in his dotage." the Louisiana Docs said. The Louisiana medical docs had trained under Dean Bass at the Tulane Medical School where he was renowned as pathologist and tropical disease expert. Now Bass was writing about dentistry. What was going on? Fortunately for the dental profession, Dr. Sumter Arnim read the Bass research and because Arnim was a dentist and a research scientist, he recognized the significance of this groundbreaking information. Arnim published his first work on the cause, pathogenesis, treatment and prevention of periodontal disease in July of 1958. However, it was published in the specialty literature (Journal of Perio) and the information completely bypassed the general dentists. That's where Barkley came into the picture. He was able to transform this scientific information that had been around since the 1940's into a marketable product that would change dentistry nearly overnight. Credit must be given to him for single-handedly taking these water-shed technologies and information globally to the dental profession. The reason that Bob Barkley was able to pull off this unbelievable feat was his God-given talents as a raconteur.

The reason that Bob Barkley was able to pull off this unbelievable feat was his God-given talents as a raconteur. Bob could literally mesmerize an audience with his homespun anecdotes and humorous stories. After he finished telling the audience about sitting in his family's outhouse at 10° below zero with a 40 mph wind blowing a wind- generator his Dad put the roof so they could listen to the radio in their farmhouse, the people were eating out of his hand. All of his stories had a message that resonated with the dental staffs. Everyone could relate to these homely stories on a personal level. Barkley was as effective with the dental assistants as he was with the dentists. That's because he was able to translate the scientific information into understandable and repeatable language. Barkley was also a very self-effacing and humble person, who was not trying to put himself on a pedestal. Anyone could relate to Barkley, either one-on-one or in a large audience. He was tall and lanky with a broad grin that wrinkled his eyes and he laughed along with the audience when they guffawed at his stories. He was as close to a true American humorist in the vein of Will Rogers or Herb Shriner as has ever graced dentistry. His audiences were in the thousands and he converted disciples to his message in the thousands.

What Happened? The problem that Barkley realized, and probably why he retreated to academia later in his career, was based upon the fact that many "disciples" went home to their practices and found that the "5-Day Plaque Control Program" wasn't as easy to integrate into a traditional dental practice as it had seemed when they heard Dr. Barkley. For instance, Barkley recommended that the dentist should charge at least $55 for the 5-Day plaque control program. Therefore, Dr. Dentist would go back home to West Watchfolb (or wherever) and start charging $55 for his control program. The patient would return angry, saying, "I told a dentist I

know at church that you had charged me for plaque control, and he said, 'You learned to brush your teeth in fourth grade for free--what a rip-off!' " Needless to say, this created a public relations problem. The dentist had merely tacked on a plaque control program to his "Drill, Fill & Bill" practice without the necessary frame of reference or patient management and communication systems in place, and it was a disaster. The new information and technology needed new systems to deal with this new paradigm. This was the mentality at the ASPD Convention; another technique for the existing dental practice without any consideration of humanity, biology, diagnosis, or philosophy. My personal opinion is that Barkley felt personally responsible for this miscommunication. He felt honor-bound to rectify the situation, even though he was the most sought after speaker on the dental circuit.

Up Close & Personal I recall Barkley talking to me about trying to incorporate his ideas into the curriculum at the University of Iowa College of Dentistry. We were both concerned with the outcomes with this idea. As Bob said in his inimitable style of an analogy that people could relate to. He said, "Dental Schools are like a battle ship. To turn them you need to have the Admiral call the engine room and go through the chain-of-command and it may take several miles before things turn. A sloop, on the other hand, only needs to say, 'Ready, About', and you've turned." He was so correct in his assessment. Even the best intentions were met with one obstacle after another and the final outcome was less than satisfactory. Barkley attempted at other dental schools around the US, but with similar results.

The Way He Was Barkley came to visit me in Des Moines in 1968. It was March and it had started to snow. Barkley said that if he didn't attend a Rotary Meeting that week, he was going to be dropped by the organization. We called around and located a meeting for that evening in a town 40 miles away. There was no compromise in going or not going. Bob was determined. I suppose I could have declined, but he was such a great guy that I decided, "What the heck!" So, we proceeded to the meeting. The snow kept coming. I deposited Bob at the Rotary meeting in the little town and told him to extricate himself ASAP so we could get on the road. He was lecturing in Des Moines the next morning. I waited in the car and snow became heavier and the wind started to blow. Over an hour passed before Barkley returned. By now there was over 6 inches and the snow was coming harder and it was drifting. I had a European sports car that Bob could barley fit his long-geared frame into. As we started back, I decided that we might be better off if we went to the Interstate, even though it was further. I reasoned that the road conditions might be better. Wrong! The storm intensified. The road was terrible with cars and trucks in the median and in the ditch. It was 20 mph top speed, with stop and go. It took us nearly three hours to get home. Barkley was cheerful the entire trip and I think he looked at it as an adventure, which it was. We even talked about dentistry. An interesting side to the story is that in that same storm, that same night, within a few miles of where Barkley and I were driving, a dental colleague and two passengers fatally crashed their private plane. The dentist was coming back from a fishing trip so that he could attend Barkley's presentation the next day. In retrospect, I felt it was a premonition of what was to come. When we found out the next morning, Barkley's reaction to the news was much more intense than I would have imagined, because he didn't know any of the people involved. He wanted to know about the pilot's training and other probing questions which made me think that there was concern about travel. Barkley was killed in a plane crash nine years later under similar circumstances. The American Dental Association had a brief obituary in the ADA News September, 1977. The article referred to Dr.Barkley as an international lecturer and originator of the 5 Day Control Program. When

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you think of the contributions that Barkley had made to the dental profession, it obvious that the ADA had no real concept of his stature or legacy. The obituary illustrated to me why Barkley had attempted to supplement his message with thoughts about human behavior, management, and education. He worked with Avrom King and others who were thought of as "futurists" to help him in this quest. Barkley said that this incident made him realize how difficult it was to make people change their behavior.

I recall Bob telling me a story of riding with a rental car employee at O'Hare Field. The driver was arching his back as he drove to the rental car return so that the seat belt alarm wouldn't buzz. Barkley said that this incident made him realize how difficult it was to make people change their behavior. He continued by observing that you would have to be very well adjusted to drive with the incessant buzz of the seat belt alarm. But why not fasten the belt?

Dental Metrics Another element that was problematic in the preventive movement was the lack of any metrics to monitor or titrate patient progress. The system that Burns and I created was based upon the normal periodontium. Any change from normal could indicate the level of disease or health. The reader must understand that at that point in time (late 1960's-early 1970"s) you could not find a periodontal probe in most dental offices. There was virtually no real recognition of periodontal disease. Many lawsuits were brought against dentists for failure to diagnose periodontal disease, which did change the behavior of dentists.

The Bottom Line Now that we have discussed what happened and the impact that Barkley and Kohn had on me and others, the obvious question is: What changed as a result? For me, and I think others, the changes were profound. The transformation from a transactional practice, concerned with fixing problems to a practice that dealt with patients as total human beings, was the basic innovation. The combination of thinking seriously about the practice and how the individual dentist wanted his practice to become was fundamental. Instead of merely following the random paths of those who went before, the dentist was shown how to chart his own course based upon his self-understanding and redefinition of practice. There wasn't one guiding principle, but a system of ideas and concepts based upon new scientific information that made the patient responsible for their disease. This was a major break in how dentistry was practiced. Instead of patients coming for dental cures, the dentist educated the patient in the control of the disease, then made the unmanageable areas manageable. The patient could then proceed on their own terms with the extensive/expensive procedures. Dentists had already realized that the full-mouth reconstructions were doomed to failure if the underlying periodontal tissues were ravaged by disease. It didn't make any difference how perfect the margins were or the occlusion, the rehabs still failed if the foundation collapsed. For me personally and professionally, this metamorphosis was the best thing that could have happened. Not only was I able to surround myself with co-workers that were very compatible, but the involving patients in their own health story converted me from having to sell dentistry into a

diagnostic healer. Patients became missionaries for my practice because of the experience they had. The dental therapy became a matter of not "if" but "when". It was a revolution. As a result of the conversion made possible by the efforts of Barkley and Kohn, I have been able to retire from active practice with financial independence. A cynic might say that many have retired to independence without all of the work I have done - they would be correct. But, I have a feeling deep inside of knowing that what I did for my patients and staff was better than it would have been without the adjustments. You could also ask, "So what?" And I would answer, that the development of my practice allowed me to become the dentist I had thought I was intended to be - that has made all the difference.

Finally My attempt has been to present a context for Bob Barkley's life and his endowment to the profession and humankind. Kudos to Dr. Lynn Carlisle and others who are continuing to offer dentistry and society with a slice of Barkley's addition. Barkley's article On Becoming a Humanistic Dentist was a result of his campaigns to change dentistry for the better. I don't know whether he ever completely understood or appreciated what he accomplished for not only the dental profession, but more importantly, humankind. But, I do know that he was able to move important new concepts to the dental sleeping giant in ways that he or others never envisioned. My hope is that his contributions live on for the benefit of us all.

References: Barkley, R.F., Successful Preventive Dental Practices, Preventive Dental Press, Macomb, IL, 1972 Green, E.J., Kohn, N., Selection, Hiring, and Training of Dental Auxiliaries, Philadelphia:W.B. Saunders Co., 1970 R.L. Burns, W.T. Brown, An Approach To Comprehensive Oral Health Care-The Preventive-Periodontal Approach, Dynamic Dental Systems, W. Des Moines, IA, 1971 Robert Barkley,D.D.S. Personal Communications. Nathan Kohn, Jr., Personal Communications.

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