Bill Klaproth (Host): This is AAOMS On the Go. I'm Bill Klaproth. And joining us today is Dr. Keith Schneider, an oral and maxillofacial surgeon from Shaker Heights, Ohio, to discuss caring for unique patient populations. Dr. Schneider has an interesting patient mix treating not only traditional patients, but Amish communities and prison populations as well. Dr. Schneider, thank you so much for joining us today and sharing your unique experiences.

Dr. Kieth Schneider: Oh, thanks Bill. Thanks for having me. I really appreciate it.

Host: Thank you so much for being here, Dr. Schneider. Looking forward to talking to you about this. So, let's start here. Can you give us a quick overview of your practice, what your patient populations look like, and how you came to care for such a wide range of individuals?

Dr. Kieth Schneider: Sure. Happy to share. So, we have a very broad-scope oral maxillofacial surgery practice. We have five surgeons in three locations. And we're on staff at about eight hospitals as well. We're trying to, you know, hit all these patient populations from all directions. We just really take a lot of pride in caring for everybody. And definitely, we're going to focus on some of the most unique ones today, but we bridge into pediatrics – taking care of kids as young as like one and two – to elderly patients up to 100, 110.

Host: So, you do cover the gamut. When you say you have a broad scope, you mean it.

Dr. Kieth Schneider: Yes, definitely.

Host: So, as I mentioned, you have two very distinct patient populations that you treat, the Amish and patients who are incarcerated. How did you begin working with these very different communities?

Dr. Kieth Schneider: Well, I've always been, I guess, proud of our background in taking care of patients in the hospital. And so, a lot of these relationships actually spawned out of all the hospital presence that we have.

So initially, I treat a lot of head and neck trauma at a lot of our regional hospitals as well as our level I trauma centers here in Cleveland. And so, I initially started treating a lot of the Amish population there, and really got comfortable and just wanted to care for them, because they're a community of need.

And on the flip side of that, the prisons have a lot of prison fights that happen. So then, we sort of met a lot of the prisons through the hospital relationships as well.

Host: Well, now that you say that, that kind of makes sense. You would think a prison population, I would imagine there are some fights that go on and somebody that gets punched hard might have a jaw issue. So, I guess that makes sense. So, how do you juggle all of this? How does your typical day differ between your private practice, the correctional facility healthcare, and then caring for Amish patients?

Dr. Kieth Schneider: Yeah. Just to touch on the prison population, we have a relationship with two prisons in sort of the eastern part of Ohio. Actually, a very nice relationship. We've become contracted with the facilities themselves. I'm in sort of text communication with the staff there. So when they have maybe an acute issue, such as somebody that got punched in the face or, as they like to say, a "basketball injury", they'll, you know, text me and say, “Hey, I have somebody that we need you to take a look at.” And then, we coordinate usually getting them to the hospital for head and neck CT.

Sometimes, we'll actually just set them up for a consultation in the office. We always talk to them within the practice as our spa patients. So, it's sort of our code word for the prison population. So if we're speaking out in this sort of community in our office, if a patient overhears a prisoner, their ears perk. But if they hear a spa patient, you know, it's sort of soft.

Host: Right. Wow, that's really interesting. I would imagine they come with guards, and the guards are in the exam room when you're in there working on them.

Dr. Kieth Schneider: Yeah. So, most of the facilities that we treat, all the inmates come with two guards. They're usually restrained in wrists and ankles. When we see them in the practice, we'll also do dental alveolar treatments, so we're removing teeth. Usually, it's infected wisdom teeth or any other infection that happens. And then, in the hospital, it's the same sort of situation. They come with two guards. They actually come into the operating room with us during the repair. They take the restraints off, we put them to sleep and then do the repair.

Host: Wow, that is interesting. Do these spa patients ever get belligerent with you or have there ever been any incidents like that?

Dr. Kieth Schneider: You know, I've never had a belligerent incident with me personally. Sometimes if they're in the hospital for a day or two, they get a little antsy and they can be feisty with like the nursing staff. But for the most part, they're actually very easy to work with. There's a whole gamut of people that are in prison. And the people that are in for drugs and trafficking, things like that, they're actually pretty charismatic people. They love to chat. The knife and gun club guys, you know, those guys can be a little more rough and tumble. They might have a little bit of a chip on their shoulder. But for the most part, they're really respectful. They love the care. They actually say, "Thank you," "Please." They're pretty nice to work with.

Host: All right. Yeah, that's interesting. How does that differ then to the Amish community? Kind of the opposite there.

Dr. Kieth Schneider: So, the Amish, a lot of them we're treating for some injuries in the hospital and infections. Sometimes they don't have the best access to care. And so, they'll let infections brew. And then, so I'll meet them first maybe at the hospital with a head and neck infection that needs treatment. But we've come to really develop a relationship in the Amish community now spawning out of that where they know to contact us.

We work with some dentists that treat the Amish as well. They know that we're in a relationship with the Amish community. And what I mean by that is the Amish, they contribute dollars to a sort of a community health fund. And so, it was very fortunate. Their community health fund advisor reached out to our practice because they saw our name coming up so frequently. And they said, "Hey, would you like to create a relationship with our Amish fund?" And so, we did. And so, we contracted with – they have two different funds that they'll utilize for "insurance". So, they're really easy to work with as well. A lot of it is paper and pencil. But we negotiated. So, we actually get paid 70% of our fee schedule, which is nice. The Amish people, they're very stoic in general. They don't express a lot of emotion, but they're super kind and very respectful.

Host: So, how do their views on healthcare, particularly regarding technology and cost, how does that influence the way you plan and deliver treatment?

Dr. Kieth Schneider: We treat the Amish – and prisoners for that matter – we treat them with the same respect we treat all of our patients. I would say the majority of our patient population is just really nice blue collar workers, really have a high value for services. We treat the Amish patients the same.

So we provide them the same technology, and they are actually very embracing of it. You'd think they're very standoffish. But most of them come via transport vehicle. They have drivers that drive them in. We don't have to hold off on offering them dental implants. A lot of them actually accept dental implants at this point. They still want state-of-the-art care.

Host: So, what are some of the most important cultural considerations when treating Amish patients?

Dr. Kieth Schneider: So, their attire of course is very conservative. They come in. Men, it's more or less like work suits. Females are very well covered. They often come with caps on their hair. We always are just very cordial with, "Do you mind if you remove your cap or you can leave it in place if you'd like?" We just – you know – always are very respectful of those potential differences. Actually, most of them are just like, "Yeah, sure, I'll take that off." And they want to just sort of go with the flow of things. And so, culturally, we don't see a lot of variance actually with our normal population. So they're very easy to bring in and just adapt to our workflow.

Host: Okay. So, we understand their views on technology and things like that. How do you navigate issues such as sedation or anesthesia – you know, current medical practices – given their cultural and religious beliefs?

Dr. Kieth Schneider: I suppose just on the technology and communication piece, most of them have some sort of telephone communication to schedule the meeting. So, they will have either, one, a community phone, where a number of people will share a line. I think it's what used to be termed like a party line back in the '50s and '60s. So, they'll share a phone. But a lot of the Amish contractors that do like construction, they have cell phones now, so they're actually very easy to get ahold of. So, to coordinate appointments has really not been an issue. We actually don't need to collect any dollars from them just with the negotiations we have through their Amish funds.

We bring them in, we propose the treatment plan. They're very quick to sign off on it. And most of them do like anesthesia. They're like, "I don't really want to feel any pain." And others are very stoic though, like I mentioned, and they'll just do local anesthesia for very invasive procedures.

Host: That's really interesting. So, getting back to the prison environment, just a few more questions as I think about this. So are there any logistical or ethical challenges when providing care in a prison environment?

Dr. Kieth Schneider: The greatest nuance that we have with treating the prison population and our spa patients is, if we're coordinating surgery on a different day, they cannot know any details about that procedure. So, for instance, if I see somebody in the office for, let's say, a jaw fracture, I'll see them, I'll assess them, I'll give my recommendation. And I'll say, "We're going to coordinate surgery for some time in the near future." And they'll say, "When is it going to be?" And I say, "Oh, I wish I had that detail for you. But there's a lot of factors at play with coordinating that visit with the hospital, my staff, and your schedule." And so, what happens if they know a time and date they can "plot an escape." So, it's important to keep that information from them.

I've had cases canceled because I had a hospital to reach out to a family member of somebody that was in prison. And the family member contacted the prisoner and said, "Hey, I heard you're having surgery in a week. I'm going to meet you there." And that's a complete breach, and they canceled surgery, they almost canceled me as a surgeon. And it was all because the hospital reached out to them.

Host: Yeah, I could see that. Oh, my goodness. So, let me ask you this question, because I am sure you have unique perspectives now on both the Amish population and spa patients, if you will. So across these different populations, how has this shifted your perspective on access to care or healthcare equity?

Dr. Kieth Schneider: I believe everybody should have the rights to receive healthcare in the same capacity. Even our prisoner population, you know, I'm very respectful with them. I give them the same adequate informed consent of what we're doing, why we're doing it. My staff's still offering them water and blankets just like we do our other patients.

But I think that there's a great need for addressing this population, both the Amish and the prisoners. And I think it's a great adjunct to building practice. You know, collectively, on an annual basis, it's just like having a good referral, like a good referring dentist. I mean, our collections last year on our prison population was, I think, in the middle of about $250,000. And the Amish, I think we collected about another $150,000. So, as far as a referral, that's a great referral adjunct to your practice.

Host: Yeah. So let's stay on that. So across these different populations, what clinical adaptations have you had to make, whether related to equipment, treatment planning, or patient management or billing, or those types of things?

Dr. Kieth Schneider: With our spa patients, we always bring them in the back door. I would tell you that our other patients would have no idea that they're there. We sort of bring them in the back door. We bring them into a specific room. They're there with the guards. We get X-rays if we need to. And then, bring them back into the room. So, just sort of the logistics of working that out.

We have the guards wait in the parking lot. Of course, they have the prison van there. It's sort of an unmarked white van. And they call the front desk and say, "Hey, we're here." And we say, "Okay, just hold tight," and then we will go out and we will open the back door and say, "All right, come on in." And then, we will all bring them in. So that's probably the only nuance with sort of the workflow.

From a billing perspective, actually, it's a very simple process. I mean, once we bring them in, I literally explain treatment. We'll numb them right away and perform care. We don't have to wait for payments or talk to our treatment coordinators, our insurance coordinators. That all just gets done on the back end. The prisons usually will make sure that we're paid within 30 days, which is great. It sort of helps with our revenue cycle.

With the Amish population, of course, we're just rolling out the red carpet for them in the waiting room, just like we do all of our patients. And the Amish funds typically pay us by check, usually within 20 to 30 days.

So from a collections perspective, they're both very reliable, easy resources to work with. And we really enjoy working with them.

Host: Yeah, it sounds like it is something different – out of the ordinary, if you will – than a regular patient population. So if an OMS is listening to this saying to themselves, "This is kind of interesting. I think I would like to look into this, maybe I could care for a different population other than a regular patient population," are there licensure barriers or reimbursement things we should know about that make it more difficult for an OMS to care for underserved or non-traditional populations?

Dr. Kieth Schneider: I would not say that there's any licensure barriers at all with caring for these populations. My recommendations for anybody that would be interested in sort of exploring this would be trying to contract with the prisons. The prisons really do like to have a very, I don't know, predictable care source. Because otherwise, they're getting sent to whatever facility or person's available, and they don't get the continuity of care that they would with somebody that's working with them.

I would also recommend trying to work them into your practice, not you going to the facility. Because I think it's easy enough just to get it into your workflow. So, just coaching your team. And honestly, it's pretty exciting for my team. They love the stories. They look up whatever these prisoners do. Some, I don't want to know. I try not to know.

The Amish community, reaching out to them and they're going to be forthcoming. They say, “Hey, do you work with my Amish fund?” And if that's the case, then, you know it’s, “Who's your liaison? Or can you give me a point person that I can contact?” And then, create the relationship that way.

Host: So, I'm curious. I don't think I've ever talked to an Amish person. And I don't think I've ever talked to an inmate before in my life. Have these varied patient interactions that you have  – have they shaped your personal philosophy or approach to oral and maxillofacial surgery at all?

Dr. Kieth Schneider: Well, I don't have any personal, I guess, interaction with the prisons per se before this relationship. But my mom was born and raised on a farm with a lot of Amish friends. So, I've always been sort of friendly with the Amish community. They're just good old timers. You know, people that really believe in family and good traditions and the land and caring for each other. And they're very sweet people. So, I've always just enjoyed those characteristics about them. I suppose it gives me some pause every day with, you know, making sure I'm taking care of my family.

And then, on the prison side, making sure I'm behaving.

Host: Right. Oh my gosh. Okay. So bottom line, Dr. Schneider, if an OMS is listening to this saying to themselves, "Okay, I'm really interested in this. I want to do this," where would someone start? What advice would you give to other OMSs interested in expanding their practice to underserved or unique patient populations as you have done?

Dr. Kieth Schneider: I'm open to open communication with me if they want to reach out. And I can walk them through the ropes if they want. Feel free to contact me. And my email address is keith@ohsurgery.com. I also hold a faculty appointment at Case Western Reserve. I've been there for about 12 years, and that's kms59@case.edu.

Host: Well, there you go. Well, you could hear it directly from Dr. Schneider then and get your questions answered. That's very nice of you to do that, Dr. Schneider. We appreciate it. Anything else you want to add before we wrap up on your unique populations that you serve?

Dr. Kieth Schneider: I guess my only closing statement would be treat everybody with respect. Love your patients. Be kind. I think that's what we value as practitioners and that's what we look for in ourselves every day to be fulfilled with what we do for people. And I find that with these sort of unique populations as well as all of our patients.

Host: Yeah, very well said. Dr. Schneider, thank you so much for your time. We appreciate it.

Dr. Kieth Schneider: Yeah. Thank you.

Host: You bet. Once again, that is Dr. Keith Schneider. And for more information on advocacy issues affecting the OMS specialty, you can visit AAOMS.org/Advocacy.

And if you enjoyed this podcast, please share it on your social media and make sure you subscribe so you don't miss a future episode on dental advocacy, leadership, and the future of oral healthcare.

I'm Bill Klaproth. This is AAOMS On the Go. Thanks for listening.