Restful Sleep is Essential for Dentists and Dental Professionals

Millions of people, especially dental professionals, suffer from sleep deprivation. While we are not yet a nation of walking zombies, insufficient sleep or poor quality sleep causes many of us to be distracted, irritable, inefficient, or prone to mistakes. The reasons for our lack of sleep are myriad – stressful jobs and family situations, health issues, night work or late shifts, and the inability to “shut off” our minds when it’s time for bed. Dentists and healthcare professionals are not immune from this debilitating trend. Adults need seven to nine hours of sleep during each 24-hour period. But here’s the caveat –sleep needs to be deep and restful. It won’t help to get even 12 hours of sleep if you’re waking each hour. We need to achieve the rapid eye movement (REM) stage of deep sleep, when we dream, to benefit from sleep’s restorative effects.

What Are Sleep Aid Options For Dental Professionals?

cbd as a sleep aid

Without quality sleep, people soon begin to experience mental deterioration, and physical sluggishness is not far behind. We can easily fall into a sleep deficit – experiencing night after night of insufficient sleep that eventually catches up with us and impairs our ability to function. Sleep deficits are particularly critical for dentists and dental professionals, who are required to perform high-precision dental procedures on a daily basis. Suffering from sleep deprivation impairs dentists and assistants both mentally and physically – and can result in lackluster dental work and a poor experience for dental patients. So where can dentists and dental professionals turn for a safe, effective sleep aid? Prescription medications are often habit-forming, can lead to dependence, and may diminish in effectiveness over time. Alternatively, melatonin is a natural hormone and is not addictive, but melatonin won’t cure insomnia. It only helps you fall sleep, not stay asleep. Melatonin can also produce side effects and drug interactions. Furthermore, it is difficult to be assured of quality with melatonin supplements, as many manufacturers include additives or unnecessarily high doses in their products.

Natural CBD Oil for Dentists and Assistants

We all need less stress in our lives, but barring that, natural cannabidiol (CBD) oil is perhaps the best choice for facilitating deep, sustained sleep for healthcare professionals. Published research has shown time and again that CBD has a profoundly positive effect on sleep. For example, animal studies have produced evidence that CBD helps enhance longer sleep duration and staves off sleepiness during the daytime. Furthermore, this literature review from the National Institutes of Health concluded that CBD can help with daytime drowsiness and REM sleep behavior disorder. Additionally, CBD has demonstrated anxiety-reducing benefits, and anxiety is a major cause of insomnia among dentists and dental professionals. Like melatonin, cannabidiol is a natural compound. While CBD oil is derived from hemp, it does not contain THC and does not produce psychoactive effects. CBD products are not addictive and exhibit no long-term side effects. Extended use does not diminish the benefits of CBD oil, in contrast to prescription sleeping pills or other drugs. We spend one-third of our lives asleep. Shouldn’t that time consist of restorative and natural rest? If you’re a dental professional and getting less-than-perfect sleep and are a dentist, consider natural CBD oil to facilitate the rest you need. Being a dentist is a high-responsibility and often stress-inducing profession – and stress is consistently a driving factor behind insomnia. Dental professionals need to have a sharp mental edge and be physically capable in order to perform high-quality dental procedures. CBD products are a safe, non-addictive, non-toxic option for any healthcare professional.

CBD Oil Is an Effective Pain Relief Option for Dental Professionals

Neck and back pain is widespread in the general population, but the incidence of these types of pain is even higher among dental professionals. The reasons for this ubiquitous problem are not surprising. Dental care providers literally twist themselves into unnatural and uncomfortable positions all day in order to treat their patients. These daily contortions contribute greatly to common neck and pain triggers like arthritis, tendinitis, muscular injuries, nerve root compression, and thoracic outlet syndrome.

CBD as an Alternative Treatment for Muscle Pain and Discomfort

Unfortunately, even with the benefits of modern medicine, most current treatments for neck and back pain are lacking in one way or another. Conservative measures include ice, heat, oral anti-inflammatory medications, topical analgesics, and rest. Of course, the reality is that extended rest is not an option for many dentists and their assistants. So you’re left with other modalities that often don’t provide much relief or for very long.

You may be tempted to turn to more invasive treatments if your pain is severe or unrelenting. But as you know, invasive therapies like epidural injections, spinal cord stimulation, and spinal surgery, come with risks and lengthy recovery times. Even if you choose to endure these procedures and the recuperation period, you have no guarantee that they will succeed in relieving your pain. Cannabidiol, also known as CBD, may be a better option to treat your chronic pain.

CBD Is A Better Option

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By now, you’ve likely heard of cannabidiol (CBD) oil. A hemp product, CBD oil has proven beneficial effects for a number of medical problems. While CBD oil is not a miracle drug or panacea, it has been shown in animal and human studies to have a profoundly positive effect on muscle pain, arthritic pain, pain referred from headaches and cervical neck issues, and spinal pain.

One way in which the components of CBD oil help with pain relief is by mimicking the effects of soothing thermal compounds. Visit any pharmacy or grocery store, and you’ll find a plethora of products that stimulate the heat and/or cold receptors of the human body – cooling salves that contain menthol or eucalyptus or warming balms that use capsaicin (hot pepper) compounds. However, your body quickly becomes acclimated to these ingredients, and medications that contain these compounds lose their effect the more you use them.

This is not a problem with CBD products. Although CBD oil makes use of these same pathways, the active components in the oil have been shown to be long-lasting and effective over extended treatment. So before you schedule risky surgery or waste more money on ineffective over-the-counter remedies, consider the many pain-killing benefits of non-addictive, natural CBD oil.

Whether to Buy or Lease a Dental Office

Risky Dentistry Procedures that Lead to Malpractice Lawsuits

The American Board of Legal Medicine reports that just over 13% of all professional malpractice claims are filed against dentists. From 2004 to 2014, there were more than 32,000 claims of malpractice brought against dentists, resulting in a malpractice payment in nearly 17,000 cases and an adverse action in roughly 13,500 more. These figures are significant enough for all dental professionals to be aware of the most common types of malpractice claims and the riskiest procedures for claims against dentists.

        Remember that to bring a successful case for dental malpractice, an injured patient must satisfy these four elements of negligence:

  • A dentist-patient relationship;

  • The appropriate medical standard of care under the circumstances;

  • A breach in the standard of care that caused harm to the patient; and

  • Injury to the patient.

Without clearly establishing or proving each of these four elements, a patient will not be able to recover damages. Even so, a complication or injury resulting from a dental procedure could mean potential litigation, a blemish on the dentist’s record, and added expense and time away from the practice.

Common Procedures Can Be Risky Procedures

One author’s research of court proceedings shows that some of the most common types of dental malpractice are infections caused by the improper sterilization of equipment, the failure to diagnose and treat periodontal disease, and the misdiagnosis of some other dental condition.

This research lends itself to the contention that many incidents that result in a dental malpractice claim aren’t the most complex or difficult dental procedures, like a dental surgery. For example, one of the most common procedures found to be the source of medical negligence claims against dentists is a complication from a tooth extraction. In many instances, a complication arises in this procedure, the incident is exacerbated by the dentist failing to provide the opportunity for informed consent from the patient, or the absence of proper referral protocols if there’s an injury during the extraction procedure. Let’s look more at tooth extraction and other risky procedures.

Tooth Extraction

Another recent study found that out of nearly 250 cases of dental malpractice, the most common malpractice claim stemmed from a tooth extraction procedure. From those 63 cases, many of the incidents involved infections (23)—all of which necessitated the patient’s hospitalization. In fact, in Dentistry IQ, eight of these cases resulted in the death of the patient. Less severe, but quite serious injuries from tooth extractions included severed lingual nerves, severed inferior alveolar nerves, sinus perforations, fractured mandibles, TMJ injuries, and the extraction of the wrong tooth.

Endodontic Procedures

The second most common alleged negligence was from an endodontic procedure. Infection was the leading injury in claims arising endodontic therapy or root canal therapy. The Dentistry IQ research showed several life-threatening infections, with four fatalities. Of those life-threatening infections, seven were caused by brain abscesses and one was due to osteomyelitis. Four of these eight infections were fatal, and the other four caused irreversible brain damage. Other complications from this type of procedure are instruments left in canals, perforation of the sinuses or nerve damage, as well as air embolisms.

Endodontic procedures made up the second highest number of malpractice claims against general dentists in the Dentistry IQ study. Similar to tooth extraction preparation, teeth requiring endodontic therapy should be examined for possible curved or hooked roots, calcified canals, proximity to nerves and sinuses, and other potential complicating factors. On that note, one more factor in this type of claim was the fact that many of the defendant dentists were general dentists, rather than specialists. Failure to refer the patient to a specialist is also a contributing factor in an injury from an endodontic procedure.

Dental Implants, Crowns, and Bridges

Treatment planning was one of the most common allegations in this type of malpractice claim by patients, along with post-op infection. Again, many of these procedures were performed by general dentists, rather than specialists. Claims for injuries from crown and bridge procedures have a variety of complaints, such as open margins, overhanging restorations, and poor occlusion. Nonetheless, overall the claimants alleged a universal lack of treatment planning in these cases, with all of the defendants being general dentists.

Other Procedures

In addition to the procedures discussed above, these are also some of the more common causes of dental malpractice:

·         The failure to diagnose a condition, such as oral cancer, gingivitis, cavities, periodontal disease, or TMJ;

·         The failure to properly supervise an employee’s actions in a patient’s treatment;

·         Error in the administration of anesthesia;

·         The failure of a technique, like the improper use of formaldehyde-based root canal filling material;

·         The intended dental procedure wasn’t performed;

·         A contra-indicated procedure was performed, e.g., the removal of a healthy tooth by negligently misreading an x-ray or other dental records.

The Riskiest Procedures

As the research bares out, many of the most common dental procedures, such as teeth extractions and endodontic treatment can, in fact be the most susceptible to malpractice claims. Without proper planning and care, these are the riskiest procedures for a dentist to perform. A dentist’s failure to develop and follow a treatment plan and his or her failure to recognize a complication are two components of nearly all of the claims examined. Without these, many patients develop post-surgical infections, which can lead to further injuries.

A smoking history should also be taken, as many of these individuals are more susceptible to infection and complications from procedures. Research showed that a significant number of patients alleging malpractice smoked, resulting in infections that required hospitalization. A major oversight by dentists is the failure to take a history of smoking and to plan treatment accordingly.

        A word of advice is to take an ounce of prevention. Dental malpractice claims are increasing, as the payment ratio for dental claims is significantly higher than that of physician malpractice. Over 41% of dental claims are paid indemnity to patients—10% higher that medical claims resulting in payment. In other words, malpractice claims against dentists are more successful than those against physicians in the past several years. With this in mind, dentists should review their procedures and techniques, especially knowing how to recognize potential complications and guarding against infection, as well as administrative requirements beyond dental treatment, such as the office protocol for obtaining informed consent and treatment planning for every case.

Top 5 Vacation Spots in 2017

Okay, you’ve worked hard all year. Your dental practice can keep running without you for a couple of weeks while you recharge your battery. But where?


If you compare vacation lists, you’ll likely find very little in common. They all sound wonderful in one respect or another. This year, our theme is “exotic” and “mythical.” At the following locations, you’ll enter another world, touch a piece of history, or both.


Tbilisi, Georgia

If the legend is correct, then Georgians may have invented wine as much as 8,000 years ago. Their quaint capital is rich in heritage, visual appeal and mythical wonder. Georgia was the destination of Jason and his Argonauts when they were out and about to steal the Golden Fleece. At the far, eastern end of the Black Sea and nestled against the Caucasus mountains, Georgia was not only home to the Golden Fleece, but also the golden dragon which guarded it. This was where strong-willed, princess Medea met her future, Greek husband and helped him overcome the challenges posed by her father, the king. Georgia has beaches, mountains with ski lifts for winter fun, and lots more eye appeal in a country known for its grand beauty. Georgians speak a language which has affinities with Basque in northern Spain. In fact, Georgia and Spain once shared the name “Iberia.”


San Sebastián, Spain (Basque Country)

Nestled near the border to France, overlooking the Bay of Biscay and not far from the foothills of the Pyrenees Mountains, San Sebastián provides numerous opportunities to savor this Old World charm and otherworldly beauty. La Concha Bay provides enough visual splendor all by itself, but don’t linger too long. There’s much more to explore in this corner of Europe touched by antiquity. Not far to the north are the caves where modern, Cro Magnon man painted the walls as much as 40,000 years ago. The Basques speak an agglutinative language with vague similarities to Georgian. Seafood is especially good here. Some of the place names may look strange. One of the easiest peculiarities to solve is the “tx” sound, which is just like “ch.” For instance, the town of Getxo, in the Greater Bilbao metropolitan area, is pronounced, “GAY-cho.”


Cádiz, Spain

People have lived continuously in Cádiz longer than any other city in Western Europe. This elegant Spanish city started out as a Phoenician outpost as much as 3,100 years ago. Cádiz, in Andalusia, is not far from Gibraltar, to the South, and, across the strait, from Morocco and Africa. A short distance to the North resides the town of Palos de la Frontera, from where Christopher Columbus launched his legendary voyage of discovery in 1492. Besides its charming architecture, the city has a unique connection to the myth of Plato’s Atlantis. This region, once called Gadira, was said to have faced the legendary lost island roughly 11,600 years ago.


Bimini, Bahamas

Nothing says “tropical beaches” quite like the Bahamas. At less than a hundred miles east of Miami, Florida, the Bimini Islands, full of relaxing, seaside splendor, attract frequent visits from the mainland. Besides the nightlife, snorkeling and beachcombing, Bimini offers its own unique touch with the past. The “Bimini Road” or “Bimini Wall” was discovered in 1968. This structure, made of natural beach rock, was fashioned in a linear, straight-edged shape nearly a kilometer long. Some experts have compared this to artificial breakwaters built in the Mediterranean and found them to be similar. The first survey of the component beachrock found the stones to have been moved into position, likely by humans, because the orientation of many of the beachrock stones is no longer naturally facing the waves that formed them. Some researchers have speculated that the breakwater was evidence of one of the colonies of Atlantis, mentioned by Plato in his Timaeus and Critias dialogues.


Ponta Delgada, Azores

Subtropical splendor with rolling green pastures, immaculate beaches and towering mountains kissed with pristine lakes. We’re talking about the Azores. Portuguese is spoken, here.


Ponta Delgada is the largest city in the Azores containing nearly 70,000 people, and possessing nearby Marina Pêro de Teive which handles recreational boating. Twenty kilometers to the northwest stands the Sete Cidades Massif with its Blue and Green Lakes and a serenely breathtaking panorama of meadows and woodlands nestled in an ancient crater. A little over twenty kilometers to the west stands another mountain wonder—Lagoa do Fogo (Lake of Fire).


According to researchers R. Cedric Leonard and Rod Martin, Jr., the Azores may have been the tall mountains of Atlantis, mentioned by Plato. The legendary island was said to have stretched from here all the way along the Africa-Eurasia tectonic boundary to face Gadira (Cádiz) in southern Spain.

4 Things Dentists Can Learn from Steve Jobs

Who was Steve Jobs? And what does he have to do with your dental office?


Steve Jobs was more than an entrepreneur and business owner. He was an innovator on multiple levels. He not only helped put personal computers in our homes, but expanded on that with the iPad, iPhone and more. His company created both hardware and software and excelled at both. Today, Apple has an amazing 7.4% of the PC hardware market which puts it in 4th place, internationally. What is amazing about this feat is that Apple uses its own, non-windows operating system and its baseline computers are notoriously more expensive than entry-level Windows units. How all this happened is a testament to Steve Jobs and his creative vision.


But what does a computer geek have to do with a dental practice? Plenty! In fact, the wisdom of Steve Jobs, and innovators like him, can help just about anyone who is alive. The following list of 4 things are only a few of the dozens of priceless pearls of wisdom which Steve Jobs left to posterity.


  1. Put yourself in the other person’s shoes.

Steve Jobs not only demanded excellence from the people who worked for him, he demanded empathy for the customer. He was able to see what they needed even before they knew they had a need for it. The iPod, iPhone, and iPad were not only innovative, but also intuitive in their design and in the software interface that made them work. Your dental office has an interface. Do your customers know how to use it. Are they comfortable with it? Is there a better way to make it. Put yourself in your patient’s shoes and see your office from their eyes.


  1. Have passion for what you do.

Passion keeps you going when all else seems to be going wrong. You have to love what you do. But this “passion” doesn’t have to be something that bites you. Every feeling you have is created by you. You can build passion where once it did not exist. It’s all a matter of finding the fun in what you do. When you find that spark of fun, build on it.


  1. Fail forward.

In 1985, Steve Jobs was fired from the company he helped to build. Later, he would remark that his being fired was a good thing. It returned him to the freedom to innovate. It unburdened him to do things he had become cautious not to do. Our time in this world is limited. We need to remain fearless, but wise.


“I didn’t see it then,” Jobs told an audience of graduating students at Stanford University, in 2005, “but it turned out that getting fired from Apple was the best thing that could have ever happened to me. The heaviness of being successful was replaced by the lightness of being a beginner again, less sure about everything. It freed me to enter one of the most creative periods of my life.”


  1. Redefine the game.

Every business has competition. The big winners don’t play against their competition at the competitor’s level of the game; instead, those winners redefine the game, leaving the competition in the dust.


When Steve Jobs was fired from his own company, he invested $5 million of his own money in a crazy idea called Pixar—the company which produced Toy Story for Disney, and brought animation entertainment to a new level.


Bonus Idea: Hire only the best

Steve Jobs believed in giving more “bang for your buck,” as the saying goes. In the spirit of that wisdom, we couldn’t resist in delivering a bonus idea. Jobs could not have done all that he did if he didn’t have a team of the best people surrounding him. He believed in not hiring Bozos—incompetent people who create more work than they accomplish. If you surround yourself with people smarter than yourself, they challenge you to do a better job, and they end up making your business thrive.


So, can you use any of these in your dental practice? If you don’t see an immediate applicability, put these ideas on the back burner of your mind and let them simmer awhile. Do it with an attitude Steve Jobs cultivated for himself—expect great things from yourself and from those around you.

How to Select Music for Your Dental Practice

What to do When Patients Cancel Their Appointments

Life happens. We know. Sometimes we can’t avoid those little emergencies that overturn our world and leave us scrambling to catch up.


Canceled appointments seem to be on the rise, at least according to one survey. Follow-up appointments seem to be especially vulnerable to this phenomenon. The reason likely has to do with the economic environment. Many people are pinched financially and would rather put their money and time into other activities.


While it’s tempting to charge a patient for an appointment canceled at the last minute, consider how this looks from their viewpoint. Every time you’re late taking in the patient, they likely consider this a “missed appointment.” Should they bill you for having to wait an hour or more in the waiting room? If they showed up on time, and you’re late taking them in, how fair is it to charge them for the time you waited when no service was ever delivered? I know of some patients who have threatened to implement this kind of billing. That tactic on your part could lose you more than the one patient.


Consider this approach: If a patient cancels, have your office staff ask them if everything is okay. First of all, the concern should seem genuine. You’re here to help; not merely make a buck. Your attitude and the attitude of your staff make all the difference in the world on how the patient “perceives” the dental practice. Are you a friend or a foe? When your staff genuinely care and want to make certain that everything is okay in their world, the patient’s perception switches from “a business that’s merely trying to sell me on a service,” to “a loving caring clinic that wants to see me thrive.”


A canceled appointment is also an opportunity to engage the patient. Are they merely canceling because they view the problem as already handled? Is the follow-up merely a costly formality to them? Is there really a good reason for them to come back into the office, other than another opportunity for your practice to make more money? Is there a danger to skipping the follow-up? If so, clarify what that danger is. Don’t inflate it, but don’t avoid it, either. Inform the patient so they are better equipped to make a decision based on the best knowledge. Scaremongering will likely backfire. It seems that more and more of the public are taking the time to search the internet for answers. If you inflate the dangers in order to scare them into coming back, they may see through this and leave altogether. Dishonesty is not the best policy, naturally.


So, here’s the bottom line: Treat canceled appointments as a chance to build greater rapport with your patients. Treat these opportunities as a method for opening up a deeper dialog. Sometimes, such a conversation reveals the real problem. If they lost their job or their insurance, this gives you or your staff the opportunity to discuss payment plans. If the patient is saving their money so their child can get braces, count that as a blessing. You might even find a way to turn such a story into an award ceremony for “Best Parent of the Month,” or something similar. Their canceled appointment could result in greater exposure and more new clients.


Should Your Practice Try to Win Awards?

Winning awards sounds nice, but what will it do to help my dental practice? That’s a good question and it deserves a thorough, well-reasoned answer.


Perhaps the most potent fact to consider on this topic is that people like winners. They like being associated with winners. They feel that somehow your good fortune will rub off on them. It’s a bit like moths to the flame, only better. Your reputation is part of what attracts your client base. The opposite idea is easy to imagine, but we don’t want to go there. Bad reputations are obviously bad for business; good ones are what we want.


Winning awards is part of image building. Don’t ever forget that you are constantly in the sales game—selling yourself and your dental practice to your customers and to your community.


With the economy languishing in negative territory with little hope of a recovery any time soon, we all need to take advantage of every possible point of leverage available to us. Competition is tough, especially with the burgeoning growth of Dental Support Organizations.


Every opportunity to win an award for your business and your dental skills should be seized with glee. Each one is another opportunity to polish off your star in the eyes of your patients and in those of the community in general. But when you do win one of those awards, make a big deal about it. Put up party decorations for a week. Put a plaque on the wall with a colorful arrow pointing to it—“Another Award Won”—and include the date. Add the award to your appointment cards. Add a notice to your website home page. Post a notice in your front window and keep it there for a month (but no more).


But more than that, you need to keep thinking outside the proverbial “box.” Besides winning awards, how about creating awards for others? If you see something exceptional in your community, why not create an award in your name, or in the name of your dental practice, and make a big news event out of it. Receiving awards makes you look good, but giving awards makes you look even better. Like the old master once said, “It’s better to give than to receive.” And people respond to such generosity. Yet, so it all doesn’t seem so self-serving, consider extending the generosity to anonymous awards and gifts. There is something truly powerful about actions taken that are not based on any form of self-concern.


What kinds of awards should you pursue? Certainly, you’ve heard of a few dental awards. And why not include every continuing education certificate you earn? Each one shows that you are staying up with the latest in dental knowledge and procedures. Likely, none of your patients know about this, unless you tell them. Making a celebration out of each one tells them in a way that doesn’t seem like you’re hamming it up or overdoing it. But go beyond dentistry. Check into the Better Business Bureau and other commerce-related organizations. Check out philanthropic associations and work with them in doing outreach to the poorer sections of your community. All of these make you a more holistic part of your neighborhood and your neighbors will appreciate that.


Can Buying New Furniture Boost Your Revenue?

Compare these two images:


  1. You walk into a dark, dinghy office with dirty windows, threadbare furniture and lots of grime and filth on the floor.

  2. You walk into a bright, pristine office with sparkling windows, and elegant, new furniture decorating polished floors.


Naturally, you’re not comfortable in the first one. You want to get out of there as quickly as possible. The second one at least feels comforting and welcoming. The people there have taken the time to make it as approachable as possible.


In the minds of customers, who can decide to go elsewhere, perception is everything. Every little detail can be a reason to stay or to leave.


The big question is, “How much will new furniture help?” There’s no way to know this until you try it, but that can prove to be expensive, if you don’t use a good measure of caution.


Finding the right furniture at a discount sometimes takes extra work. Instead of spending thousands on the finest, store-bought furniture, consider garage sales or estate sales. Yes, you’ll likely run into a lot of junk, but occasionally you’ll find something that is perfect and at a price that is shockingly comfortable.


If you’re feeling impatient when you do this shopping, then stop and go do something more constructive with your time. Impatience will likely result in a bad purchase.


Consider this analogy. If you’re a guy and you’re out with your wife shopping for a party dress, you know what it’s like to have her try on dozens of outfits for which you always say, “That’s nice.” But occasionally, she will try on an outfit that “clicks.” There’s something about it that is right on so many levels, you have to buy it. In a way, it’s like “love at first sight.” Everything fits. The designer was one of those big names before anyone knew him.


A good, clean environment says, “I care about you.” Good, new-looking furniture says the same thing. You may think about how much the furniture costs, but consider how much it costs to lose existing customers.


Now, consider the opposite effect. New furniture says “prosperity.” That translates as “success,” and “doing the right thing.” If you’re waiting room is in any way grungy, how likely are you to have clients recommend your dental practice to a relative or friend. They may start to say something, but frown and purse their lips when they remember how bad it all looks. Then, they may wonder why they, themselves, are staying at the same dental practice. The little things don’t have to be expensive to have each and every one of your patients look upon you and your practice with favorable eyes.


Also, you don’t have to have a professional interior decorator take charge of the project. If you don’t have the budget for such things, consider a bright student at a local college for the project. They can add the project to their skimpy resume, and you get some helpful advice from someone before they can charge the proverbial “arm and a leg.”