Episode #577: Disease Prevention & Wine Tasting, with Katrina Sanders

Your practice can save lives. With routine care and education, you can help patients prevent many of the diseases they present with. So, how can you make the most of this opportunity? Today, Kirk Behrendt is back with Katrina Sanders, The Dental WINEgenist, to share advice for building value to the preventive care and treatment you provide. Help your hygienists do what they were trained for! To hear more about Katrina’s course and how it can help you optimize disease prevention, listen to Episode 577 of The Best Practices Show!

Episode Resources:

• Katrina’s website: https://katrinasanders.com
• Katrina’s email: [email protected] 
• Katrina’s Facebook: https://www.facebook.com/katrina.sanders.948
• Katrina’s social media: @thedentalwinegenist
• Tooth or Dare social media: @toothordare.podcast
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Links Mentioned in This Episode:

Register for Katrina’s next Disease Prevention & Wine Tasting course (October 5-6, 2023): https://www.eventbrite.com/e/act-dental-hygienists-live-course-october-5-6-2023-tickets-368595568267

The Trust Edge by David Horsager: https://www.simonandschuster.com/books/The-Trust-Edge/David-Horsager/9781476711379

Main Takeaways:

Trust is the currency of business, and core values are the pillars of trust.

Don't limit the opportunities for disease prevention in your practice.

Support your hygienists by being engaged in their education.

Help patients value their preventive care appointment.

Hygienists are not “just teeth cleaners”. 

Quotes:

“A recommendation would be, ‘You should go to the gym every day.’ A recommendation would be, ‘Have five servings of fruits and vegetables.’ Those are recommendations. We use that “recommendation” word when we’re talking about treatment modalities that need to be done in order to address an active infection for the patient. And when we use the word recommendation, somehow, inside of the lizard brain of our patients, they think, ‘So, I have the option to not do it.’ Now, we know inside of autonomy, the patient always has an option not to do it. They could easily walk out. If you're in a hospital, and you've got a gunshot wound, and you choose not to have that treatment done, if you can walk out, you can walk out. They have autonomy inside of that. But the idea is, we need to be coloring this picture to help our patients understand that the treatment that we are talking about is a prescription from a licensed practitioner, because that's what it is.” (6:51—7:48)

“You have to have leadership. You have to have a culture inside of the practice, and you have to be very crystal clear about your core values.” (8:13—8:21)

“It’s called The Trust Edge, and this book is absolutely unbelievable. Inside of the book, it talks about the fact that trust is the true currency of business. It is. Because people will buy if they trust. They will actively seek out a Starbucks because they trust that logo. They trust that there's going to be consistency in what they order, that I can go to a Starbucks here in Milwaukee, I can go to a Starbucks in Honolulu, and I can order the same drink and get it prepared exactly the same way. There's consistency. I see a lot of trust inside of businesses that have worked and focused to maintain that trust. And then, you see things, I'll use an example, Southwest Airlines had a big issue with trust because they were not consistent. They lacked some competency in what was happening over the holiday season with flights and things like that. And because of that, because of that decline in trust, they see a decline in their overall revenue. Trust is the currency of business.” (8:33—9:37)

“This is what's crazy about [The Trust Edge]. He talks about the eight pillars of trust. There are eight specific pillars of trust. And inside of that, you have to be able to build those pillars of trust. And he says that a critical aspect to that trust is knowing your core values. That's a huge piece. In the book, the author says that if you, as a business owner, practice owner, whatever, if you are not communicating your core values and your mission statement to your team every 30 days — every 30 days — your team members cannot recite that back to you. Now, that's important. Because in a dental practice, if you think about AZPerio, I mentioned I walk through the entire process of care. The doctor comes in at the end. So, who’s conveying those core values to the patient? Myself. The assistant in the operatory with me. The front office team member. Even the website. These are all touchpoints, before the doctor even has the opportunity to communicate with the patient.” (9:42—10:42)

“If we don't know the core values of the practice, then I don't have a scaffolding, I don't have a framework for how to behave inside of this.” (11:03—11:10)

“This is the important piece of what AZPerio does. We look at numbers. We look at production. Every day, we've got our big, hairy, audacious goal. We look at what do we want to see. What percentage are we on our way to our goal? What opportunities do we have? What openings does doctor have? The masculine energy around a lot of that, those processes are built out. That is the framework. That framework is intended to protect so that when something like this happens, the bone material falls out, the sutures don't go in, the patient’s anesthesia isn't working as readily as possible, that when those things happen, that the framework protects us inside of that. But it also means that we have to be okay when we’re not productive. Because, at the end of the day, we’re not taking care of people’s insurance plans and billing, we’re taking care of humans, and humans with beautiful, robust lives. And our job is to be a part of that and to make it better for them.” (17:15—18:13)

“Disease prevention is something that dental hygienists focus on in our training, and yet we get out into the real world after we graduate from hygiene school, and I think we’re so limited on what our opportunities are inside of disease prevention. So, we’re looking at a myriad of diseases that we can see in the oral cavity or that patients are going to present with in the operatory and, ultimately, talk about what our role is inside of that. We’re going to do this from a team perspective because we need our doctors, we need our front office team members, we need our practice managers to understand that when a patient comes in and they have periodontitis, that we have to be treating this disease fully and thoroughly. We need the time to effectively treat these cases. We need the products. We need the medicaments. We need the entire scaffolding of what that process of care looks like for a periodontally diseased patient to occur. We need the same thing with caries. We need the same thing with oral pathological lesions, oral cancers, tethered oral tissues, airway complications, infection control that inside of all of this, these are all of the ways that we contribute to preventing disease, and we have to be able to break apart what these modalities look like so that we can understand what are some of the modern trends or techniques inside of delivering care for our patients.” (18:45—20:05)

“This is what's so crazy. The average statistic right now is one in three individuals who have dental insurance use it routinely. So, we already know that there is a small portion of our population that will come in and receive routine dental care. And by routine, I think we’re all in alignment that this is a patient who comes in for their every-six-monther. And I tell this story all the time, but where did that six months come from? This drives me crazy. In the 1950s, there was a toothpaste called Ipana Toothpaste. That spokesbeaver, Bucky Beaver, says, ‘Brush-a, brush-a, brush-a. Here’s the new Ipana.’ And then, at the end of the commercial, he says, ‘Brush your teeth with Ipana Toothpaste and see your dentist twice a year.’ Now, that was done by Ipana Toothpaste as a means of encouraging these individuals, the general public, to go in, see a dental hygienist, and have that dental hygienist say, ‘Oh my gosh, the Ipana Toothpaste commercial brought you in? Absolutely, you need to be brushing with Ipana.’ It was an interesting marketing strategy, was it not? Well, that was in the 1950s. And here we are 70 years later, and most individuals across the United States think it’s completely normal to see your dentist twice a year.” (20:22—21:35)

“If you see my very first slide in this program, it’s going to say, “That's how we've always done it.” That is the toxic statement that we have said inside of dentistry. In fact, I think that is the most disease-ridden statement. Dirty mouth? You've got to clean up that.” (21:40—21:55)

“We have seen an evolution inside of dentistry. And we’ll talk about that this afternoon, how we’ve evolved in dentistry in a myriad of ways: disease prevention, infection control, technology. There are so many ways that we’ve seen a change. And yet, it doesn't matter because, at the end of the day, we are still doing the same procedures. If you're using a rubber cup polisher, and you're using hand instruments, and you're treating your patients every six months, no matter what the complexity of the disease looks like, we are not delivering the correct layer of care for that patient.” (22:04—22:32)

“[When] we look at the prevalence of oral disease, currently, the statistic is about one in two adults between the ages of 30 and 79 have some form of periodontitis. Dental caries is the number-one chronic childhood disease. It is five times more prevalent than asthma. And every hour, one individual will lose their life to the ramifications of oral cancer. So, when you take a look at that, the reality is the disease is not stopping. Porphyromonas gingivalis isn't like, ‘Oh, I'm sorry. I didn't realize that you guys were all banding together and trying to help.’ The disease is still occurring. The disease is showing up in our chairs and across our communities. And so, when we take a look at what it is we understand about prevention, the first step in that is, what are we doing to actually prevent this? Because there's such an activity of the disease right now.” (22:33—23:22)

“It has to start at the top . . . And [by the doctor not being involved], what you're doing is you're bringing in a team member and now expecting that team member to transform the entirety of the scaffolding of your hygiene department, including how you're diagnosing periodontitis, diagnosing incipient decay versus active decay, identifying modalities in how to detect oral cancer, looking at pathological lesions, transforming the way we look at oral and subsequent systemic disease. You are expecting one individual, or maybe you send your two hygienists, you're expecting two individuals to go to a workshop, come back after three hours, and implement this when these individuals are not going to have the support from the top.” (24:10—24:54)

“I've worked with doctors who are very fixated in high-end cosmetics. ‘I want to be over here. I want to cut and prep veneers all day long. That's what I want to do. I want my hygienist to really be the wheelhouse of the practice, and I'm going to give him or her everything they need. So, I'm going to send them to this workshop. And then, afterwards, I'm going to sit down with them. I'm going to say, walk me through the pieces that you learned that you find to be impactful inside of our practice. What pieces of equipment do you need? How much more time do you need in the patient hour in order to be able to implement these strategies? What support do you need from our front office team members? What ways do we need to change some of the protocols? What needs to be done in the clinical notes? What types of conversations do we need to be transforming? What needs to be added to the website?’ When you implement a change in the practice, it has to go through every step. That change is like hot potato. It has to touch every hand.” (24:58—25:55)

“As a hygienist, if I go to a disease prevention workshop and I learn about how great probiotics are for oral disease, and I come back and I want to implement that, and the doctor says, ‘Yeah, go ahead. That’s great,’ now, I need the doctor to understand what these probiotics are, why these probiotics are important, why patients who not only have gingivitis but periodontitis, periimplantitis decay, risk for candida, are all going to be terrific candidates for that. I need the doctor to be on board so that when I prescribe this, that the doctor comes in behind me and says, ‘Absolutely, Katrina is correct. Here’s why we need to integrate this into the practice.’ I need whoever the lead is who’s ordering products to be able to order these products, stock them in the practice. I need my front office team to understand how we bill for that. I need to know, how do we integrate this into an explosion code so that any time that I'm diagnosing a patient with gingivitis, periodontitis, periimplantitis, decay, candida risk, that these are automatically exploding into the patient’s care plan. I also need support from the front office team in the event that the patient calls in and says, ‘Hey, I don't exactly remember. How often am I supposed to be taking that probiotic? Once a day? Twice a day? I'm not quite sure,’ because it’s going to be different depending on the patient. I might need an administrative team member to help me print out even postoperative instructions so I can send the patient out with it. I need every single team member to be involved in that tiny protocol.” (25:55—27:16)

“I travel all the time. I'm speaking, I'm presenting, I'm delivering. I can't tell you how many times a hygienist will come up to me and say, ‘All of this was amazing. I wish my doctor were here.’ I think doctors have this thought, number one, that hygienists want to be empowered to do this. And we do. But we want to be supported by our doctors. We want to be backed up by our doctors.” (27:20—27:42)

“I can't tell you how many times I'll go into a restaurant, and you know right away, it’s not what anybody is saying, it’s the choreographed dance behind you. Now, people talk about The French Laundry all the time. It’s the amazing three-Michelin star experience . . . But when you go to a restaurant like that, it is choreographed. There is no room for issues. It’s just ships passing in the night. The drink comes down, the empty glass gets taken away. It’s not cumbersome. It’s not clunky. But you will go to a restaurant sometimes and experience this where it’s like, ‘Where is the waitress? What's going on?’ Well, how many times do you leave a patient sitting in the operatory, everybody is running behind, and the patient is just sitting there staring at the wall, going, ‘Where is everybody? Did they just leave me in here?’” (29:55—30:48)

“It's those little nuances that an intellectual human being is going to observe. And they won't be able to put their finger on it but, ‘I walked in, and nobody greeted me. Everybody at the front desk, they were all on the phone. So, I just sat down. Then, when somebody got off the phone, nobody said hello, so I had to be the one to get up and say, hi, I'm here for my 9:00. Then, I'm sitting here. It’s 9:05. Nobody is coming back to get me. Nobody has said anything. It’s 9:10. By the way, none of these magazines are up to date. They're all from the 1990s. So, what am I supposed to do? So, I'm just sitting with my phone. My phone has a clock on it, so I'm watching as I'm playing a game on my phone, or on Instagram, aimlessly scrolling. And nobody’s brought me back.’ All of these little inconsistencies — and that's before anybody has actually said anything. That's before I'm interacting with the clinical competence that I expect to see, tiny, tiny little things that we are casting judgment on right away.” (30:49—31:45)

“It drives me crazy when I would work in clinical practice, I'd be working on a patient, front desk would come back — I'm literally working with a patient, and the front desk would say, ‘Oh, doctor is buying Panera today. What do you want?’ That's so weird. You're going to have me list off my lunch order while delivering clinical care to a patient? It’s those little micro nuances that completely erode and break it down. So, when we come together, when we bring the entirety of the team, when they hear a speaker say, ‘Here’s why we need to integrate this into clinical practice,’ I'm going to give you and the team time to now say, ‘How do we take this? How do we integrate this?’ so that anybody who has a touch point with a patient experiencing this disease modality understands why we’re approaching care this way.” (32:23—33:10)

“They say all the time, people make decisions based on emotion.” (35:50—35:55)

“It’s the invisible things that people will comment on.” (36:11—36:13)

“When you think about the brilliance of what happens inside of a practice, think about it. You have patients that come in and see your dental or hygiene departments every three, four, or six months. These patients, for one reason or another, do trust you. And the biggest issue that I see is that dentistry doesn't necessarily fully understand that with these individuals, these patients who come in three, four, or six months, that these individuals, at a minimum, are experiencing risk factors associated with oral disease.” (38:07—38:38)

“It is unbelievable what we’re unpacking inside of that oral and subsequent systemic disease profile. And this is where, I think, we have to change that conversation. Because our patients are so used to seeing us as, ‘I've been going in every six months. I get my teeth cleaned.’ Okay. Well, language issue number one, we don't clean teeth. I'm not a tooth cleaner. That's not what I do. I'm not a cleaning lady.” (40:20—40:43)

“The vast majority of the issue that I see inside of patients’ declining treatment plans across the United States is a lack of value and trust in what we do . . . These individuals see our value as, ‘I have a dental insurance. The dentist I go to takes my dental insurance, so I'm going to use my free coupon.’” (41:00—41:21)

“These patients come in, and this is what they see. It’s transactional. ‘I'm going to get my free cleaning that my insurance covers. That's what I'm going to get.’ What they don't understand inside of that is the fact that they are presenting with these risk factors. And if we don't educate them on this, we’re going to run into major complications down the road. It’s not just, ‘You could lose a tooth, and then we'd have to do a tooth replacement.’ Because for whatever reason, the general public does not see teeth as body parts. They see it as like, you put it under your pillow, you get a couple of extra bucks from the tooth fairy, and then we’re good to go. They don't see this as body parts. They don't see that when a tooth gets removed, that you are amputating a body part because the body is literally demonstrating signs of distress. They don't see things like 90% of systemic diseases and nutritional deficiencies can be seen in the oral cavity first, that I can tell if a patient is pregnant just by looking in their mouth . . . I've sent patients to get HIV tests done. Most hygienists are, right now, sitting there nodding and going, ‘Yup,’ that we have sent patients to get bloodwork done for autoimmune issues, nutritional deficiencies, something. We know when something is wrong.” (43:02—44:08)

“That's the is — [hygienists] see too much. And so, now, inside of this hygiene hour, we’re trying to find these magic minutes of, how do we expedite some of the quick things that we need to do? Because really, the reason why the patient is here is for their “free donut holes”. That’s what they're here for. And I'm trying to walk this patient through the fact that, ‘I don't think your free donut holes is going to suffice for today because, inside of this, you have all of these other factors. And if we don't address this, we’re talking about cardiovascular disease. We’re talking about stroke, upper respiratory tract infections. diabetes. certain types of cancers. So, no, you're not going to die in my chair today. But I don't want to sit and watch my patient population get sicker and sicker. And unfortunately, that is what has started to occur.” (44:09—44:49)

“We see periodontitis on the rise. The amount of periodontitis from the 1990s to today has increased about 55%. My hypothesis on this is, number one, patients are living longer and living longer with their teeth instead of having them extracted and wearing dentures. So, we’re starting to see some complications there. Inside of that, I think we’re also getting a lot clearer about how to diagnose periodontitis. And so, because of that, that's giving us a lot more information on how to address our patients. But I think the biggest issue is that with all of the economic recessions, some of the complications that we've had, that the bread and butter of dentistry is the patient will come in and get their free cleaning that their insurance covers. They will get their dental X-rays done, their bitewings once a year, and the doctor exam. And so, we have relied on trying to manage a lot of this disease inside of what is truly a preventive procedure.” (44:53—45:49)

“I'm going to quote Hippocrates because what he says is absolutely critical. He says true illness does not occur out of the blue. It doesn't show up. Decay doesn't show up out of the blue. Perio doesn't show up out of the blue. People don't just have a heart attack. It doesn't show up out of the blue. He says — now, this is Hippocrates, the father of modern medicine. This is in the BCs. He says that disease is formed from small, daily sins against nature. When enough daily sins have accumulated, illness will occur. Well, here’s the issue. Let's pretend you have a patient who’s been a long-time patient of your practice. Like, they started seeing you when they were 18 years old, fresh out of high school. My brother is a really great example. At 18 years old, he became a patient of mine because he moved down to Arizona. He went to Arizona State. So, he's been a patient of mine. And my brother is in his 30s now. He’s married. And he’s still a patient of mine. So, we see patients over a long time like that. Right? How does that happen, that a patient at 18 has a clean health history, and then, by the time the patient is in their 40s, they’ve got high blood pressure and high cholesterol? And then, by the time they're in their 50s, they're prediabetic. And then, by the time they're in — you know what I'm saying? How is this happening? We are literally spectators watching the spectrum of disease happen to our patients. They're getting sicker. And yet, inside of that, if we can stop the propagation of that disease and, I think, demonstrate to our patients — I think that's what it is, demonstrating to our patients that we’re with them on this journey. Because I do see patients that will say, ‘I didn't know that the inflammation in my mouth could be making my blood pressure worse.’ It can. And in the United States, we’re so used to just taking medication for that, or telling the patient not to consume as much salt when the reality is, my work [as a hygienist] could be influencing. Now, the issue is, I don't think dentistry has been armed and leveraged enough to feel confident inside of those conversations.” (46:42—48:35)

“These same practices, when I ask them, ‘Do you take blood pressure on your patients?’ They’ll say, ‘Oh, no. Only if the doctor is going to use anesthetic today.’ Well, you can't have your cake and eat it too. Meaning, if you're actually concerned about that patient’s cardiovascular condition, why are you not monitoring it? Twenty-seven million Americans will see a dentist, but they will not see their primary care physician this year — 27 million individuals. Now, that's crazy, because that means that we are theoretically seen as the preventive specialist for 27 million individuals.” (48:58—49:31)

“Fordyce granules is a really great observation. Fordyce granules are fatty deposits underneath the oral tissue or xanthoma you can see on the face. Now, I identify those things and I'm telling the patient, ‘You have these lesions in your mouth that tell me that you have fatty deposits in your oral tissue. When is the last time you had your cholesterol checked?’ I haven't even started cleaning their teeth. Now, think about what's happening inside of the brain of that patient. Now, it’s, ‘Oh, I was here to get my “free donut holes”. And now, you're walking me through this gourmet experience of all of these amazing donuts that I can experience, and you're pairing them with gorgeous mochas and cappuccinos. You're walking me through a completely different experience. I'm sorry, I'm here to experience this now. It changes — and again, we’re distilling it down to a donut experience. But the important piece being, when you ask your patients, ‘Is your oral health, is your physical health something that you value?’ That's what you're asking.” (50:17—51:19)

“Now, people have access to be able to Google or research things. People are taking their healthcare into their own hands. They're recognizing that just because I was provided this Cigna or Delta Dental insurance plan doesn't mean that I have to be tethered to exactly what this insurance plan says. So, you're starting to see a lot of exploration. The millennial spending shift that we’re starting to see where millennials — I am a millennial, albeit the oldest of the millennials, but I am a millennial — that we’re starting to see a shift in that renewed sense of health, wellness, and vitality. The global health crisis kicked open that door for people to say, ‘I recognize that I need to be protecting myself. I need to be protecting my family,’ that a lot of us didn't necessarily fully understand that you could have a disease, asymptomatically, you could have a disease, and that disease could be something that can impact you from a long-term standpoint.” (52:27—53:21)

“People say all the time, ‘I didn't go to hygiene school for your dental insurance company to tell me what it is that I need to do.’ Because if that's all I had to do, if all I had to do was show up and have an insurance company say, ‘Thank you for taking the X-rays. Here’s what you need to do,’ and just do it, then it would've taken me three months to get through hygiene school. There's a reason why we understand the complexities of the work that we do. And part of that significance of our work and a significance of the relationship that we have with our patient, I do believe, boils back to, I feel insignificant as a dental hygienist when I am told that the power of my work is in the Dentrix appointment book that says four bitewings, prophy, exam. Four bitewings, prophy, exam. Four bitewings, prophy, exam. Because, respectfully, that is not how disease works, and that is not how my clinical decision-making works.” (53:27—54:16)

“As much as I get doctors that say, ‘How can I get my hygienist to talk to my patients the way you talk to your patients?’ Well, respectfully, I can talk to my patients with confidence because I've got a doctor that'll back me up. So, my question to that doctor is, how can you learn from my doctors, how they support me? Because confidence is a critical aspect of building trust, and I can confidently sit and talk to a patient. Yes, albeit, I know the research. I've done the research. I feel pretty confident that if my back is against the wall and a patient asks me a question about something, I probably know the answer, or I'll be the first to say, ‘I don't have that answer. But I'm going to get you that answer, and I'll shoot you an email with that information.’ But my doctors support me inside of that.” (56:36—57:22)

“The hardest part for dental hygienists is the leadership piece. I think we really struggle with that. Give me an instrument. I'll figure out how to make it work. But we have to be leaders in our practice. We have to lead in front of our assistants. We have to lead ourselves. We have to lead in front of our colleagues. We have to lead with the doctor. We have to lead with our front office team members who don't oftentimes understand the clinical reasons why. And so, leadership becomes a critical aspect to that. But we have to be able to build out the confidence, the consistency, and the clarity. We have to be able to build out a lot of those pieces so that when the clinicians get back into clinical practice that they can do so as a transformed clinician.” (1:00:01—1:00:42)

“For those who know my story, we lost my mom in 2018, suddenly, tragically, unexpectedly. And then, just over two years later, we lost dad, suddenly, tragically, unexpectedly. Both of them, needlessly with diseases, acute infections that should've been identified by healthcare practitioners who had been routinely seeing my parents. But it was skipped. Because they did the bare minimum. They did the things that they needed to do in order to cover their butts and not get sued. But it wasn't enough. And when we think about the importance of the work that we do, we have to start looking at not just, what is going to be enough, but what is the correct way to care for patients sitting in our chairs, knowing that those individuals are somebody’s mom, somebody’s dad, somebody’s brother, somebody’s sister, that dentistry has a responsibility to these individuals. And that goes well beyond the bare minimum, whatever it is we need to do to not get sued, whatever it is we need to do to submit enough to insurance companies so that we can cover our production. This is about human beings.” (1:01:18—1:02:29)

Snippets:

0:00 Introduction.

4:27 About AZ Perio.

7:13 Treatment is a prescription, not a recommendation.

8:14 Trust is the true currency of business.

10:03 Communicate your core values regularly.

12:24 Empathy is the crux of dentistry.

18:30 About Katrina’s course.

20:39 What people get wrong with disease prevention.

24:08 It all starts at the top.

29:26 Give the three-star Michelin experience.

33:10 Sweat the small stuff.

38:07 Build value and trust for your patients.

45:50 Hygienists can influence people’s health.

51:50 Be more than a dental office.

56:00 The future for Katrina.

1:00:57 Last thoughts about disease prevention.

Katrina M. Sanders RDH, BSDH, M.Ed, RF Bio:

In the ever-changing world of dental science where research, technology, and techniques for patient care are constantly evolving, dental professionals look to continuing education to provide insight, deliver actionable steps, empower, and create a dramatic impact within their clinical practice.

With wit, charm, and a dash of humor, Katrina Sanders enchants dental professionals with her course deliverables, insightful content, and delightful inspiration. Her message of empowerment rings mighty throughout her lectures and stirs a deep sense of motivation amongst course participants.

Katrina is the Clinical Liaison for AZPerio, the country's largest periodontal practice. She performs clinically, working alongside Diplomates to the American Board of Periodontology in the surgical operatory. Katrina perfected techniques during L.A.N.A.P. surgery, suture placement, IV therapy, and blood draws. She instructs on collaborative professionalism and standard-of-care protocols while delivering education through hygiene boot camps and study clubs.