The productivity paradox: Secrets of highly productive practices
Let me tell you something weird.
I’ve discovered that it’s less tiring and stressful to produce $8,000 of dentistry per day than to produce $1,500.
During the past several years I’ve been extremely fortunate to work in more than 20 practices all over the country. As I travelled around, I couldn’t help but contrast my experiences in the various practices.
Over time I noticed a very interesting phenomenon that I named “The Productivity Paradox”.
Why it’s a paradox is that it’s the opposite of what I’d expected and it greatly surprised me, yet it’s been consistently validated in all the practices that I’ve visited.
The practices that left me exhausted and miserable at the end of the day were always the low-grossing ones. High-grossing practices were the opposite — I’d leave energised, and elated, surprised by how easy the day had been.
The friction factor
The answer to the paradox lies in a simple but overlooked truth: productivity isn’t about how fast you work — it's about how much friction your systems create.
In a poorly run practice, the dentist absorbs all of that friction personally slowing them to a crawl. In a well-run practice, the systems absorb the friction leaving the dentist to absolutely fly.
Well run practices have systems that make the entire team’s life — particularly the dentist’s — easy and productive. Working in a well run practice feels like riding a sleek, ten-speed bike downhill on an open road — everything flows effortlessly.
By contrast, in low-grossing practices it feels like you’re trying to ride a rusty bike with flat tires up a steep dirt road. Everything is so very difficult.
Low-grossing practices
Let me illustrate what I’m talking about.
While I was working in a low-grossing practice some time ago a patient came in with a toothache and, after some discussion, decided to save the tooth with a root filling. I said to the nurse: “Let’s go!” Immediately she vanished out of the room.
Ten minutes later I wondered what had happened and went to the sterilisation area to find her. She was still getting things ready — opening and closing drawers and fetching individual items with tweezers. Finally, after sixteen minutes we were good to go. By then, we were hopelessly late for the next patient. Our schedule had been utterly destroyed by slow setup which put us under the hammer for the rest of the morning.
In another practice I visited it took seven minutes just to set up the rubber dam.
The treatment rooms in such practices appear to have instruments and materials laid out in pretty much random fashion. Setting up for a routine procedure might require the nurse or the dentist to open four or five different drawers.
The dentists in these practices work just as hard as anyone else — they’ve simply never seen a better way.
The teams in low-grossing practices have not been trained to be proactive — they sit and wait for instructions, neither listening to what the dentist is saying nor anticipating what comes next. Frequently they go missing and the dentist has to get up and find them. In a low grossing practice I visited recently, in the space of one hour, the dentist owner of the practice was left completely alone with two different patients while two nurses chatted in the hall. The dentist had to come out of the operatory each time occasions and say: “Can I get some help in here?”
In low-grossing practices the dentist carries out many tasks the team could and should handle — tasks that would actually add variety and interest to their jobs. I once compiled a list of 43 such tasks I’d been forced to do in low-grossing practices. And because there are rarely checklists in place, the dentist must constantly watch for mistakes rather than focus on the patient in front of them.
Such practices are exhausting. By 5.00pm you feel like a wrung out dish mop. To add insult to injury when you look at the day list the grand total production is $1,500.
The systems in low-grossing practices are often maddeningly inefficient. In the least dentist-friendly practice I’ve ever worked in, the checkout procedure was a nightmare. It had eight steps (all of which the dentist had to do) and ran like this:
1. Enter the item numbers in the computer, 2. Enter the clinical notes in the computer, 3. Debrief the patient on what had happened today, 4. Enter the treatment plan on the computer, 5. Write out the treatment plan on a sheet of paper, 6. Walk the patient to the front desk, 7. Hand over the sheet of paper and explain it to the front desk person in front of the patient, 8. Say “goodbye” to the patient.
No matter how hard I tried I could never get that all done in less than 12 minutes. Sometimes it took longer. If I saw twelve patients a day it means I spent over two hours checking patients out — time that could have been spent treating additional patients.
High-grossing practices
Once a practice surpasses $8,000 a day, everything just flows.
The practice systems are streamlined and setting up for any procedure takes just moments. The teams in productive practices are so well trained that they often have the instruments ready before the dentist even knows they need them. It's like the dentist is riding in the slipstream of the staff.
In such practices, the dentist only has to treat patients — everything (and I do mean everything) else is taken care of by the team. Instead of the dentist watching the team, the team watches the dentist. They know at all times what the dentist is up to. If the dentist forgets something they gently remind them. They virtually never need to ask the dentist questions.
A friend of mine who is a retired medical practitioner puts it like this: “If I can go through a whole day and not ask the staff for anything or have to tell them to do anything then I know they are perfectly trained.”
Take for example clinical notes. The dentist never has to write them — the nurse handles it all, and does it perfectly. Or referral letters. All the dentist has to say to a patient is “I’m going to send you to see my gum specialist.” The nurse hears that, and from that moment handles everything. the dentist never needs to think about it again.
Then there’s the missing lab case — the kind of thing that can derail an entire afternoon in a less organised practice. In a high-grossing practice the dentist never even finds out it was missing. The nurse has already rescheduled the patient, found someone to fill the gap, and the day rolls on without a ripple.
The systems have been perfected — nothing is random. There is neither wasted time nor wasted movement. While working on a patient the dentist never breaks their concentration. They never have to look up, or ask, or wait. All the ultra high producing practices I have visited use 6-handed dentistry.
At this level all the dentist needs to do is go with the flow. =They find myself standing in the hallway and a team member says: "Surgery 2, Mrs Mary Jones, ceramic crowns 14, 15." The dentist salutes and off they go. When they enter the room everything is ready and the team is waiting. They just sit down and start.
Conclusion
If the bike you're riding has flat tires, here are a few things to put some air in them.
Start by timing how long it takes to set up for any procedure. Under a minute is good. More than that and you have some work to do.
Next, ask yourself: does the dentist ever touch the computer? Fill in referrals? Complete lab sheets? In a well-run practice the answer to all of these is no.
Finally, count how many times in a single session you have to give an instruction or ask the nurse for something. A retired medical colleague of mine knew he had his team perfectly trained when he could work an entire day without ever having to ask for a thing.
The productivity paradox is counterintuitive, but once you've seen it you can't unsee it. The dentists working the hardest are often the least productive — ground down by systems that consume their energy without reward. The ones with the easiest lives are the ones with the best systems.
The gap between where you are and where you could be may feel vast. But it is absolutely bridgeable, and the dentists who have crossed it will tell you it was the most worthwhile thing they ever did for their practice — and for themselves.
