The productivity paradox
Secrets of highly-productive practices
Let me tell you something strange. 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 call “The Productivity Paradox.” It’s a paradox because 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.
I had expected that the high-grossing practices would be tiring to work in. That was not the case. The practices that left me exhausted and beaten up at the end of a work day were 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 the friction personally, slowing them to a crawl. In a well-run practice, the systems absorb the friction leaving the dentist free to soar. This is what dental practice systems and efficiency really mean: the removal of every obstacle between the dentist and the work they were trained to do.
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 old bike with flat tires up a steep dirt road. Everything is a battle.
Low-grossing practices
Let me illustrate what I’m talking about with some examples.
While I was working in a low-grossing practice, a patient came in with a toothache and, after some discussion, decided to save the tooth with a root filling. I said to the DA, “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 ready to go but by then we were hopelessly late for the next patient. Our schedule had been destroyed by slow setup which put us under pressure for the rest of the morning. In another practice I visited it took seven minutes just to set up rubber dam.
Treatment rooms in such practices have instruments and materials laid out in pretty much random fashion. Setting up for a routine procedure might require the DA or the dentist to open four or five different drawers and pick out items one by one.
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 says nor anticipating what comes next. Recently I had a porcelain onlay made for me. The dentist talked the DA through the whole procedure: “Please pass me the articulating paper.” On and on. This is the opposite of dental team efficiency. It is the dentist carrying the cognitive load of two people.
In low-grossing practice DAs go missing and the dentist has to get up and find them. In one practice I visited, in the space of just one hour, the dentist was left completely alone with two different patients while the DAs chatted in the hall. The dentist had to come out of the surgery each time and say: “Can I get some help in here?”
In low-grossing practices the dentist does many tasks the team could and should handle. Tasks that would add variety and interest to their jobs. I compiled a list of 43 such tasks I’ve been forced to do in low-grossing practices. And, because there are no checklists in place in such practices, the dentist must constantly watch for mistakes which takes away focus from the patient in the chair.
In a low-grossing practice I was about to start a crown prep. I had my bur poised over the tooth when the receptionist appeared at the door: “The printer is not working,” she said, then stood waiting for me to solve the problem.
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 was required to do) and ran like this:
1. Enter item numbers in computer, 2. Enter clinical notes in computer, 3. Debrief patient on today’s treatment, 4. Enter treatment plan in computer, 5. Write treatment plan on sheet of paper, 6. Walk patient to front desk, 7. Hand over sheet of paper and explain it to front desk person in front of patient, 8. Say goodbye to patient.
No matter how hard I tried I could never get that done in less than 12 minutes. Sometimes it took longer. If I saw ten patients a day it meant that I spent two hours per day checking patients out. Two hours that could have been spent treating additional patients.
Such practices are exhausting. By 5:00 p.m. you feel like a wrung-out dish mop. To add insult to injury, when you look at the day list, the total production is $1,500. Understanding how to run a more efficient dental practice begins with recognising how much of the dentist’s day is consumed by tasks that have nothing to do with dentistry.
High-grossing practices
Let’s look at a practice that produces $8,000 a day. At this level everything flows. The practice systems are streamlined. It’s like the dentist is riding along in the slipstream of the staff. In such practices, the dentist only diagnoses and treats patients. Everything (and I do mean everything) else is taken care of by the team. The dentist’s day is spent 100% diagnosing and treating patients, 0% anything else.
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’re perfectly trained.”
Setting up for procedures takes no more time than it takes to recline the chair. By the time the dentist has their loupes, mask and gloves on all they need to do is extend their hand and a DA gives them the syringe. The DAs are so alert and well-trained that they often have the instruments ready before the dentist even knows they need them.
The dentist never has to write clinical notes: the DA 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 DA hears that and from that moment on handles everything. The dentist doesn’t need to think about it again.
Then there are missing lab cases, the kind of thing that can derail an unorganised practice. In a high-grossing practice the dentist never even finds out they were missing. The DA has rescheduled the patient, found someone to fill the gap, and the day rolls on without a ripple.
The systems in high-grossing practices have been perfected and 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. You can do an entire quadrant of crowns without having to say a word. Patients find the precise choreography amazing.
All the high-producing practices that I’ve visited use 6-handed dentistry. This cuts treatment times by a further 30-40% while simultaneously reducing stress and fatigue.
At this level of practice organisation, all the dentist needs to do is go with the flow. They find themselves standing in the hallway and a team member says: “Surgery 2, Mary Smith, ceramic crowns 4 and 5.” The dentist nods and off they go. When they enter the room, everything is ready and the DAs are waiting. They just sit down and start.
Conclusion
Discovering how to become more productive starts with looking at your systems. If the bike you’re riding has flat tires, here are three ideas to put some air in them.
First, time how long it takes to set up for procedures. Under 20 seconds is acceptable. Longer than that and you have work to do.
Second, ask yourself: Do I ever touch the computer? Fill in referrals? Complete lab sheets? Do anything other than diagnose and treat patients? In a well-run practice the answer to all of these is no.
Third, count how many times in a single session you have to give instructions to the staff or ask the nurse for something.
The productivity paradox is counterintuitive, but once you’ve seen it you can’t unsee it. The dentists working the hardest are the least productive, ground down by systems that consume their energy. The most productive dentists 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’s absolutely bridgeable. The dentists who have crossed it will tell you it was the most worthwhile thing they ever did for their practice and for themselves.
If you’d like to go deeper on dental practice systems and efficiency, my Efficiency course covers the full system built entirely on real chairside experience. You might also find The Jack of All Trades Is Going Broke a useful companion to this piece.
Dental practices do three things: attract patients, gain their agreement on treatment, and deliver the care. Get all three right and your practice will thrive.