The productivity paradox: Secrets of highly productive practices

I have discovered that it's less tiring and stressful to produce $7,500 of dentistry per day than to produce $2,500.

During the past several years I've been extremely fortunate to work in more than 20 practices all over Australia. 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 the exact 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 beaten up, 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, almost surprised by how easy the day had felt.

The friction factor

The answer 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. In a well-run one, the systems absorb it instead.

Superbly run practices have systems that make the entire team's life, particularly the dentist's, easy and productive. Working in a high-grossing practice feels like riding a sleek ten-speed on a smooth open road — everything flows effortlessly in the same direction.

By contrast, in low-grossing practices it feels like you're trying to ride a push bike with flat tires up a steep dirt road. Everything is so very difficult.

Low-grossing practices

While working in a low-grossing practice a while ago a patient came in with a toothache and 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.

In another practice I visited it took seven minutes just to set up the rubber dam.

In such practices, the treatment rooms often have instruments and materials laid out in, what looks to me, pretty much random fashion. To set up for a procedure you might need to open four or five different drawers.

Most 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 mostly sit and wait for instructions, neither listening to what the dentist is saying nor anticipating what comes next. Frequently they go missing and I have to get up and wander around to find them.

This means I end up carrying out dozens of tasks the team could easily handle — tasks that would actually add variety and interest to their jobs. I once compiled a list of 43 such tasks. And because there are rarely checklists in place, I must constantly watch for mistakes rather than focus on the patient in front of me.

Such practices are exhausting. By 5.00pm I feel like a wrung out dish mop.

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 them.

High-grossing practices

At this level of productivity, everything flows — just like that ten-speed on a smooth open road.

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 I even know I need them. It's almost like I’m riding in their slipstream.

In such practices, I only have to treat patients — everything else is taken care of by the team.

Instead of me watching the team, the team watches me. If I forget something they gently remind me. They virtually never need to ask me questions.

Take clinical notes. I never have to write them — the nurse handles it all, and does it perfectly. Or referral letters. All I have 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. I never need 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 I never even find 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 I never break my concentration. I never have to look up, or ask, or wait.

At this level I just go with the flow. I find myself standing in the hallway and a team member says: "Surgery 2, Mrs Mary Jones, ceramic crowns 14, 15." I salute and off I go. When I enter the room everything is ready and the team is waiting. I 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.