Having moved around a lot in the last twenty years, I've never had the same dentist for more than three or four years at a time.
On one hand, it's amazing to see the immense variation in how dentistry is practiced. Some dentists aggressively push different treatment options (or cosmetic options) and some seem to be almost undertreating me. How can I have serious gum problems when visiting one dentist, and then two years later not show anything that concerns the new dentist? Hmmm.
I also see variation in how practices are managed. Some of it is the size of the practice and the team size. I've been in practices that have multiple rooms, multiple hygienists, and sometimes multiple dentists. But, the patient (me) usually waits between steps. Sometimes you feel forgotten. I've seen the same dynamic in ophthalmology care, too.
Dentists, like Sami Bahri, DDS, “the world's first Lean dentist,” who focus so much on patient flow instead of their own personal efficiency and utilization are rare. As we see in many cases, Dr. Bahri has led the way in finding a better way (it's been better for his patients and his practice) — and others are not interested in following. They'd rather struggle through “the way we've always done it” instead of follow somebody else, it seems.
My Non-Ideal Visit
I've been going to a dental practice in the DFW area that's part of a chain — “Ideal Dental.”
In the Lean language, we like to talk about “the ideal condition” or “the ideal state” or “ideal care.” The word Ideal sets the bar high. But, I also realize it's just a brand name.
The location I had been going to moved to another city, so they transferred me to another Ideal Dental that's equidistant from my home. I wouldn't say the other location was “Ideal,” but they seemed efficient enough. I didn't spend much time in the waiting room.
So I came to this new location for a checkup and cleaning. In my past experience, I should be able to get in and out within an hour. I had a 10:30 appointment and I was supposed to be back home to record a podcast at noon. If the appointment took less than 75 minutes, I'd be fine.
What happened?
I got brought back to a chair pretty immediately after filling out paperwork. I arrived early to do that and they called me back at 10:30. So far, so good.
I waited for a bit in the chair, and they then took some digital x-rays and photos of my teeth as a new patient, which took just a few minutes. Shortly after, the dental assistant did some initial checking of my teeth and gums.
“The dentist will be right in.”
About twenty minutes passed. Waste. Waiting. Not ideal.
I'd gotten spoiled by a dentist in San Antonio who was retired Air Force. I think he was in private practice because he enjoyed it and he wasn't looking to maximize revenue or profit. It was just him and an office assistant. I was always the only patient in the building. The dentist would do everything himself, from exam to cleaning. So, there was never any “waste of waiting” in between. And I got excellent care.
Back to the other day, the dentist determined that I'd need a filling replaced. I probably didn't have time for that, so I'd come back. I talked to the dentist. Then waited. Later, somebody came in to talk about payment. Then, I was told the hygienist would “be right in” to do my cleaning.
More time passed. I was watching “Shark Week” on the TV on the wall. I lost track of time.
I realized it was about 11:40. Oops!
I had been there 70 minutes and there had been about 10 or maybe 15 minutes of “value added” time (treatment time).
I went to the front desk… “I'm running short of time. I've been waiting and it's like they forgot about me for the last half hour. Can I come back tomorrow morning when I have more time?”
They apologized. Does an apology always lead to process improvement? Probably not.
The Next Day
I arrived about 15 minutes early for my 10 AM appointment. I was brought back right at 10 AM.
This day was different. The dentist came to the chair immediately. There was no apology for the day before (she might have been unaware that I left without being cleaned).
But, she said, “I'll be doing everything… no hygienist.” It was unclear if that was her choice or if somebody hadn't shown up.
This was the most efficient, most ideal visit ever.
She apparently had sequenced the work out very well.
First, she numbed my gum with a swab. Then, after that kicked in (I consider that wait to be value added, not waste), she injected my gum with whatever they use these days to numb your tooth.
Then, while that kicked in… she did the cleaning! Brilliant.
Then, when the cleaning was done, she did the filling work. No waiting or delay between steps.
I was out of there, happy, in exactly an hour.
Comparing the two visits — in the same practice on two different days:
- Visit 1: 75 minutes total, 15 minutes value add
- Visit 2: 60 minutes total, 60 minutes value add
My “patient flow” was ideal. And, the dentist was fully utlized that hour. One could make the case that the dentist shouldn't be doing cleanings, since somebody at a lower pay rate can do that same work. But, I appreciated what was actually pretty close to “ideal” care.
What are your experiences with patient flow in a clinic setting – the good, the bad, or the ugly? Are you like me, who has “fired” a primary care physician because they were habitually an hour behind schedule? Do you value your own time more than the providers sometimes?
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A few people, including my podcast guest commented something to the effect of, “They need Lean!”
Do they?
Apparently, the process is fine, from their perspective. Do they *need* Lean? That’s for them to determine.
Is there a huge opportunity for improvement? Of course. But, if they don’t see a problem, I’d never go pushing a solution on them.
I have a dentist like your San Antonio retired Air Force dentist. I am generally in and out in under 25 minutes for a routine cleaning. One office assistant, one dentist, one patient at a time, no hygienist.
It’s not always about eliminating all of the handoffs, but reducing the number and wait times between handoffs to provide more value for the patient. It’s a simple concept, but difficult to implement. I appreciate your story, because it reminds me of how much we can still do to improve patient care.
Thanks for your comment, Caitlin. I’m envious of your situation.
You’re right that handoffs are just one cause of waits between value added steps.
Great post, Mark.
Can you say more about the tension between
A) “practicing at the top of your license” and
B) just doing it all yourself to minimize waste and delay due to handoffs?
I wonder about this trade-off a lot, especially with respect to physicians.
Advantages of A may include: higher profit for the provider/employer, more “fun” for the provider to avoid less challenging work, higher level of skill in each role due to specialization.
Disadvantages may include handoff waste and delay, quality of information suffering from the handoff, lower availability of services if both dentist and hygienist must be present ( or a 2nd visit on days when only one is present), risk of having a great dentist but so-so hygienist or vice versa.
Advantages of B may include: Good flow from the get-go, the potential for synergies (as your second day showed), patient only needing to establish a relationship with one person.
Disadvantages for the patient may be limited to the skill question, which your Air Force dentist had overcome, as had your Day 2 dentist.
Perhaps the main difference between A and B is that bringing the patient experience of A up to the level of B is hard – really hard, and often just not done.
How do you think about this?
Steve
Steve – I think you say it well that there are tradeoffs. The personal evaluation of which is more “fun” (or rewarding or engaging) might be a very personal one. My San Antonio dentist might have enjoyed doing everything. And, I think you’re right that some might be happier not doing for more boring, lower-level work.
I think this goes to show that while Lean might provide some principles and ideas about how to run a practice, everybody has to decide what works best for them — which hopefully involves structured experiments and also taking into account what works for patients.