What dentists can teach us
The dentist had been in the room less than four minutes.
The door of her car seemed to slam just a little too harshly as she looked with expectancy at the bright front entrance of Academy Dental Center.
Marcie Wheeling, DVM, then walked into the small waiting room, and the familiar smells were immediately apparent despite the well-dressed and smart surroundings of the room. The smells were the same, but muted from the days when she was a young girl in the rural south. The scent was never an inviting fragrance, but instead a consistent harbinger of things to come. Marcie paused. She had never been afraid of the dentist's office but her senses were always heightened when she entered. Today was no different.
Each encounter with another allied profession always piqued her interest. She inevitably compared it with her own small veterinary office, where she and her staff battled against the sights and smells that emerge amid the sporadic cacophony of the office. She wondered whether the dental staff battled half as hard as she did to make her office as comforting and odor-free as possible.
Janet West, one of Academy Dental Center's hygienists, called Marcie the night before to remind her of her hygiene appointment. Janet had been very friendly and seemed enthusiastic and comforting in her approach. Marcie had assured her she would make the appointment.
Ushered into the exam room, Janet brightly informed Marcie that she would be taking a preliminary X-ray during her periodic examination and that it had been a year since the last X-ray and oral examination by her dentist — Dr. Ron Harrison. Dr. Harrison would review her findings after the scaling and exam by the hygienist. Janet asked whether there were any questions.
Marcie shrugged and opened her mouth to receive a rather uncomfortable but tolerable piece of X-ray gadgetry that seemed totally new to her. In fact, she noticed a substantial amount of new equipment in the office.
Janet placed a lead shroud from neck to knees on her patient and quickly maneuvered the small radiological apparatus in place and nimbly exited the room and made the exposure. Marcie hadbeen inside the exam room for less than three minutes. Janet removed the film and entered the small dark room a few feet away.
Janet was back from the X-ray room in less than two minutes and removed the apron, maneuvering her patient into the hygiene room in just a few moments.
Marcie melted into the comfortable chair, and Janet started a very systematic cleaning and probing of her teeth. She noticed that the office kept exacting notes of each of her teeth on a touch-screen computer behind the chair. After the scaling, Janet examined and probed each periodontal cuff and graded the depth accordingly. Each filling and crown was evaluated for wear and potential leakage. A few notations were made for the dentist. Janet informed Marcie that there were two teeth that could be trouble spots and that Dr. Harrison would evaluate those areas and perform an oral examination in just a few minutes. Marcie had been in the office for approximately 30 minutes.
Dr. Harrison entered and greeted Marcie warmly and began a complete, but quick oral exam. During the exam he listened intently as Janet went over the areas of concern that she had found during her prophy. Dr. Harrison carefully made his evaluation and then looked at the X-rays. He informed Marcie that one of her premolars, filled by a previous dentist, was leaking and would require a crown. The good news was that the tissues and canal looked fine and that a root canal at the same time was very unlikely.
The other area of concern was a molar that was wearing excessively. He told Janet to put a notation on the record to watch that tooth for the next cleaning.
After some brief pleasantries, he turned and gracefully entered an operatory next door. He had been in the room less than four minutes. Janet quickly took control and walked Marcie to the front desk and made some hasty explanations to Beverly Wheat, stationed at check out.
Beverly interpreted everything quickly.
"Thank you, Dr. Wheeling for visiting us today. We need to make your appointment today for your crown. Are you still available on Wednesdays?"
Marcie fumbled for a moment. Her day off was Wednesday. She hated to give up another for the dentist but saw no way out.
"Yes, Wednesday would be fine."
"I have an opening on a Wednesday one month from now — would that be fine?"
"Yes, that would be great."
"Terrific," Beverly stated and gave her a card.
"Today's visit was $310 and next month's crown will cost $566. Would you like to pay all of that today, or break it up between this visit and next month?"
Marcie thought for a moment and flipped out her credit card.
"What's the difference," she thought.
"Egad, that is a lot of money," she further mused.
Beverly presented the slip of paperwork to Marcie. She signed the credit card slip, took her receipt and was out the door.
Marcie flopped into the front seat of her car.
"I think I need to raise our fees," she said out loud to no one in particular.
She had been at Academy Dental Center for a total of 50 minutes.
Thursday morning: Wheeling Animal Clinic
Dr. Wheeling usually entered her office to a pile of notes and requests by the staff. Today, two of her staff members were lined up with several questions from callers with a potpourri of issues. Dr. Wheeling quickly gave her responses and waded deeper into the clinic. Darla Johnson, the morning technician, was bent over the counter working on the morning schedule. She frowned as Dr. Wheeler approached.
"You had three spays this morning and an ear flush, but only the small cat spay has shown up and everyone else isn't here yet," she lamented.
"Did Suzie make some phone calls last night to these owners?"
"I don't know; I wasn't here," Darla commented with a faintly perceptible edge in her voice.
Dr. Wheeler walked up front. Pandemonium ensued despite the gaping holes in the surgical schedule. Dr. Wheeler found out that Suzie, who usually works evenings, had gone to the dentist and her replacement wasn't trained to make the phone calls.
She then prompted Suzie and Jenny to make hurry-up calls to the tardy clients.
"Never hurts to try," she offered with a weak smile and she turned and went to the back.
Several phone calls and 20 minutes later, the morning schedule remained unchanged. Dr. Wheeling spayed the kitten, called the owner and spent the remainder of the morning doing paperwork. She hated paperwork.
Thursday afternoon: Wheeling Animal Clinic
Ginger Mabry moved her obese small Cocker Spaniel Diddles, along with some sort of stick, as she entered the exam room. Dr. Wheeling hadn't seen anything like that since she was showing pigs in 4-H as a kid.
"She doesn't like a leash," Ginger commented without looking up. Dr. Wheeling thought it best not to comment. She also noted that the ripe aroma from Diddles' ears suddenly had opened her sinuses.
"Diddles needs some shots and some of that ear medication you sell here."
Dr. Wheeling noted on the chart that Diddles hadn't been in for more than two years. She had missed an appointment to have her pet's teeth cleaned a few months after that.
The ensuing conversation was akin to a pep talk for Mrs. Mabry. Dr. Wheeling made several suggestions for improving Diddles' health. Ginger nodded and seemed interested, but Dr. Wheeling's conversation was so polite and non-committal that it didn't convey a sense of urgency.
"Mrs. Mabry, Diddles really does need to get his teeth cleaned, and you need to try to schedule that sometime in the coming months."
As Dr. Wheeling left the room, Suzie looked up and asked whether Ginger would like to make an appointment for her dental scaling.
"I don't know my schedule, and I'll need to call back in a few days. Besides I need to hurry along to keep an important appointment. You'll need to send me the bill."
"What's your appointment for?" Suzie inquired politely.
Ginger opened the exit door and turned.
"It's with my dentist, Dr. Harrison. They have a very nice hygienist there named Janet. She called me last night. Isn't that thoughtful?"
Observation: Put it into practice
On Wednesday morning: Did you notice how Marcie was processed through the dental center?
Here are the key observations:
- The visit was staff-centered and not doctor-centered.
- The visit was systemized and was likely very predictable to staff and doctor.
- One person was assigned to the client and stayed with them throughout.
- The staff boldly knew how to proceed although questions were encouraged.
- The additional equipment noticeably improved the patient experience and care.
- The procedure was very systematic and organized.
- The doctor was in the exam room for a fraction of the patient's visit.
- Without badgering the client, the next visit was scheduled and payment was received prior to the event.
Is this a realistic experience?
Yes it is. In fact, I learned all of this by going to my dentist recently. As is my custom, I usually pump him for comparisons between our professions. In fact, the things that happened to Dr. Wheeling are exactly as they happened to me recently in my dentist's office. Hint: he has a management consultant in his office regularly.
On the other hand: This is us.
Dr. Wheeling is a typical veterinarian. She drives the clinic, and the clinic drives her. She is a bottleneck for the practice and most decision-making is done by her. Staff is basically waiting for Dr. Wheeling's next decision in order to proceed.
Why? For the most part, we have yet to use the most important and pivotal member of our staff: the technician. Ninety percent of the work that veterinarians do can be systemized and delegated to the technician. Veterinarians don't particularly like to systematize the delivery of animal care because they have been taught that they are the focus for that delivery and that every situation is unique and theirs to control.
In fact, although many exceptions arise, most of what we do in exam rooms can be systemized and delegated to technicians.
We can see that the bulk of the oral exam done in the dentist's office is systemized by the hygienist and checked by the dentist. This delivery model can occur in our profession if we just lose a bit of our pride.
Dental hygienists are often paid by commission. They are an obvious choice to call the dental client and get them in the door. Under this arrangement, the reminder system boils down to making the appointment and making the phone calls. Appointments are booked every six months. There are no elaborate reminder cards; the system basically gets internalized. Wow #1.
Dentists are procedure-oriented. They set up the procedures with biannual dental checkups and cleanings. They make sure the appointments are made and kept, and then do the procedures — over and over again.
On the other hand, veterinarians are urgency-oriented and see several patients that make appointments that same day. Unfortunately the practice is unwittingly pushed into a reactive scheduling mode.
In the system
Dentists know how to keep you in the system. Often dental clinics are booked many months ahead. Patients know that if they want a spot in the schedule, they must make that appointment at the end of the current visit.
How does the receptionist pull this off? Simply by telling the patient that they have an available time on a particular day, and then they ask the patient if that is acceptable. It is all in how you ask questions. The appointment is made, and it is up to the client to reschedule if a conflict exists. This is simply proper and ethical salesmanship, nothing else.
Hmmm. Sounds good to me, but we are so nice and accommodating in our offices. What really happens is that often we let our clients run the show. That certainly does not qualify as being an advocate for the patient. Yet, it happens in most practices. Shame on us.
Yet another trick from the dentist's bag
Many of us have finally learned to make phone calls the night before to confirm appointments. Dentists don't want "white space" in their schedule. Therefore, the hygienist will start calling the week before and continue to call until a confirmation is made. Why? Remember the word commission; it drives the practice of dentistry. The twice-a-year checkup is a paradigm.
Isn't that the holy grail for veterinarians — biannual visits?
Can we do this?
First, we must commit to being procedure oriented. This means finding the problems when the patient appears normal to the client and then to have the moxy to (gasp!) sell the client on the procedure.
Second, we must put some of the work that certified technicians do on a commission or bonus system in order to move the practice into a "biannual visit" mode. This strategy means delegating a lot of the gateway medicine downstream to the technician.
Third, this leaves the veterinarian free to increase the number of procedures performed and make diagnostic decisions. Isn't that why you went to veterinary school?
Fourth, a really beautiful thing can then happen — more patient visits and procedures mean more cash in the practice, leading to more equipment and more pay for staff and veterinarians.
And that leads to staff longevity.
This is what we should be doing, should I hold my breath?
Dr. Lane is a graduate of the University of Illinois. He owns and manages two practices in southern Illinois. Dr. Lane completed a master's degree in agricultural economics in 1996. He is a speaker and author of numerous practice management articles. Dr. Lane also offers a broad range of consulting services and can be reached at firstname.lastname@example.org.
David M. Lane DVM, MS