Dr. Albert (Ace) Goerig describes how the principles learned through Endo Mastery coaching can result in better daily productivity and less stress.
Dr. Albert (Ace) Goerig discusses how to achieve the same or better daily productivity and case completions post-COVID-19
For most endodontic practices, the past few months have probably been some of the busiest. As GPs returned from shutdown in May and June, pent-up patient demand and subsequent endo referrals have surged from July onward. Yet the precautions we implemented in our practices have continued, including check-in procedures, limiting contact between patients, enhanced PPE, mitigation of aerosols, and coronavirus disinfection both inside and outside the treatment rooms.
In high-productivity practices like mine, keeping up with the surge in patient flow has brought unique challenges, especially given our current reluctance to transition during a patient appointment due to PPE standards and to minimize possibilities for cross-patient exposure. As a result, I took these factors as an opportunity to examine my clinical care approach and evaluate the underlying systems and routines that had previously guided my schedule and delivery of care. My goal was to achieve the same or better daily productivity and case completions as I was able to achieve before the pandemic. I also had the benefit of sharing and learning with endodontic colleagues in my Mastery Circle group as we explored different options through biweekly Zoom meetings.
Here is what I found.
Initial patient form: All initial patient information, medical history, and consent forms are requested to be completed online and sent to our office before the appointment — 90% of our patients are now doing this. The assistant simply meets the patient at the door, does the COVID-19 screening and temperature check, and brings them directly back to the treatment room.
Diagnosis: My assistants are highly trained to interview patients and ask assessment questions, plus take CBCT scans and radiographs. My clinical team identified two areas where efficiency could be improved.
First was increasing the number of radiographs from the referring doctor in advance. The coronavirus prompted us to improve our language around referrer-sent X-rays and to communicate how patients might avoid a nontreatment evaluation appointment if radiographs can be sent in advance. It would also save our schedule from nontreatment cases. As a result, enough GPs improved their efforts on enough cases that we have an appreciably lower rate of nontreatment cases now.
Second in diagnostic efficiency was being meticulous with my team to not duplicate our assessment efforts. My team helped me identify where I routinely ask patients the same questions they have already asked. We also reviewed the imaging needs for various case types to ensure that they took all the diagnostic images I typically want so that time was not wasted once I entered the operatory.
Anesthesia: All doctors have a clinical comfort zone — their armamentarium of preferred supplies, equipment, technology, and techniques that underpin their clinical practice and help them achieve consistent case results. One area my Mastery Circle group identified for efficiency improvements was anesthesia, where the waiting time before treatment can be significantly shortened through supplemental anesthesia in addition to regional nerve blocks.
Periodontal ligament injections (PDL) can be effective in as little as 30 seconds to 1 minute. This can be effectively done with a standard syringe, lidocaine 1:100,000 epinephrine, and a 30-gauge needle applied buccal and lingual on the distal of lower teeth or mesial and distal of upper teeth after initial blocks or infiltration injections. My preference for vital lower molars is to use intraosseous injections (such as Stabident) mesial or distal to the tooth with mepivicaine without epinephrine.
Since anesthesia time can be shortened so significantly with supplemental anesthesia techniques, even without a pandemic, it warrants reconsideration of whether transitioning makes sense. Today with improved diagnostic and anesthesia efficiency, I am completing routine cases in less time than ever, and completing more cases per day. This has the added benefit of staying focused on one patient at a time, and never feeling as though I have to bounce out of the treatment room. Our patients appreciate us not interacting with other patients during their treatment.
It also means that with transitions not occurring, assistants have more time for disinfection and documentation in each operatory before the next patient is seated. They can be very thorough, which saves me even more time at the end of the day as I review treatment notes that are 99% complete in advance.
Sidebook and daily flow
One of the things we usually relied on transitions for was sidebook appointments. We have always strived to minimize the number of recalls. For routine cases, we never recall patients automatically and prefer to follow up by phone. If the patient reports atypical post-op symptoms of discomfort, we will assess them by phone first and bring them in only if the symptoms indicate.
For evaluations, we are using two strategies: First is to appoint “evals” at the end of treatment slots rather than in a transition slot. Second is to reserve power hours. A power hour would mean booking back-to-back evals, so we can assess patients in a very efficient way — for example, five 12-minute eval appointments or four 15-minute appointments. In fact, the eval fees from a power hour plus the CBCT fees can be just as much as an RCT fee.
A final note about improving daily productivity and dealing with the surge (and it is entirely a personal preference): Consider how much time you are taking for lunch. If you need the time for re-energizing, by all means continue to take an hour lunch. However, if you have the energy and you want to maximize your daily productivity, a 10-minute lunch could be worth $1,000 daily, or $15,000 to $20,000 per month, depending on the number of days you work.
The new normal
Much has been said about the “new normal” imposed by the pandemic. But in my experience and many Endo Mastery coaching clients, the new normal is a better normal: better flow, better teamwork, better productivity, and less stress. At this point, I wouldn’t want to go back to the way it was.