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The "Third" Statistic |
Searching for the root cause of practice stress |
by Tyson Steele |
In the mid-seventeenth century, 578 people died in the Soho district of London, England in a period of just ten days due to an outbreak of cholera.
To the physicians and scientists of the 1600's who knew nothing about bacteria, the diarrhea and deadly dehydration that accompanied it was impossible to cure. Trying everything to stop the disease, doctors prescribed bed rest, dietary changes and increased fluids. Finally, a physician named John Snow tried a different approach. He marked the home of every victim of cholera on a map. The result clearly showed that majority the victims of the disease lived around Broad Street.
Unlike other physicians of his day, Dr. Snow believed that diseases could be carried by drinking water. So, he placed a mark on his map, locating every water well in the district. As it turned out, the victims' homes surrounded just one well.
Dr. Snow showed his findings to London officials who promptly closed the well. The deadly outbreak was suddenly contained and many lives were saved.
Dr. Snow's approach to finding a cure for the outbreak was entirely new in his day -- rather than being content to treat the symptoms, he sought to find the cause. Using a very rudimentary statistical analysis, he quickly found the cause, and stopped the epidemic.
Unfortunately, when it comes to practice management, we still try to cure the symptoms without addressing the cause. Like so many ancient physicians, we avidly attack the symptoms that bother us, without stopping to consider if our energies are being well spent.
Today, dentists face a particularly virulent epidemic. That epidemic is known as stress. As the pace of the world has increased, stress levels have risen exponentially, especially for dentists. For while these are some of the most productive years dentists have ever seen, they are also the most time consuming, leaving many of our clients scratching their heads and wondering if they will ever get a break.
Unfortunately, faced with this dilemma, many dentists take a course of action they would never take when healing their patients -- they attack the symptoms. Scheduler overwhelmed? Get a new computer system. Scheduled out three months? Work on your day off. Too many "no shows"? Get a high school kid to help confirm appointments. Burned-out? Get an associate.
At best, these solutions will temporarily relieve some stress. At worst, this approach actually consumes more time and increases your stress. The new computer system is a headache, the extra work days make no dent in the schedule, patients continue to cancel at the last minute, the associate doesn't fit in, and all the while, your stress level keeps going up. Sound familiar?
The solution, of course, is deceptive in its simplicity. Like the wise Dr. Snow, you must address the cause of your symptoms, effectively cutting off the source of much of your stress.
Start with a Map
I know we shove this stuff down your throat, but you cannot manage your practice effectively without proper statistics and the knowledge of what they mean. In other words, you need to start with a map.
The map provides you with an objective analysis of your practice -- a diagnosis. The map consists of the scores and statistics that drive your practice. The map is the beginning of the search for a real solution.
The three most important statistics to track in your practice are production, profit and the number of active patients. Unfortunately, in our experience, only about one doctor in ten knows statistic number three -- their active patient count. So, if you don't know, it's time you found out.
First, our definition. Active patients are all patients seen at least once in your practice during the last two years.
Second, ignore your computer. Most computer generated counts are grossly inaccurate. This is because the computer often counts visits instead of patients, or counts all patients seen regardless of how recently, or counts multiple entries for the same patient due to address changes, name changes and other updates. In other words, this count is often too high, and, coincidentally, should not be trusted unless you have a firm knowledge that your file management is up to date.
Third, assuming that inactive patient charts (patients who have not been seen at least once in the last two years) have recently been removed from your shelves, you can arrive at a reasonably accurate patient count by simply counting the number of charts on one shelf and multiplying that number by the total number of shelves (i.e. 380 charts x 4.25 shelves = 1615 active patients.)
So, what are you waiting for? Do this! Take this article right now, give it to your office manager and say "get me this count!" Once you have your count, you can continue with this article and find out what to do about it.
Mapping the Surroundings
Now that you're ready, let's start with a little background information.
As most of you know, the population in the Pacific Northwest has increased and the number of full-time, practicing dentists has decreased throughout the last decade. (See the June, 1999 issue for more on this trend.) Ultimately, this has led to an increase in the number of active patients seen in most mature one doctor practices from an average of 1,300 patients in the mid-1980's to 2,000 or more patients today. And although new equipment, materials and strategies such as expanded hygiene have increased doctor and hygiene efficiencies, we haven't come anywhere near cutting treatment times in half.
This, of course, leads us to our hypothesis that much of your stress may be caused by having...(don't freak out on me) too many active patients.
How Can I Have Too Many?
I know the thought of having "too many" active patients sounds ludicrous to most of you. After all, you've spent your entire life trying to attract more patients. How could you possibly have too many patients? Aren't patients the life blood of the practice?
Well, the answer to those questions goes something like this -- it depends. It depends on how many active patients you currently have. It depends on the quality of the new patients you receive. It depends on your personal philosophy regarding the level of care you desire to provide for each patient.
The truth is . . . when taking those factors into account, many experienced dentists in the Pacific Northwest today have too many active patients. (And, by the way, if you aren't already facing the stressors caused by having too many patients, odds are you will soon.)
So, how many active patients can you handle?
In our analysis of hundreds of practices, we have found that most quality, fee-for-service, one doctor practices can provide adequate care for about 1,500 to 1,700 active patients. Of course, we are talking about family oriented practices with a strong restorative focus. If you are highly capitated, or if you are primarily focused on cosmetics, these numbers would change.
Unfortunately, many one doctor practices currently have 2,000 to 3,000 active patients. (If you happen to have fewer than 1,500 patients, don't worry, we'll address that problem in an upcoming newsletter -- but please read on, because you're likely to still get something out of this.)
The Root of the Problem
If you have more than 1,700 active patients, you've discovered the root of many practice problems. After all, if you have more patients than can be handled by even the most efficient practices, traditional solutions like adding computers, staff members and work days will never really solve your problem. That's because you are attacking the symptoms rather than the cause.
Assuming your patient mix and the amount of treatment they need is relatively normal (meaning your patients aren't all generation-Xers with few or no restorations), having more than 1,700 patients naturally leads to an increase in band-aid dentistry, emergencies and a lower percentage of patients in hygiene. And, of course, this creates a vicious cycle of more emergencies and band-aid dentistry as the schedule seems to permanently careen out of control.
Addressing the Cause
Obviously, having too many patients is a problem many dentists would be happy to have. Unfortunately, however, it is also a problem, that once acquired, is difficult to address. You see, this is an emotional issue for many dentists, and as such, requires a complete shift in thinking from the "scarce patient" philosophy they adopted early in their career.
If you find that you appear to have too many patients to handle, and if stress seems to be a major problem in your practice, we suggest the following approaches:
- Continue taking new patients
You should never quit taking new patients. Rather, you should begin to focus extensively on the "quality" of new patients you take in.
You could take new patients by referral only. You could interview them to see if they fit your practice style. You could require new patients to handle their own insurance. You could do a lot of things. Regardless, you should always take new patients who fit well in your practice.
- Refine your practice style
Establish your distinct practice style. Rather than being all things to all people, focus on serving a certain portion of the population. Ideally, you do this by providing treatment you deem most "ideal" to patients who agree with and appreciate your practice philosophy. Ultimately, by avoiding band-aid dentistry, you will eventually avert many emergencies and scheduling difficulties.
If you don't like doing dentures, don't. If you don't like working with amalgam, don't. Refer out endos and time consuming cosmetic cases, quit tinkering in ortho, whatever. In other words, find what you do best and focus on it, make it profitable. Of course, you should and will make exceptions, but make those exceptions for patients who otherwise buy into your overall treatment philosophy.
Don't be pedantic, but do know that if you have too many patients, you certainly have an opportunity to begin focusing more on your personal preferences. Take advantage of this!
- Refer out patients who don't fit your style
As you focus on your "ideal" treatment, whatever that means to you, and as you continue to take quality new patients, you will need to refer out patients who don't fit your style.
Remember, many young dentists don't have enough active patients, and they are more than happy to take the people that you don't need. In addition, many of these dentists would be pleased to provide treatment that, while it might be preferred by the patient, is not "ideal" for your practice. Often, these dentists will even develop a great relationship with the patient. People are different. Patients are different. Dentists are different. Quit being all things to all people.
And what about your worst patients? You know, the one's who never pay their bill, miss half their appointments, complain when you do a pano once every eight years. Well, if you've done everything you can to educate them and they still won't fall in line, there's this crazy thing call managed care...need I say more?
- Set appropriate fees
In every other business in the world, having too many customers naturally leads to higher prices. Unfortunately, dentists have allowed non-market-driven forces to limit their fees. Ultimately, this has led to fees that, over the last two decades, have failed to keep pace with staff salaries, equipment costs, lab fees, facility expenses, and patient incomes -- let alone your personal cost of living.
In other words, dentists have been forced to work harder, faster and more efficiently just to keep up!
Make use of the law of supply and demand. Set your fees appropriately for the quality of service you provide. Apply for a fee increase to your state governing body every time you can. And be certain to apply higher than you think will be approved and negotiate downward so that you maximize every fee. In addition, if you are in Oregon, or another state where you can have a higher fee-for-service schedule outside your approved schedule, establish one. All your suppliers, patients and insurance companies make use of market forces, you should too.
- Bring in another dentist -- if appropriate
Finally, we come to the most obvious solution. Unfortunately, it's often the most difficult solution to implement effectively. As consultants, we think multi-doctor practices represent the future of dentistry -- sharing fixed costs, maximizing staff value, improving coverage and patient flow. However, before you jump on the associate/partner bandwagon, consider it carefully.
Are you suited to having a partner? Are you willing to sacrifice free time to train an associate? Will your team be receptive to another doctor? Do you have the minimum of 3,000 patients to keep two doctors busy full-time? If not, are you willing to take what may amount to a several year pay cut? How will you handle different treatment philosophies? Are you willing to keep trying the three or four times it may take to get someone who "fits"?
Bringing in another doctor could be an excellent move. Just be certain to plan carefully for a successful venture. On the other hand, if the multi-doctor practice is not your style, don't worry about it. By using the strategies outlined above, you can still benefit from your high number of active patients while enjoying a great lifestyle.
Remember Dr. Snow? His rudimentary statistical analysis helped him track down the cause of the epidemic. You have just embarked on your own analysis, a look at the "third statistic" -- your number of active patients.
If you've determined that you have too many active patients to handle effectively, I hope you've also made some distinctions that will help you reduce scheduling difficulties, lower your stress and increase your profits.
If you don't currently have too many active patients, I hope you've read carefully enough to still get something out of this. After all, sooner or later you are likely to be faced with the same problem. Fortunately, unlike those before you, you'll already have a game plan. |
