Thursday, June 9, 2011

Tracking new patients

Friday! Woooo hooooo!

Lately, since I am not doing as much dentistry, I have had more time to think about practice management. I started a spreadsheet to track what is going on with my new patients. The patient will come in for a new patient exam and then get a cleaning the next week. Are they coming back in six months, or are they falling through the cracks? Do you do this? Do you track stuff?

Okay, here is what I found. Wait, before I tell you everything, let me tell you about our new patient exam (experience). They get a full mouth series and a pan, then the new patient and an interview. We just talk about what they expect from me, what they should expect from my office, stuff like that. Then we talk about teeth and what their chief complaint is. I educate them on what perio disease is and explain to them that we are going to do this exam in the room (more than 75% of my new patients have never had perio charting done and don't have a clue about gum disease). Then we go to the operatory. I check for decay, occlusion, TMJ, perio, oral cancer, everything.

I think it is a thorough exam. It takes, from x-rays to exam, about 80 minutes. But I hope they feel like I care. I hope they feel like I am thorough and have time for them.

My exam is $60, so I am not over the top on my price. Though, the x-rays are a little steep at $172. Now, before you get ticked at me for the x-rays, you all know that a full mouth series shows you a lot about a patient (and if you don't take a full mouth, you wish you did). I take a full mouth series every 5 years. You all know that bite wings are not enough if you are trying to be thorough. And while you are trying be thorough, you have to admit that a pan is necessary. I don't know why, other than price, I wouldn't do the most thorough x-rays. (Did I say "thorough" enough in that paragraph?)

I looked at Jan-June of 2010, and found that 103 new patients came to see me. Now that is kids and adults, charity and everything. I wanted to know who is coming back. I told my staff to look up the New Patient exam code and print out every patient because I want them to investigate every one of them. It is a "Where are they now?" kind of thing.

Now, I would say a percentage of those patients would feel that we are not the office for them. They want the total opposite of what I try to do. They might feel like the new patient exam was too much. "I just wanted my teeth cleaned." They went through the exam just to get their teeth cleaned and never come back saying, "This guy is over the top. This kind of dentistry is a bit intimidating and"it is not like my old dentist." I can see that.

Now for actual numbers. I am embarrassed to tell you these, but I started this and I might as well finish. Out of 103 patients, 52 have been back for two cleanings. I feel this is kind of the threshold for new patients that like us and are probably staying. Eighteen are a bad debt issue - ON THE NEW PATIENT EXAM!!! Some of them are college kids that have not been back abd some of them live in another state. But some of them have just not come back.

I am not going to get all upset. I am not going to jump off a cliff. Do I just blow it off, knowing I can't please everyone? No. I am going to learn from this. But how?

I am thinking of drafting a letter to send to all the "I have no idea why they did not come back" people. I understand that these are hard economic times for some people. Who's to say they didn't love me, but they lost their job and insurance and they just couldn't afford to come back?

In the letter, I just am going to ask them straight up, "How did you like our office? If you didn't like our office, can you please tell me WHY NOT?" All under the umbrella of "we are trying to improve our service every day."

This is hard because there is a part of me that just doesn't want to know. Has a friend ever come in and told you there weren't greeted when the walked in? Has a patient that you are pretty close to ever said that someone was kind of rude on the phone, or they the front staff wasn't helpful? This drives me absolutely CRAZY.

I have this idea that everyone in my office is on the same page. People first. And if this isn't happening, then something is very wrong in my world. It could mean that it is happening all the time and you only hear about it from your friends. Then you have to go and have conversations with your 15-year employees about service.

Do I want to know that my people are not on the same page as me? Do I want to know that when I am not looking, there are staff that are not treating people with Ritz-Carlton service? Argh!!!

Okay, I am going to stop here. I will let you know when the letter goes out. About a week after that letter goes out, I might not be in a very good mood.

Do you track your new patients? Are my numbers like yours? Or do you not want to know? Let me know.

Have a good weekend.


Charles said...

Dr. Gammichia -

I will second your Woo Hoo Firday comment! Since you started your blog today focusing on Practice management I did want to highlight a couple of things AGD is doing to be of assistance to our members. We have been ramping up and there is actually a lot going on. First we just launched our first Financial Management Special Interest Group being moderated by Brian Hufford. It is free to AGD members, you just need to sign up and we will provide access to tools, advice and counsel to help with the financial managment aspects of your practice.

Second, AGD just announced our first practice managment conference this fall in Las Vegas. It is very reasonably priced for members and should be very practically focused and designed to give participants tools to use in their offices.

There is more to....webinars, annual meeting courses, etc. Go to AGD's website and click on the Practice Management tab on the top middle of the page or paste this into your browser.

Practice management is an area AGD members told us they need help in. The data from our market research could not have been more clear. I hope we are acting on that need and adding value to your membership. Let us know what you need and we will do our best to get it to you.

Thanks for the platfrom to "self promote AGD".

And another Woo Hoo Firday!

Chuck Macfarlane
Executive Director, AGD

Patient Activator said...

New patients who go MIA after one appointment can really drive you crazy. Sending a follow up letter to these one-timers is a good idea. A better one is to automatically email every patient – old and new -- a customer satisfaction survey after their appointment. That way you can monitor your office's performance in real time and quickly identify any issues that are preventing return visits.

Anonymous said...

Dude, it's almost like you're falling on your sword - trying to provide the most thorough services when in a time when most are just seeking good enough.. It would seem that in doing something thoroughly sends the message to patients that you are expensive. I think that patients in this day just want the bottom line on their conditions. My np exam is 40 minutes with xrays which usually is a pan and 2 bws unless we can get them from the previous dentist to save them some cash and radiation. We chart the usual and I think the patient senses that we are thorough without being expensive. It's a weird one I agree - patients need to know they're being taken care of without being soaked and the bigger the initial visit is, the worse they think it's going to get. I often watch stuff that will need work shortly or within the year or so just to gain the confidence of the patient in that I'm not the money grabber. It plants the seed but the work gets done anyway. We can't change the world - I just went to buy a ceiling fan for my really hot townhouse today (I am recently divorced) and the guy found out I was a dentist and said I could afford it if the 10 percent factory rebate wasn't approved. I calmly sat through a 1 minute litany of how he hated dentists (his immediate customer) - and refrained through gritted teeth from a reply - and then politely asked his name and then walked out. We can't win in the world so we just have to adjust our ideals to meet the world's demands. Godspeed there.G

Unix said...

First I want to say is that I really like your blog. I also admire your style and personal integrity. Although we have never met, from your blog I get the impression that you are a dentist of great integrity who will go to a great length to put your patients benefit first. As a patient, I do really like that.

Like the previous commenter, I believe that many of your patients probably didn't come back because they were looking for a less thorough (and cheap) dentist.

I have never been to your office; I don't even live on the same continent, so it would be very impractical for me to be your patient. Again, this is by no means a review of you or your office because we have never met; Fort Lauderdale is probably the closest I have ever been to your office.

From reading your blog I also get the impression that you and I have quite different views when it comes to dentistry. It's quite possible that even if I lived nearby, I wouldn't want to be your patient and I think it goes both ways; most likely you wouldn't want to be my dentist either. Now, this probably sounds horribly arrogant since you are a dentist and I am not. Shouldn't I change my views to be more in line with yours?

Well, my answer is that there are (extreme) dentists out there whose views are quite close to mine and I prefer to go to them.

For all my faults as a patient I also have a couple of positive qualities:
- I always pay my dental bills on time
- I have never complained about the price

As a patient I have certain requirements and expectations on someone who is aspiring to be my dentist. These include CEREC, cast gold inlays/inlays/crowns, and willingness to discuss pros and cons of different treatment options at great length and detail.

I have had seven composite fillings in my posterior teeth. All of them have failed after a relatively short period of time. They were placed by five different dentists. The one that was longest in my mouth was there for four years, and given the amount of caries under the filling (visible only on X-ray), I think you cannot argue that it would have had as many as four years of good service.

I gave composites not only one chance but seven chances with five different operators and it failed on me, this is the reality that I live in. Anyone who wants to be my dentist must make this part of his/her reality too, totally regardless of the fact that they might have been placing composite fillings like crazy for many years and only had a small number of known failures. After all, there could very well be patient specific reasons why fillings are failing, such as diet, clinching/grinding of teeth, bite, bacteria population, karma, etc.

Those two composites that managed to serve for years (as opposed to mere months) in my mouth had a horrible failure mode, carious lesions under the filling that is only visible on X-ray. Both teeth came close to RCT, one of them became a case of pulp exposure. I also had a quick series of four composites in a fractured tooth, which ended up to be a failed RCT, failed resection and then finally an implant.

I have decided that all of my fillings are going to be either cast gold or CEREC. BTW, when I am looking at the price of a filling, I am thinking mostly of the cost divided by the number of years it can be expected to last and how much the RCT, resection, extraction, and implant will be in terms of money, pain and annoyance when the filling has failed and the subsequent RCT fails.

My point was not really about cast gold or CEREC. I am not arguing that patients are abandoning your office because you don't have a CEREC machine. I know that I am an extreme patient. My point was that some patients (like me) will have weird requirements, or just have a different view of dentistry.

Unlike me, many patients probably have a "cheap" view of dentistry. They are struggling economically and they just want a cheap quick exam and they can't afford the X-rays.

gatordmd said...


I want to say how I appreciate your comments.

I know you have been through the gambit of dental work and you feel like you have a pretty good understanding of restorations.

Let me educate you (I hope I don't sound like I am talking down to you, because I am not) on what there is out there to fill a tooth.

A dentist has a hole they are going to fill. What are his options?

Lets talk about the hole. If you don't get all the decay out first, it doesn't matter how the restoration is made it is going to fail.
But lets say the hole is free of decay...It can be filled with a direct restoration, that is something that is put in right then and there (we are talking about a composite resin, amalgam, gold foil or some sort of temporary material) or an indirect restoration, that is made either by a machine or at a laboratory then is cemented in, we are talking a gold, porcelain or a CEREC restoration.
But since you brought it up, lets talk about resin fillings vs CEREC.
There is a couple of things you have to do to a tooth that prepares it for a restoration. Both indirect and direct are the same.
You prepare the tooth for a composite filling the same way you do a CEREC.
Usually with a fourth generation bonding agent. You are etching the tooth with phosphoric acid for about 15 sec. You are priming the tooth and then bonding the tooth.
These products should be the best. If they are the best it is going to go a long way to making either restoration be successful.
Now when you put in a direct composite resin filling you put the resin right on top of the bonding agent, cure it and WHAM you have a filling.
Now when you are doing a CEREC you have a piece of block porcelain
it doesn't just lay in there. You have to chemically bond it to the tooth.
Well the interface between the prepared tooth and the block of porcelain is cement.
Well guess what the cement is made out of?
Composite resin.
So underneath a CEREC restoration is the same material that is used for a filling.

So I hope I didn't make your head spin but....

Do you want to continue this conversation?
This one was on the house.
Since you say you never complain about price, the next one will be very expensive.
Just kidding.

Write anytime,

Ps. I have, off the top of my head 6 patients that live in other countries than the US.

Anonymous said...

John you have to accept the fact that once the pt goes out the door you cannot control whether they will be back or not. I will refer to to the Serenity prayer. I live by that and it is my motto. Why beat yourself up over something you cannot control.

Unix said...

I actually knew that CEREC fillings are cemented with composite materials that are similar or even identical to those that composite restorations are made of.

However, I believe that there is a huge difference between using a material as a cement vs making a restoration out of it and I think it's not limited to dentistry.

My two cast gold onlays are also cemented, I think it's with zinc phosphate. Would I like to have an onlay made out of zinc phosphate?

No. It could perhaps work really well as a temporary but as a permanent restoration I suspect that it would most likely be a disaster compared to a gold onlay that is cemented with the same material.

This is not to say that I am huge believer in CEREC and the composite cementing of them; there is a reason that my two biggest and deepest cavities are restored with gold, not CEREC. My thinking is that CEREC is sort of OK for not so deep cavities. Regarding the use of composite cement in CEREC restorations, my biggest worry is its biological properties.

When it comes to composite restorations, I suspect that the material isn't mechanically strong enough for my mouth. A related issue is that they shrink when they are being cured.

Now, when the composite cement of a CEREC restoration is being cured, it will of course shrink too. I believe that the severity of the potential shrinking problem is quite closely related to the total volume of composite material. Thus, I believe that the potential for mechanical stress from shrinking tend to be larger for a large restoration than for a small one.

When used as cement, the total volume of composite material will be orders of magnitude less than when it's used to make up a restoration and so too will the potential for mechanical stress from shrinkage.

I have seen that there are composite restoration advocates who claim to have various solutions to manage the shrinkage problem. Am I going to let them try their magic on my teeth?

No. Sometimes, there has to be a line in the sand and for me that line is already crossed a long time ago when it comes to composite restorations. I will let this one pass and wait until there will be scientific studies that shows the survival rates in posterior teeth (for example after 10, 20 and 40 years) of the latest and greatest composites compared to CEREC, and cast gold.

However, scientific studies are no better than the people who make them. I think that there will always be an element of marketing, ideology, and religion when it comes to materials for dental restoration. At the end of the day, I think it comes down to what you believe in. Personally, I just don't believe in composite resin as material for restorations for myself.

Do I think that cast gold restorations are perfect?

No, but I don't really know anything that possibly could be more predictable either. We live in an imperfect world. The best thing would be to not get any decay or cracks in the teeth but once you got that, what can you do?

BTW, I hope that I am not coming off as being wealthy. I am not; I am just someone who has spent money on dental restorations instead of buying a nice car. I see a lot of people who drive quite expensive cars complain that they can't afford good dental work. I just happen to have reversed priorities compared to them.

gatordmd said...

No you don't appear to be wealthy.
You do appear to be very educated on materials and teeth.
I commend you for that.
But you are finding is, on a very small scale, what brings most of us dentists to the window sill of a very tall building.
Nothing in dentistry is easy. Nothing works all the time. There is no perfect material (although gold is close).
And that is just fillings.
Kids get decay under sealants.
Pulpotomies fail.
There is no perfect routine for oral hygiene that will make some people not get perio disease.
And it goes on and on.

So thank you for entering into our world for a bit. It ain't easy.
I appreciate the dialogue.

Talk to you later,


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