Building Efficiency in Your Practice: It's More Than Just Speed!

You're listening to the Phil Klein Dental Podcast. As dentists, we're not only healthcare providers. Many of us are running a business. So we know that in order to succeed, we need to be efficient. And there are certainly many ways we can improve our efficiency in our practice. And we'll be talking about some of those issues today. But typically when we begin our career, we ask more experienced clinicians, how do I get faster? How do I increase my speed in my routine procedures? Our guest today offers his perspective on that question, and we'll also be sharing some basic ways you can become more efficient in your practice of dentistry. So joining us today is Dr. Mitchell Rubenstein. He practices aesthetic and restorative dentistry in New York City. He is the Education Director for the New York County Dental Society and chairs the Technology Committee for the New York State Dental Association. He also serves on the Standards Committee for the ADA. Dr. Rubenstein, welcome to the show. Thank you very much. I appreciate the invite. So we're going to be talking about efficiency principles, and these apply to any business, not just dentistry. Any business that's looking to make a profit certainly wants to have a good product, good services, but they have to optimize efficiency, have systems to do that. Otherwise, their profit margins are going to go down, and there's going to be more headaches, and it just gets tiring after a while not to be efficient. So you've been practicing for a long time, 30 years. What do you think of when you hear the term dental efficiency? Well, thanks for asking that question. And the way you asked the question, I like. We are running a business. You know, sometimes it seems like that's a bad word, but it's okay. We need to be efficient to run our business, but also to treat our patients. Efficiency is not just speed. A lot of people think of it as being how fast you can get something done. You know, after doing this 30 years, I realized if I do something fast and then I have to redo it later, or if the patient is uncomfortable, if they want me to change something, that's... efficient, because then you have to count all the time that you need to fix what you should have done right the first time. So what made you so passionate about teaching others about the value of efficiency? Because you really seem to thrive on that topic, which is, of course, very important. It actually came from going to a lot of CE myself and learning. I go to a lot of meetings. I'm a bit of a CE junkie. And over the years. I learned so much at these meetings and I had these opportunities to meet other people and kind of share some of my, you know, expertise as well. I just began to enjoy that part of the process, too. It came out of, you know, attending a lot of C and wanting to be more of a part of it. So then I began organizing a couple of different types of lectures, mostly for younger dentists, who I enjoy teaching because they don't feel like they know everything yet. And that's how I got into it. With your experience, do you think dentists are generally inefficient in their procedures and methodology and their protocols and their practice? Generally, I think we are for a couple of reasons. I think dentistry is still kind of a cottage industry. A lot of us work either by ourselves in very small groups that don't have a lot of outside feedback of how to improve things. Dentistry is also very systematic. We have to have systems in place to get... done well, which can make it hard to be flexible and change things when an improvement becomes available. You know, like I said, I mean, efficiency being both quality and speed, you know, efficiency links those two things together, links the speed with the quality. And you really don't need to reinvent the wheel because a lot of people will in a CE program tell you, okay, this is the way you have to do the procedure from start to finish. You have to change everything. And usually that's not the most efficient thing to do because then you have to learn a whole new system. I prefer to pick one thing and kind of try and dial that in and then move to something else one thing at a time, like a scientific experiment. So you've taken some heat for saying that as dentists, we make too many clinical decisions based on outdated or erroneous information. Tell us about that. Why did you take heat for that? And what did you mean by that? Yeah, that was in an interview a little while back in an article I wrote in response to the term evidence-based dentistry, which is a very important thing, which is really just this notion that we should be making decisions based on perhaps not impartial, but objective factors. But I found a lot of people were end up becoming like a slave to this evidence-based conundrum where, I mean, you can look at data and Almost any composite manufacturer will show you data showing that their product is the best, but there's more to it than just the data. There is how we work. For example, I'll give you an example. You're talking about what the best thing is to restore a cervical lesion with, and somebody might say direct gold is the best. It's been shown to be the best. In my hands, I doubt it's the best. I did direct gold a couple of times in clinic when I was in dental school in the 90s. And not since then. So I think by whatever data it shows that it's best in my system and in my hands, direct composite is much better performer. And so that's what I say. Morton Amsterdam, I was at Penn. He used to have this saying that every patient is their own research study with an N of one, meaning that you have to modify a little bit of your, you know, a little bit of the data driven aspect to what works for you and for your patients. And I don't think that's a bad thing. That makes us flexible. Yeah, we're both alums of the same school. I graduated Penn Dental School in 85 from endo, 83 from dental school. Okay. You're just a couple of years ahead of me. Just a couple. Yeah. So I just revealed my age and everybody's saying, God, I don't know why. That's okay. I won't tell anybody. Yeah, I don't know why I listen to this old guy on this podcast. What does he know? So listen, well, direct filling gold, if someone's reading something, a peer review article at this point in time on direct filling gold, You know, that's so extreme. That's crazy. That's so outdated. It was an extreme example. I agree. Yeah. So, I mean, you can't compare DFG fillings to composite. Right. Anybody that's still reading that stuff is living in the Stone Age. But it was great for endodontists, by the way. DFGs were great for endodontists, unfortunately, for the patient. So let's talk about rotary instruments. We have burrs and diamonds. That's a pretty big part of what we do on a daily basis in our operatories, right? We need to cut preps, whether it's direct restorations, whether it's indirect restorations. So tell us how you manage your selection of burrs and also just your protocol with rotary instruments. I think of the diamond. The burr or the diamond is, you know, it's in some ways the most important thing that we're using because it's the singular direct link. It's this point of contact between you and your knowledge and the patient's body and the patient's tooth. That's that's where the rubber meets the road, so to speak. I think it's very important to have systems, but also to try new things. It's one of the reasons actually that I like working with microcopy because when I want to try something new. I will some like, for example, a couple of months ago, I had an experience where I decided I wanted to change one of my diamond instruments that I used to prep a crown. I had a few different things I wanted to try. I called them up and they sent me two, I think, of each of the things. I tried one of four different things. To buy a box of each of those would have cost a lot of money, but they made it easy for me to just try new things, which I think is important. The systematic nature of a crown prep. is again, something that can be problematic. if you're resistant to change. A small improvement can make a big difference in your procedures because you spend so much time with the handpiece in your hand. If you can, particularly what I try to teach people to do is to change your burr as infrequently as possible. In other words, set your system so you do everything you can possibly do with one instrument before moving to the next one. Because the burr changes like a pit stop in a race, you know, and they do it when they have to, but... you go in to get the fuel, they also change the tires. They check everything else and make sure everything gets done in that one stop so you don't have to do it again another couple of laps later. We waste a lot of time. And it's not just time, but also you misdirect your attention when you leave the patient to kind of change your instrument. So I focus in teaching crown preps and direct restorative preps in doing as much as you possibly can with each instrument. Now, how many burrs do you typically use for a class two? direct restoration because it's not only changing your burrs the frequency of that you obviously like you said you don't want to keep changing your tires when you're going around the track because you're going to lose um you're going to lose time uh and so when it comes to dentistry even though you mentioned speed is not the only factor in efficiency it does it does help to reduce chair time by limiting the number of times you change your burr so there's several things involved here i assume one is How many different burrs do you need? And tell us about that. And then how sharp are those burrs where you don't have to realize, wait a second, I've sterilized this burr four times. Now I have to change it. So talk to us about that. Oh, yeah. So you use the example of a class two, let's say a simple class two prep. Typically, I'm using two rotary instruments for that, either a 330 or a 557 Fisher burr to remove any. restorative material decay. I use it a different, I use an electric handpiece so I can slow it down to get decay out. And then I use a thin parallel sided diamond. I forgot the number. Microcopy makes it. It's actually almost like a 558, like a, like a Fisher burr, but it's, but it's a diamond coated instrument. And I love that instrument because it can make very precise, you know, very precise changes in the prep, you know, without. dinging or nicking parts of the prep that you want to keep smooth. And as long as there's nothing atypical about the prep, those are the two things I will use. And you mentioned having them sharp. I'm a huge fan of having them as sharp as they possibly can. I'm a big fan of using them only once. Almost any burr, except occasionally maybe a finishing burr that I just touched the tooth with for a couple of seconds, I throw it out after every procedure. I have found that even after You know, once around a tooth for a crown prep, a diamond does not cut anywhere nearly as well as when it first touches the tooth. Also, when you sterilize it, a lot of the gunk that you didn't get out from between the little bits of chopped up tooth structure, it becomes like cement in there between the diamond grains and you never get it out. It generates more heat. It cuts less efficiently. It puts more stress on my turbine. And I actually learned this from microcopy also. I was using other diamonds that were much more expensive. And so I wanted to keep them much longer because they cost a lot of money. I figured cheaper ones would have to be of lesser quality. And I just didn't find that to be the case. I'm able to throw them out now. And again, my assistant knows. She doesn't even ask me. Unless I have used it only for a moment. They just get thrown out and I've never regretted it. I'd like to have that thing just melt through the tooth. Are they designed for single use, those diamonds? So that's a good question. I mean, Microcopy says that their diamonds are meant for single use. They're individually wrapped and sterilized. I like the fact that they only have one type of diamond. They don't make like sometimes I'll see other companies that have a regular one and a disposable one. And then I wonder. what are they leaving out of the disposable one that I'm not getting? And should I really, you know, with the microcopy diamonds, I don't have to think that much. I just see the shape I want and I get it. They're very reasonably priced and I don't have to worry about it too much. The short answer to your question, which I'm making very long, is when I first started using them, I had my assistant give me one or the other brand without me knowing what it was to tell if I could, could I tell the disposable ones from the... regular ones I'd used for years, and I was never, as long as they were brand new, I couldn't tell the difference between them. Now, what about the efficiency of not sterilizing them? How much time and effort does it take to actually sterilize these things and re-inventory them that you're saving all of that, right? Yeah, it's really, it's not something that makes the rounds. The burrs don't come in and out. Often what happens, I see people do, is they'll put the burr back in a burr block and sterilize the whole block. In which case... The burrs that weren't even used went through the autoclave too. And even autoclaving them, that's wear and tear. That's the high pressure steam, the temperature changes. It's not really good for them. So in that sense, my assistant does not have to clean them, which is sit there with a scrub brush trying to get them clean. And they never really get clean. So tell me more ways in your office that you can increase efficiency without losing quality in your practice, besides burrs, materials, anything else. Talk about systems that you have in place that over the years have improved efficiency and you're getting more production out of your day. The most important one is information efficiency. By far, I have a principle that is every person who's going to interact with that patient should know all the information about that patient that needs to be known. What was the last procedure that was done? What happened during that procedure? What is treatment plan for the next visit? What are the patient's preferences? And I've carefully curated an information system for myself where I can have that information. And anybody who enters something about the patient, that information is available everywhere. We don't spend a lot of time trying to figure out what to do. We already know what the plan is when we sit down with a patient. So we're not kind of reinventing the wheel and kind of reinventing the patient's plan. I find a lot of people actually waste a lot of time doing that kind of thing. So you talked about that you curate the information. So tell us what you used to develop this method to curate this information and when do you look at it prior to the patient's visit? So I recently switched my practice entirely to a cloud-based practice management system. There's a few of them. The one I'm using is called Curve, which I'm very happy with. I also am using Pearl's AI software, which helps interpret x-rays and also makes them available everywhere. So if I have a patient who calls me, you know, and I'm walking on the street and they have a question about something, about a prescription or an appointment, as long as I have my phone, I know everything about that patient I would know in my office between Curve and then Perl. And I also am a huge, huge, huge fan of the AI voice dictation software from Bola. And now almost all of my notes and everything I do, I don't sit down and write it or type it. I talk into the computer because I find I think more of my thoughts get more directly into the into the machine that way. So those are some of the ways that I try to minimize losing information in my practice. Okay, so when you first see a patient, you dictate into this AI voice software system, and then it transcribes all your verbal notes. Into a document? Yeah. So each of the software packages that I use will accept this type of voice dictation. Usually what I dictate is sort of a clinical exam, not necessarily a clinical note in the presence of the patient. Sometimes I do, but things like charting. I can voice chart now, which I think is also helpful. Here's an efficiency. The patient hears what I'm saying while I'm saying it into the record. And then once I explain something to them, They've already gotten it a little pre -explained by listening to me talk to my assistant, to my computer, and they, well, gee, why were a few of those pockets fives and sixes and the rest were threes? I mean, even if they don't say it, they're thinking it already. And so when I start to explain, I don't have to reinvent the wheel. When I go in for a hygiene check with my hygienist, she has information already displayed for me. She has... taken some photos. She had all these things that I would need to kind of start from scratch. I don't need to start from scratch. And the patient is getting the information from more than one source, which is very reassuring to them because they don't always know how much they should trust us because we're kind of strange people, dentists. We have these funny clothes and masks and we come in and say, oh, here's what you need. If there's been a process where they have slowly awakened to these things that they need, much, much easier to kind of ease them into the treatment process. And you're talking about being awakened through the hygiene department. Yes. The fact that they have this information on their screen when they're doing their re-care appointments. And do you do this? Do you collaborate with your staff to make sure that they're on the same page as far as communicating this to their patient? Yes, I try very hard. Sometimes it's difficult. A lot of people have been trained to be overly differential to us and not, you know, when... somebody has an observation of something in a patient they think it needs treatment, they might not bring it to me because they might be afraid if I don't agree, I'll say, oh, come on, what are you talking about? That's not a problem. When, in fact, I don't do that, I make it very collaborative and I say something like, oh, yeah, I see what you're talking about there. I'm actually not too worried about that right now because of A, B, and C, but I see what you're saying. I see what you're saying there, and that's a good observation like that. Then you build the process up to your patient. The patient wants to see everybody. functioning properly, not just the doctor. They want to see a system that has their best interests at heart. And if they see that, they will have much greater faith in these really strange things that we're telling them that don't necessarily make a lot of sense to normal people. They have to understand they're being cared for. Self-care is only two words. And one of the words is care. We got to be caring for people. Right. And it takes away that whole feeling of being sold. when you feel like you're being cared for. And if the caring starts in the re-care appointments or continues in the re-care appointments with your dental hygienist and your staff, the assistants, it carries forward to you and they have this feeling of trust and it certainly makes the acceptance rate go way up. So do you think technology is the most important component of efficiency that you've seen in your practice? as you implement this new technology? Is that the main thing that has helped you? That's a good question. I think now it is because technology changes a lot more rapidly than many other things that we use. And so there are opportunities for as technology improves for some of these things to improve for us. Technology also makes it much easier for us to learn new things. For example, you have a podcast. You teach people stuff. Every week, all kinds of different things that 10 years ago or five years ago, people would never have had access to. So in that way, in us understanding what the possibilities are, I think technology is invaluable in getting better. In the office, yes. Things like the cloud, things like the availability of information on the internet, you know, all of those things give us more opportunities, opportunities to get better. Yeah. Let me ask you a question. And I know this is probably not a question we talked about that I might be throwing at you, but teledentistry. Teledentistry is something that some dentists are starting to look at and consider. And, you know, to me, when I first heard about teledentistry, it's like, come on, dentistry, you got to put your hands in the patient's mouth and you need to take an x-ray and you need to look and see and probe and palpate. This is a hands-on deal here with dentists. Teledentistry. What is someone going to do? Stick an iPhone in their mouth and you're going to try to start to make diagnoses. So do you use teledentistry at all? Have you thought about it? I do. It's not a big part of my practice, but it is available. Now, again, I have some technology that can do this in a HIPAA compliant way. I've worked with Brian Herman. He's got a company called Mouthwatch that makes a very nice infrared camera and an extremely complete. tele-dentistry platform. It's one of the things that I use. So here's the thing, right? My first impression was exactly the same as yours, Phil, which was, come on, this is an analog thing. We got to get our fingers wet. We got to, you know, but the fact is people want you available. Just like patients want to go online and make an appointment in your office at three in the morning when they're up and they can't sleep, they want to know that they can get in touch. Now, patients can always call me, but Even though I can't necessarily palpate the vestibular fold, a teledentistry appointment can be, you can see in a patient's face and you can read things from them about the seriousness of their problem that are meaningful. And honestly, it's good for them to be able to see you. Right. Because you're spending some time here and it's a very efficient thing to do because a lot of times you can either tell them we got to get you in ASAP or just let's wait a little while if it doesn't get better call, you know, and you can. quickly deflect things that don't require your immediate attention and focus your actual attention where it is most necessary. So I think it's a good thing. You know, like everything else, it's a tough thing to implement. You have to move it into a system that you already have in place. And that's difficult. I just started making it available to people, you know, when they would call after hours, I would simply have a link and they can click it and they can make an appointment with me to talk virtually. In my office, I have a membership plan where patients can pay a certain amount and they have all their preventative care. And so for those patients, I include that for free. And it's a very nominal cost. I don't want anybody to not call because they're afraid to get insurance. It's a nominal cost. It's really just to make them think about it before they ask for it. And not many people take advantage of it, frankly, but some do. So the nice part about it is if they want to get to a dentist. And they could be a patient of record, maybe not. They can go to your website or any dentist website that has it incorporated into their website technology. And then they could click a button and then probably look at a calendar and pick a time. Not too far out, they could schedule a televisit with you right online. So it's kind of satisfying for them. Yeah, this is something I expect a lot of change and improvement in over the next few years, especially as more and more practice management. options become available that are cloud-based, that aren't linked to a server under your desk gathering dust in your office. That, although people will say, gee, I'm afraid of having all this based on the cloud. What if the internet goes out? And I say, you know, if the internet goes out, you're going to have a lot bigger problems than maybe you don't know who's coming in to see you at nine o'clock in the morning. That is true. And so I think that's going to dramatically increase the safety and security. the variety of teledentistry things available to us. You frequently teach courses aimed at younger dentists, which I think is great. I love working with younger people. I love working with all people, but younger people are just a whole nother exciting passion that you see in younger people. They haven't seen anything yet, so they're open-minded and so forth. What advice do you have for recent graduates who want to improve their speed and clinical efficiency? If you had to give them two things. Because that's the number one thing I think older dentists get asked by younger ones. They always say to me, how do I get faster? I want to get faster. I graduated from dental school. We took two hours to do a one surface amalgam. How do I get faster? I say the same answer all the time. Concentrate on getting better. Concentrate on getting better systems and more reproducible and more reliable that your procedures will go exactly as planned and you will get faster. You can't help. but get faster. Speed comes from, again, efficiency. It's that word I keep using, but it's from having a reliable system. So you don't have to think, what are you going to do? What's the first thing? What's the second thing? You know, and then the speed comes. The other thing is to, I advise younger dentists is to keep doing something I think they're already doing, which is being good at learning new things and not being set in their ways. and asking questions. Guys, you know, our age, let's say, sometimes we'll feel like we're under pressure to know everything because we have gray hair. We've been doing this a while. So to say, gee, I've never seen that before. That's interesting. How do you do that? That's something I hear much more frequently from younger dentists. And I tell them, please don't lose that. There is nobody out there who knows so much that they can't at some point say, wow, that's cool. I've never seen anything like that before. Where could I learn to do that? If you can maintain that attitude, your career will be full of not just productive dentistry and lots of cool procedures, but like a lot of fun and enjoyment. Yeah, absolutely. Well said, well said. As you do, take a lot of CE courses, whether it's online at Viva Learning or anywhere you want to go. We don't want to push everybody to Viva Learning, but we always plug it. Yeah, I mean, it's taking those CE courses and finding a mentor and listening to respected KOLs that you like the way they operate, you like they have integrity. People like you, Dr. Rubenstein, who's really interested in education. I know you're on the Standards Committee for the American Dental Association and you, like I mentioned, you serve on the New York State Dental Association. You're chair of the Technology Committee for Education. So these are all the kind of people, and I'm talking to the audience now, that they should be looking for to reach out to and ask the questions like you just mentioned. And then, you know, you're destined to have a really... Really gratifying and great career. It's a great profession, and we really love having people like you on. Thank you so much for your time, Dr. Rubenstein. No, thank you for the invite, Phil. I really appreciate it, and I really enjoy the podcast. I look forward to continuing to listen to it in the future. Thanks. Thank you.