Spring 2000 Editorial:

At staff meetings, a typical concern was the need for additional appointment space on our calendar. Apparently we had not scheduled any deband appointments for five weeks. The coordinators wanted to know if the doctors could come in an extra halfday. At the same time, in the doctors’ meeting we were discussing how to arrange our schedules so that doctors could take three-month sabbaticals.

These issues may seem far-fetched to you if you are in solo practice. But our need for additional doctor time might resonate for those solo practitioners interested in cutting their work week, for example, from 4 days to 3.5 days.

A few years ago, after careful planning and about 12 months’ of lead-time. we introduced the sabbatical and, simultaneously, came up with some good ideas for reducing doctor time in the schedule. We were able to take a practice requiring two doctors four days per week and made it possible for one doctor to run the practice for six weeks on his own, working 4.5 days per week.

Changes That Made Sabbaticals Possible, While Increasing Appointment Hours

Increased appointment intervals — We increased the interval between patient visits from four to six weeks. Before the change, we saw 70 patients per day for eight doctor days (two doctors, four days/week, or 2,240 patients every four weeks). When doctor days were reduced to 4.5 and the appointment interval increased to six weeks, we could see 1,890 patients. But, we still had to find room for 350 patients.

Treatment efficiency — We analyzed the treatment records of our deband patients using the following criteria: the number of appointments to treat, estimated vs. actual treatment time, missed appointments, proper time to start treatment, number of band/bonding appointments, progression and kinds of the archwires, appliance prescriptions, and use of removable appliances. Based on our analysis, we made these changes in treatment protocols:

• Delay starting permanent dentition treatment until the second molars are 50% erupted.
• Place as much of the appliance at the beginning of treatment as possible and avoid placing appliances in stages.
• Introduce prescription changes to eliminate the most common adjustments. We now use three prescription options.
• Band molars and second bicuspids to provide level marginal ridges and fewer bond failures.
• Use square archwires to offer the greatest range and least slot play. The first archwire is 175x175 heat activated. The final archwire is 175x175 SS.
• Consolidate all repositioning of bands and brackets into one appointment about six months into treatment. (We use x-rays to evaluate root positions prior to that repositioning appointment.)
• Identify three treatment phases: 1) Appliance perfection (including resets), 2) Work (bite opening, arch coordination, and space closing), and 3) Detail — we monitor progress through each phase.
• Limit Phase I treatments to those that provide significant benefit.

Treatment beyond estimated completion date — Each month our appointment coordinator generated a computer list of all patients being treated beyond our estimated completion date. We reviewed the treatment records, and made decisions such as whether to have a progress consultation.We also looked at progress records to review treatment goals and plans, and to determine if we should see the patient in three-week intervals.

Post-Treatment recall protocol — We had been using removable upper and lower retainers, but determined that doctor time could be reduced if we cemented lower 3-3 bonded retainers and used upper slipcover retainers.

It became apparent that we were seeing our retention patients too often. Using a new protocol, after the pre-deband appointment, we post a letter to the family to explain the deband, the retainers, and the final records. We also ask for family feedback and if there are any concerns about the braces coming off. After retainer delivery, we schedule the next visit in eight weeks in order to check the retainers. The next check is in six months, and the final check follows 12 months later. At this point the patient is moved to an on-call status (the patient calls us if there is a problem). The dentist receives a letter advising of the change to on-call status and the presence of the cemented retainer. We explain to the patient that they must wear the bonded retainer until college graduation, at which time they should return to have it removed.

During the sabbatical, we limit post-treatment recall visits. In most cases, it made no difference whether the patient was seen a month earlier or two months later.

Pre-treatment recall — We were also seeing the pre-treatment recall patients too often and changed to seeing these patients on a 12- or 18-month recall schedule when appropriate.

During the sabbatical period, we scheduled only those pre-treatment recalls who were ready to progress into diagnostic records.

Eliminate uncooperative patients — Some patients simply won’t cooperate, which poses real risks to treatment and to the health of a patient’s dentition and supporting tissues. We decided to confront these patients with an ultimatum: either improve or transfer out of our practice. For this, we follow the AAO guidelines. Of the 12 patients notififed, two transferred from our practice. We also advised patients with chronically delinquent accounts that we could no longer continue treatment. Of the 10 patients so advised, four left the practice or had their appliances removed. Those who stuck with us became much better patients. Those who left our practice hopefully got off to a new start with an improved outlook on their treatment.

Add an assistant — On typical clinic days, two clinical assistants and one doctor would see 60 patients. We increased the appointments to 80 patients and added a clinical assistant on certain days. In California, a clinical assistant may perform basic procedures, remove and replace arches, fit bands, and remove appliances.

Increase fees — We were worried that when one partner was on sabbatical, the practice would suffer financially, so we raised our fees modestly.

Many of these changes took place 18 months before the sabbatical. Each partner was able to leave for a three-month period during consecutive summers. The patients did not notice the absence, and the practice actually experienced an increase in income. Upon return, the partners went to a three-day workweek.

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