A Conversation About the Experience of Returning to Work
We sat down, virtually these days, of course, to talk with a group of Seattle Study Club members, directors and advisors about the process, experience and surprises they’ve encountered in reopening their practices. The conversation touched on communication tools and strategies, maintaining patient experience when the astronaut gear you’re wearing makes friendly hugs and handshakes improbable, changes to patient flow, and unexpected gifts of mandated quarantine. We ended the conversation by asking each of them to share a piece of advice, trusting you’ll find a tool, approach or philosophy you can implement in your own revised process and delivery of patient care.
Contributors (above, from left to right): Dr Tara Brindis, Dr Jennifer Hirsch Doobrow, Dr Chad Duplantis, Dr Charlie Regalado, Dr Jason Stoner
QWeeks of mandated closure have likely translated into an extensive list of patients eager to see you. How are you handling the backlog—how do you decide who gets to see you first?
TARA — We are currently booked in hygiene for several months and cannot accommodate new hygiene patients. In the beginning, we contacted the patients who were scheduled during the shutdown to cancel all appointments and kept a priority list of these patients. Emergency treatments such as endo and extractions remained on the schedule during the mandate and were treated to prevent patients from seeking emergency room care. Louisiana was able to open April 27 for necessary treatment. We then scheduled urgent fillings, fractured teeth, periodontal treatment and hygiene patients who were willing to come in. About half of the hygiene patients were willing to come in at that point and we offered the openings to patients whose appointments had been cancelled. Most elderly or compromised patients have elected to postpone all visits. Upon opening, we opened up additional days to accommodate the backlog of patients. Many Saturdays and Fridays were opened and our staff put in the overtime and worked many hours. We have opened one additional Saturday per month at this time and a Friday added if we miss another day due to a holiday closure.
CHARLIE — We used the approach of primarily serving those patients who immediately scheduled to see us right before the shutdown. They are triaged based on urgent needs like pain or irritations, then asymptomatic disease I identify as critical to avoid pain or more extensive treatment if not taken care of relatively soon. Of course, we have had to move many patients, but I’m happy to say our patients have been very understanding. So far, it has worked out without much complaint.
JASON — We have been open for more than two months now. As we opened our office, we wanted to immediately connect with our patients. We weren’t sure if people were going to be hesitant to come in or not, so we wanted to connect in order to maintain some idea of what the demand and necessary staff requirements would be the first few weeks. We connected through phone calls, emails and texts to triage patients to let them know we were available for their care and to determine their needs and urgency. It was important to ensure them we were available, as many of the other dental offices, including their general dentist offices, weren’t open yet.
QHow are you communicating your office’s safety plan to assure patients and team members you are taking every precaution?
JENNIFER — We have used Weave, a communication platform, to text, email and call our patients, as well as our social media platforms (Facebook and Instagram) to keep patients aware of everything going on over the past few months. Immediately upon closing March 17, we called every patient scheduled through the month of March to inform them we would be closed through the end-of-the-month. At that time, we were unaware of how long we would have to remain closed. We also immediately increased our use of Weave to provide updated, real-time information, as well as uploaded the same information on Facebook and Instagram. Patients also had my personal cell phone number if they needed us. Throughout our closure, we called/contacted as many of our at-risk patients we could to check in and see how they were doing. So many of our patients thanked us graciously, as many of them had been completely isolated.
The same applied as we have began our process of reopening. We drafted numerous communication pieces to be sent out via Weave and posted on our social media pages, informing everyone when we planned on reopening and all the precautionary measures we would be taking.
Prior to their appointment:
- We call every patient and review a COVID-19 screening questionnaire, as well as review and update their medical history and the appointment plan prior to them arriving to our office (this cuts down significantly on in-office time).
- We inform them to stay in their car and either text or call us upon arriving.
- One of our team members greets them outside, takes their temperature with an infrared, no-touch thermometer, and leads them in (one patient in the waiting room at a time)—and we have an entire protocol once they enter our building.
Our goal is to minimize the time they have to wait in their cars, as well as be in our office!
CHARLIE — Before starting up again, we had a staff training day. The team was amazed at all the thinking put into this. We needed to rethink situations such as how to leave and enter a room and role-play that a bit. I’m incredibly grateful for the Seattle Study Club webinar put on by the Kois Center! That was a big turning point for me. There was no need to reinvent the wheel, and we utilized a lot of their protocol. We sent letters and emails to all our patients detailing our procedures going forward. The added protection of using HOCL and fogging the rooms and clothing was a huge sign of our commitment to patients, and that made a big impact on their assessment of how we were caring for them.
QTell us about patient experience—how has it changed, and what have you done to modify and retain the aspects you really liked?
TARA — We are happy to be back at work and try our best to maintain an optimistic and positive attitude. We want patients to feel welcome and safe in our practice. Our staff is screened before entering the clinic each day. Patients are asked to call upon arrival and stay in their cars. A team member meets them at their car to prescreen, take their temperature, and provide a face mask if they do not have one. When the clinic is ready, they are escorted directly from car to their chair. After treatment they put their mask back on and are escorted to check out. All touchable surfaces are wiped after each patient. Extra time is added to appointments. Clinical staff engage patients about their experiences and well-being of their families during the pandemic to provide comfort and build rapport. This is our intentional effort to maintain the familiar atmosphere patients love about our office. Also, it keeps our schedule from running behind, as patients have always valued not having to wait at our office.
CHAD — First off, we have a virtual waiting room. Our waiting room is completely shut down and patients communicate via text and phone call upon arrival. We then communicate back when it is their turn. We have an in-depth screening process that we communicate prior to and at the appointment time. We take their temperature upon entering. We limit the number of patients in the office. We monitor the office to make sure patients aren’t in close proximity to one another or checking in or out at the same time. We now stagger hygiene appointment times. We give the patients a pen as soon as they enter, and they use that throughout their time here and take it with them. We have gone to virtual intake forms and consents. We offer text-to-pay and have digitized our in-office payment protocols. All these changes are for the better, I believe.
JASON — Our patient experience is a major characteristic of our practice and it cannot change. If anything, it’s been better because patients have had the opportunity to utilize their time more efficiently. For example, we don’t have a waiting room anymore—patients wait in their cars. This gives them the opportunity to work from their cars, peruse the Internet (we have boosted our signal for their use), and such. I would love patients to feel welcome enough to walk right into the office as before, but this isn’t a reality at the moment. The park-and-wait concept may be permanent for us as it reduces traffic flow in our office, allows us to converse on the phone with less concern for people hearing sensitive information, and reduces the overall perception of busyness and noise in the office.
QWhat have patients said about their access to care? Are they happy to have access restored, nervous about seeking care of any kind, or somewhere in between?
JENNIFER — Our patients have been extremely understanding, appreciative and grateful for all the additional precautionary measures we take. We repeatedly hear how grateful they are that we have reopened. Everyone has been extremely understanding of the reasons why we are asking our COVID-19 prescreening questions and that they have to wait in their cars until we contact them.
A few patients have decided to delay returning to our office because they are still not comfortable going out in public, and we are making it as easy as we can for them to reschedule these appointments. We have also seen an outpouring of appreciation, as our office has been the first place many of our patients have stepped into outside of their own homes. One of the interesting challenges we didn’t anticipate is that patients who have not gotten out of their house until now are overly excited to have human contact and want to stay around and talk (possibly more than normal). Same situation on the phone, where it has been somewhat challenging to keep phone conversations short, as several of our patients are just extremely excited to talk about everything! To manage this, we now carefully explain the flow of the appointment during confirmation calls and reiterate that in keeping with current recommendations we will be limiting our in-office appointment time. We still have patients who want to talk, and my team is phenomenal at facilitating these conversations during the allotted time without making patients feel slighted.
An added bonus—this appreciation for human contact and our response has resulted in several referrals since reopening because patients felt we truly went the extra mile.JENNIFER HIRSCH DOOBROW
CHARLIE — Patients are thrilled they can get care again! In talking with them, they consider their dental health important, so reopening has been a pleasure. I’d say more than 95 percent have no qualms about coming to see us, where 5 percent have expressed concern and asked questions about what we are doing to keep safe, or have elected to stay home until more confidence in dealing with the virus is shown nationwide. Overall, it has been a happy reunion, and I’m surprised because I expected many more to decline treatment.
JASON — For many we seem to be the very first place they have visited since quarantine. I was surprised to find patients were very relaxed about coming in. It was almost as if there was no virus to worry about. This made my team feel much more relaxed after two days. I have to admit, given the unfortunate marginalization that dentistry saw throughout the shut down, I thought patients would be very reluctant to come back into the dental offices. Instead, there seemed to be great enthusiasm for having dentistry done, with many patients asking to have treatment the same day as their examination. This has continued over the past six weeks, which has been dominated by more isolated, emergent procedures such as fractured teeth. Case acceptance is at an all-time high.
Helping our general practice teams feel more at ease has been our main priority, as we want to maintain the flow of patients and not catch up in July with nothing to do. Even though dentistry has taken the precautions listed in the guidelines for decades, there is an underlying uneasiness that remains in some offices.
QWith your team wearing all that head-to-toe gear, patients can’t easily connect with the people taking care of them. Comforting them with a simple smile isn’t so simple at the moment, so what are you doing to help make connections?
CHARLIE — We like to make light of it since the patients already know what we look like! We are all in the same boat in a way since patients come in with masks. It has actually formed a unified front among us all, so rather than being an interference, we’ve turned it into a positive thing.
JASON — It seems patients are absolutely satisfied with seeing the precautions we’re taking for their health interests. This has resulted in patients being more open to chitchatting and general conversation, which has built relationships.
We use these precautions and dress as a reason to laugh with patients which makes them feel even more comfortable.JASON STONER
But in general, they are very appreciative of seeing us take these measures.
QMore extensive cleaning before and after each patient impacts patient flow, which means you’re seeing fewer patients per day. That affects the bottom line and probably doesn’t thrill patients who have to wait for an appointment. There are only so many hours a day, so how do you manage this?
JENNIFER — We have really been able to reduce the patient’s time in the office by reviewing their medical history and COVID-19 prescreening form prior to their appointment. Also, for our new patients, we are not only reviewing the above but everything we can related to the chief complaint and reason for referral to our office. My team has been exceptional performing all of the above and it really has helped to reduce the amount of time lost compared to the number of patients we are seeing on any given day.
This has allowed for us not to have to really reduce our appointment numbers per day. Also, we have several operatories, which has allowed for us to space out our patients appropriately. I have a team member cleaning one room so my other clinical team member can go ahead and get their next patient. I would say at about one month after reopening we were about 90-95 percent of our normal capacity for patients and patient flow.
CHAD — It’s easier to manage than one might think. We concentrate on more comprehensive and concise care. We have two doctors, so we delegate appropriately. We also stagger hygiene, which has been huge. Once we got the routine down, our production has increased. Initially, we were operating at 30-35 percent.
Now, I believe that we are at 75-80 percent, and I believe it will get closer and closer to normal as time goes on.CHAD DUPLANTIS
CHARLIE — We have added an extra day to our workweek to accommodate patients, and that has been a big success. We see about the same number of patients per week that way, but again, my office was already used to a lower volume, so nothing seems out of place for us. We do have extra time between patients for sure, however, and sometimes patients have been a bit put out, but a quick explanation of the time we are taking has taken care of that right away.
JASON — We have extended our care hours by half a day per week. Having extra team members has allowed us to turn over and sanitize rooms efficiently and quickly. With the added half day a week we are running at about 90 percent patient flow compared to February and before. The referrals are growing but are not at pre-COVID-19 levels, so I’m not in a hurry to see as many patients as I possibly can, given the guidelines. As I mentioned before, we don’t want to catch up the backlog and have nothing to do, so as the referrals return to normal levels we will slowly go back to regular hours.
QDescribe the first few weeks back in practice—how long were the workdays, what question were you most frequently asked, and what surprised you?
JENNIFER — For the first three weeks we were working Monday through Friday with additional hours (previously we worked Monday through Thursday). The biggest surprise was due to the additional PPE and the entire donning and doffing process we were all exponentially more tired mentally, physically and emotionally at the end of the day. I didn’t realize it for the first couple of days, but wearing the additional PPE was making it extremely hard for me to breathe and I started becoming hypoxic (having headaches, becoming dizzy, etc).
Per recommendations of our Alabama Board of Dental Examiners, I now only wear a Level III surgical mask and a face-shield when checking non-aerosol producing patients. It has helped significantly not to have to wear a N-95 or KN-95 mask all day long.
CHAD — The first few days were shorter, but they felt much longer than usual. We were not seeing hygiene, so the doctors were working split shifts, 8:00 am – 1:00 pm and 1:00 – 6:00 pm with no crossover. We kept extending that, and now we are working from 7:45 am – 6:00 pm. The question I was asked that surprised me was this . . . “Doc, how are you holding up? Is your family OK? Is the business OK?” This surprised me because it was such a selfless question.
CHARLIE — Our individual workday hours stayed the same, but we added an extra day. We run an 8:00 am – 5:00 pm day except for Fridays, where we cut out an hour or two early. Most of the questions from my patients have been questions about how I was doing! That surprised me because it shows the kind of patients I have, that they would be more concerned with me than themselves. My biggest surprise? That the first week, we had many patients over the age of 70, even up to 96, who were eager to come to see us! I expected that number to be near zero. The other big surprise for me has been the ease of working with our enhanced regulations. I got used to the PPE almost within a couple of days and have come to like it in many ways.
The first few days back were a wake up call. Going from basically no work every day to 10 hour workdays with the flip of a switch was shocking to our bodies and minds. I couldn’t believe I had worked that hard previously.JASON STONER
JASON — It certainly has shaped my outlook moving forward. I will take a continuous one month off per year moving forward, at the suggestion of Pat Allen, and for my sanity have restructured my work schedule a bit to add in free time to better strategize. Most common question: What did you do while staying at home?
QHow did you revise the list of services offered? If anyone comes to you for something you’re not currently offering, what do you say and where do you refer them?
JENNIFER — This has not been an issue, as the only restriction we had initially was that hygienists were not able to use ultrasonics for hygiene procedures. We had the hygienist specifically address this with our patients prior to commencing their periodontal maintenance appointments. Most patients were used to having the ultrasonics and often report they feel like their mouth is cleaner with it, so we made sure they understood we were following recommendations from the CDC/OSHA/ADA.
CHARLIE — Of all the services I offer, we’ve elected to keep them all. Since we are an adult practice and our patients almost always come alone and have been well separated in our waiting room since before the pandemic, we feel quite safe about our process. Also, our operatories are walled and separated. Not having the open concept provides a great deal of safety for our patients and us. Therefore, we are proceeding with the same care as we are mainly a restorative practice.
QThe down and dirty question—do you think we need to be providing routine dental hygiene care at this point?
CHAD — Yes! Dentists have practiced utilizing universal precautions for several years. The lack of hygiene will only lead to more periodontal disease and restorative needs. In Texas, we can practice hygiene . . . but no Cavitron unless indicated with a periodontal diagnosis.
CHARLIE — Yes, I definitely wholeheartedly believe dental hygiene is a critical part of overall health, so we provide it! I frequently tell my patients the dental hygienist may be the most important preventive healthcare provider they have. We put a big focus on inflammation and controlling it the best we can. My hygienist is the best there is, and she educates them well, and the first thing I do after greeting the patient is to ask my hygienist about areas of bleeding so we can talk about it. Not only is it our focus, but our patients literally have been begging for their hygiene visits, so it looks like we have made a big impact with all our prior encounters.
JASON — As a periodontist the obvious answer is yes. We’ve already seen deterioration of our patients who missed their cleanings over the stay-at-home order. For anyone to think oral prophylaxis is less-than-critical treatment and doesn’t have the importance of operative or surgical intervention is not acceptable. We spent decades researching the connection between oral and systemic health. To sideline cleanings as being less important throws away the entire concept of this important aspect of systemic health for us all. As Oren Harari would say, this is the pathway to commoditization and marginalizes the importance of dentistry and overall health.
QWhat are you looking for as a sign that someone on your team may be struggling in their return to the workplace, and what do you have in place to address struggles when they occur?
TARA — We have seen staff break down and cry, and excuse themselves from the office several times. Fellow staff pitch in and cross-cover when someone needs a break. One employee was struggling so much that her intention was to leave, but after encouragement decided to stay. Seeing each other struggle and being compassionate is what keeps our team together. The doctors’ doors are always open to listen to these concerns and provide help when needed.
CHARLIE — Happily, we have not had anyone struggle about coming back to work. We ask the standard questions every morning and take and record temperatures. They also know if they come down with any symptoms they are encouraged to stay home. We use a good human resources company as well, so we have forms available to us at all times. Our staff has been very complicit in maintaining disinfection and PPE protocols, so I’m blessed by them.
QInteracting with the world must have you concerned about the impact you may have on your own family’s health and wellness—and then we add concern for your team and your patients. That’s a big load to shoulder. How are you taking care of you?
TARA — It is truly difficult. I have small children at home and a spouse with an immune deficiency. I have only left home for essential business and have not socialized with friends except a few times outdoors at a distance. I have used technology such as FaceTime, Zoom and Houseparty to connect with family and friends. I go outdoors whenever possible. At work, I stay covered up all day from hair to toes. Upon leaving the office I change my clothes and shoes and put them in a plastic bag which goes straight to the washing machine. My shoes are left in the garage and sprayed with disinfectant. When I enter my house, my children run to me and hug my legs which is why I have to ensure they are clean. I wash my face and kiss my husband and feel grateful that I have a job, a roof over my head, and a loving family.
JENNIFER — Great question! Staying mentally, physically and emotionally strong. I have been doing a lot of stuff with the Headspace app (meditation app). What has been awesome is my son is an aspiring golfer, and since the whole COVID-19 situation started we’ve been doing the Headspace app every night together before we go to sleep. I have been doing a lot of Pilates and working out. We spend a lot of time outside, we even try to eat dinner outside every night, just to get fresh air. And I listen to a lot of inspirational and motivational podcasts, like Simon Sinek’s new podcast series. I have also listened to and replayed all of the SSC Thursday night series as I drive to work. Working on as much self-help, self-growth, inspirational, motivational, and leadership programming as I can.
CHAD — Physically, I am in the best shape I have been in for a long time. I took the time off and got to know myself and I grew my relationship with my family. We saved a ton of money and ate at home. Being a man of faith, I believe the layoff was “God’s way of hitting the reset button.”
The time off was needed. The attention to my health was needed. The connection with my family was needed.CHAD DUPLANTIS
We have grown. Our team has grown. Although this sucked financially, I feel we will all be better for it.
QIf you could share one piece of self-care advice with colleagues, what would it be?
TARA — We are all carrying more stress than normal and it is so easy to go down the path of negativity. What helps me most is going outdoors during my lunch break. Taking off my mask to breathe fresh air and feel the sun on my face is a quick fix to boost my mood and recharge my batteries for the afternoon. I find that eating lunch in my parked car allows me to relax because I can maintain control over my immediate environment, rather than being concerned about social distancing. I can open the windows or crank the air conditioning, listen to music, or catch up on the news.
JENNIFER — Understand through adversity comes opportunity! We need to find the light at the end of every tunnel. I know this has been an incredibly challenging time for us all, but we have been given such an amazing gift—the gift of time. It allowed me to home-school my fourth grader, spend time with my spouse, revamp my office manual, work on my website, engage weekly with my SSC members over Zoom, communicate on a different level with my team, teach and participate in numerous webinars, and connect with friends and family in new ways! As tough as this experience has been, we need to realize so many good things can come out of challenging situations. We have to make the most of every moment, make every moment count, as we cannot get that last moment back and life can be extremely short!
CHAD — I have a couple bits of advice:
- Enjoy your family. We are only here for a little while, so make the best of it.
- Find a hobby you enjoy, something that takes your mind off dentistry. For me, this is cycling and fishing.
- Take care of your body, you’ll need it for a while.
- Save as much as you can, because we never know when something like this can change. No matter how good your practice is, we are all prone to disaster in the blink of an eye.
- Take care of your team. If you treat them right and ensure their safety, they will always be there for you.
CHARLIE — My one piece of advice would be to avoid negativity. Let’s face it; these are depressing times. In the midst of an amazing amount of financial suffering and COVID-19 suffering, we have social upheaval. I’ve stopped watching the news and have focused on listening to great music, great podcasts, sermons, and reading helpful things. It’s tough enough to get up and be your best when things are going great, and cutting out the negativity right now is good mental and spiritual health for me and hopefully for others. Just don’t make time for what will bring you down. Prioritize what will strengthen your mind.
JASON — I would encourage my colleagues to have power hygiene days and getting as many patients in as possible to triage and just make them aware you are available to help. My experience, especially the first two weeks of getting back, was that patients whose dentists were not available were looking for a new dentist. Reaching out by email, phone or text would be the first point to start. Power hygiene would provide the opportunity to catch up with patients and diagnose new treatment. Right now, everyone is busy because we have a two-month backlog, but in mid-August this will dissipate if we’re not treatment planning new treatment for our patients. Case acceptance universally seems to be extremely high, so capturing that opportunity is very beneficial right now as well.