Ep. 262: Five Reasons Dentists Don’t Delegate (and How to Fix it)
Are you spending your day doing work that someone else on your team could handle? Jeff explains why dentists get trapped doing everything themselves and how better delegation can free you up to focus on your patients and running the business.
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Have a question for Jeff?
Fill out the form and he will get back to you.
Why does Jeff say a doctor doing their own hygiene after 10 years in practice is a red flag?
In a well-run GP practice with steady new patient flow and decent retention, hygiene demand grows naturally over time, to the point where a single doctor's schedule mathematically can't absorb it. If a doctor is still doing tasks like hygiene a decade in, it usually means delegation broke down somewhere, not that the practice never grew enough to need help.
What are the three "hats" Jeff says every doctor-owner has to wear?
The executive hat is concerned with the business overall: growth, planning, profitability, and whether customers are being taken care of. The doctor hat is delivering excellent clinical care to the patient in front of you, while also making sure the whole patient base is cared for. The sales hat is explaining treatment in a way that makes patients want to move forward with it.
Why does Jeff say "I can't find anybody" usually isn't the real reason a doctor is doing a job themselves?
He argues that hygienists and other staff can almost always be found by adjusting pay to match current market rates, posting where people are actually looking, or recruiting from a nearby city if the local pool is thin. Treating it as impossible usually means the practice is undervaluing the position, not that no one is out there to hire.
Why does Jeff say doctors shouldn't use "I can't afford it" as a reason to keep doing lower-value tasks themselves?
If a doctor's time producing dentistry is worth hundreds of dollars an hour, it doesn't make financial sense to spend that time on a task, like filing insurance, that could be paid to someone else at a fraction of the cost. Jeff says this becomes a slippery slope where doctors take on more and more lower-value work and end up worse off financially, not better.
What does Jeff mean by doctors "undervaluing themselves," and how does he say it happens?
Productive people often struggle to objectively state what their time is actually worth, so they end up doing tasks they'd never tolerate an associate doctor doing, because there's no guaranteed per diem to make the cost visible to themselves. Jeff also points to doctors who learned bad habits at a chain or DSO, where the doctor did everything, without ever seeing the books to know whether that model was actually profitable.
Episode Transcript
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I was talking to Sabri the other day, who, if you've been listening to the podcast for any length of time, you'll know has been on a number of episodes. If you don't know Sabri, she's in charge of all of our technical delivery here at MGE, and she's also our Deputy Chief Operating Officer. We're also married, which is why we talk a lot.
We'd just had one of our monthly Sales and Communication Seminars. If you want to know more about those, I'll put a link on the episode webpage, that's my shameless plug for the episode. But basically, when someone signs up for MGE, this is usually one of the first services they come to, and it's usually the first time we actually meet a client face to face.
So Sabri and I were discussing some of the scenarios she'd run into with newer clients she'd met with that weekend. The funny thing was, beyond the usual issues you'd expect with a new client, overhead problems, profitability problems, case acceptance, staff, and so on, one thread kept coming up, and it's been coming up more and more over the past two years: the doctor-owner doing tasks and jobs that, strictly speaking, aren't doctor jobs. They're jobs that should be handled by another team member.
Now, it's not like we'd never heard this before, someone filing their own insurance or whatever. But in the past it was much more of an outlier than the norm, and it's rapidly becoming the norm. When you're talking to a dentist who's doing their own hygiene, and they've been in practice for 10 years, not a new doctor with a brand-new practice, but a practice that's been around a decade, that's a red flag from a business perspective. We used to see this once in a while. Now we're seeing it at an uncomfortable level of frequency.
Normally when you see something like this, you'd expect everyone's situation to be different, with their own unique reason for doing it. But that's not really the case. It usually comes back to one, or a combination, of five basic reasons. You might think, "Well, Jeff, what's the big deal, maybe they like filing insurance or doing their own hygiene." Here's the problem: if this is you, and you're doing things you should be having others do, you've essentially put a stopper in your ability to scale or expand your practice and increase profitability. You've also limited your practice's long-term ability to properly take care of and service your patient base.
So for this week's episode, I want to dig into this. We'll look at the five common reasons for this lack of delegation, two of which are somewhat hidden but more common than you'd think, and then get to the punchline: how to fix it so your practice can grow properly while still maintaining a high level of patient care and quality. My name is Jeff Blumberg, and I'm your host.
Let's start by looking at the fundamental problem these delegation issues create in your practice, especially if you're a GP. Take a 10,000-foot view of a GP practice for a second. If you're a GP, you do dentistry, you take care of patients, and you also have a hygiene department, or recall. Because of the way that's structured, it's only natural, if you're doing things correctly, that your practice will grow.
Let's say I'm a doctor seeing 30 new patients a month, and I'm losing about 20 percent of them over time, maybe a little more, but let's round to 20 percent, since that's roughly what you'd expect to lose if you're doing things right and your retention is decent. If I'm seeing 30 new patients a month, that's 360 a year, and after 10 years, that's 3,600 patients. If I lost 20 percent of them, that's 720 patients lost, leaving me with 2,880 active patients.
Since I'm seeing those patients on recall at least twice a year, not counting four-month recall or perio maintenance, that's 5,760 recall visits a year. With 52 weeks in a year, and let's say I'm closed two weeks for vacation, that works out to about 115 unique recall patients per week. If I have a four-day-a-week practice and 115 recalls a week, assuming decent retention, that means I need almost 14 and a half days of recall hygiene, which means I'd need to employ three and a half hygienists just to handle recall. And that's not even accounting for soft tissue management, or new patients being seen in hygiene for their initial charting and X-rays before the doctor comes in for the exam. We're talking almost 14 and a half days of hygiene just for recall patients.
So let's say I started my practice with four chairs, plumbed for six, and eventually added the other two. What does that look like 10 years later if I've been doing things right, keeping retention good, patient loss low, and still bringing in 30 new patients a month? I'm going to have three to four hygiene chairs running full time, and two to three doctor chairs available. But here's the problem: how am I supposed to do three and a half exams an hour while still seeing new patients, treating patients, and having time to sell? I'm probably not.
There's an ideal doctor-to-hygiene ratio, usually somewhere between one to 1.5 and one to two. If you have two full-time hygienists and one doctor, you wouldn't want to add a third hygienist, or the doctor loses the ability to spend the time with patients they need to. Go below one to 1.5, or one to one, and there usually isn't enough happening in hygiene to keep the doctor busy. In this scenario, if it were just me, I'd be sitting at one to 3.5, which is a problem. So at some point you bring on an associate, maybe to see kids and emergencies and be on call, or to handle specialized procedures, it doesn't really matter why, that's a whole other episode on expansion. The point I want to make is that if a GP practice is run properly and retention holds, even at just 30 new patients a month, it has no choice but to grow naturally.
If this is you, and you're having trouble filling three days of hygiene, you need a recall reactivation strategy, which I've covered in other episodes. But I wanted you to have a grasp of the numbers here. In a well-run practice, hygiene is growing and the doctor is getting busier. So where would the doctor be most valuable? Obviously, dealing with patients. But as a doctor-owner, there are other things you'd be expected to do too.
As a doctor-owner, you wear three fundamental hats, each with its own deliverable. You have an executive hat, since you own a business, and an executive is concerned with whether the business is taking care of customers, growth, planning, overall business health, and profitability. You have a doctor hat, taking care of the patient in front of you and delivering excellent service at or above the standard of care, bringing them into excellent oral health through treatment. That's part of your doctor hat, but the doctor hat also means making sure that, as a group, all of your patients are being well cared for, not just the one in front of you at any given moment. And then you have a third hat, the sales hat, which is the job of explaining treatment to patients in a way that makes them want it and move forward with it.
So let's say we have a doctor making their own temps for a patient, when they have an assistant who could do it, it's legal in their state under the Dental Practice Act, or at least the assistant could be taught to do it. The doctor might think, "Well, I'm the best at making temps." We had a client years ago, and I asked him how long a single-unit crown prep took in his office, what the schedule looked like for it. He said three hours. I'm not a dentist, so I can't really judge, but I know it doesn't usually take three hours, more like one. He'd spend so much time on the temp, shading it, making it beautiful, that he'd have trouble getting patients back in for the permanent crown.
So you could get into the frame of mind that you're the best at making temps, so you need to be the one making them. Here's the thing: you could approach any task with the belief that nobody's going to do it better than you, and you might be absolutely right. You could apply that to an office manager too: "Nobody's going to close a patient better than me on a large treatment plan," or as the doctor, "Nobody can do this procedure better than me." You might be right, since no one else is ever going to do it exactly like you, because they're not you. But the real question, as you grow, is whether you can get other people to do some of these things at an acceptable level of quality, one you'd be comfortable having done to you.
You can sit in that doctor mindset of "I'm the best, so I need to do this," but you also need to step back into the overall doctor perspective and think about ensuring all of your patients are cared for. That's a time question, there are things only you can do, and things others could do, especially as you acquire more patients. From an executive perspective, you need to look at it as building an organization that can properly care for all of these patients as you scale, at the same or higher level of quality as when you were small.
As I go through the reasons we find behind poor delegation, you'll notice most of them come down to thinking from the wrong hat, or, and I don't mean this negatively, not properly wearing your executive hat. You might not even realize you have one, or you just don't enjoy that part of the job. But if you own the business, you're an executive whether you like it or not.
So let's look at the major reasons we see for lack of delegation. The first one: you can't find anybody. There's nobody available in your area to do it. You hear this a lot with hygiene specifically. Here's where you have to look at it from perspective: if you have a new practice starting from scratch with 50 patients, fine, do your own hygiene. But if you have 2,000 patients, you should never be doing your own hygiene. Never.
You might say, "Well, I can't find a hygienist." That's not actually true, you can always find one. Part of what happens, especially as costs rise, is we get stuck in the frame of mind that something is too expensive, without tracking how much costs have genuinely changed over time. When I was a kid, having a million dollars was an unbelievable amount of money. Now it's more like, okay, that's fine. Inflation changes your perspective. So what you have to do is compare the value of having a hygienist to what you're actually paying for one, relative to your own value to the practice.
If a doctor's value to the practice, when producing, is $500 or $1,000 an hour, why would you have them doing dental hygiene when you could hire a hygienist for $40, $50, or $60 an hour? That doesn't make financial sense, and that's assuming the doctor is doing something related to actually being a doctor in the first place. If instead they're off filing insurance claims rather than doing hygiene, well, I'd rather you were doing hygiene at that point, though ideally you'd be doing neither.
You can talk yourself into believing you can't find anybody, but it's simply not true, you can absolutely find people. Start local, look at what's posted on Indeed, see what people are actually paying, you might be offering too little, I've seen that happen plenty of times. Or look outside your immediate city. If you're practicing in the Tampa Bay area, for example, you just need a hygienist licensed in the state of Florida, so you could advertise in Miami, where there are more hygienists and they tend to be less expensive than in Tampa. There are different ways to solve this, but if you immediately default to "I just can't find one," you're already sunk, and you end up doing something that actively damages your business, since your time has more value applied elsewhere.
Then there's the one we touched on already: "I can't find someone who does it the way I do it." If you're making temps when a dental assistant is legally capable of making them, or could be taught to be clinically capable of it, it's worth investing that bit of time, because you could be spending it on something more valuable to your practice and your patients instead, especially during clinical hours: talking with another patient, treating another patient, seeing someone sooner, seeing more patients in a day. We want you focused on being the doctor.
The next one we hear a lot is, "I can't afford somebody, I can't afford the help." This is part of the problem a lot of practitioners are facing today, largely because of where fees are now, especially for practitioners heavily in network, which is a whole other episode you should go listen to. I understand the concern. But if you're already being paid less than you should be, and you could be applying yourself to procedures where that time is actually well spent, why would you apply yourself instead to a position you could pay someone far less to do?
In other words, if I'm getting $880 for a crown instead of my private fee of $1,400, why would I go file insurance claims, something I could pay someone $30 an hour to do, instead of doing that $880 crown? It becomes a slippery slope, because then you find yourself doing more and more of this kind of work, and you get yourself into trouble. Finances should never be the actual reason. I've had people tell me, "I can't afford to hire a hygienist right now," and then when you look at how much hygiene they actually have on the schedule, and they've only been in practice six months, I get it, they don't have enough patients yet. But you could probably afford one day of hygiene a week. The idea is that when you're freed up, you're not sitting around scrolling the internet, you're doing something productive to build the practice, or seeing a patient.
Then we get to the two reasons you don't hear about as often. The first is undervaluing yourself. This one relates to the last reason a bit. People, especially very productive people, have a hard time objectively saying "I'm worth X," because it's difficult to look at yourself objectively. If you hired an associate doctor, and that associate was doing things you wouldn't expect an associate to do, like sterilization, that would bother you, because you're guaranteeing them, say, $800 a day when you could pay an assistant $20 an hour to handle sterilization instead. It's the same principle applied to yourself. You have to step back and think, "Okay, I own the business, sure, and I understand that sometimes, in moments of real urgency, you have to do things that wouldn't normally be part of your role, but it shouldn't be a regular occurrence.
If you look at yourself objectively, you'll recognize, "I'm a doctor, capable of doing X, Y, and Z," and you wouldn't point yourself at tasks outside that, because it's a waste of the business's money. That's the key difference: you have to pay an associate their guaranteed rate, but you don't have to pay yourself, so it's easy to justify. But why would you treat yourself that way? People get stuck in a frame of mind where they can't objectively assess their own value, worried that acknowledging it makes them sound arrogant or too self-assured. I wouldn't worry about that. Look at yourself and your capabilities, and figure out the smartest use of your time, without feeling bad about it. You have the doctorate, you have the capability, you should be applying yourself to the things that actually fit under your wheelhouse.
Which brings us to the next reason, one Sabri and I found kind of unique and funny, and one we're seeing more and more: you're doing things in your practice today simply because that's how you learned to do it. Out of school, you went to work for somebody, maybe a doctor who wasn't great at running a practice, or you went to work for a chain. In a chain, the doctor does hygiene, the doctor does temps, it's high volume, triple-booked because they're on every plan under the sun, and you're not really doing anything related to sales or the other business side of things. You just assume that's how a dental practice runs.
Then you go into private practice, try to apply those same lessons, and find it doesn't run very well. Here's the problem: when you were working for that chain or DSO, you never got to look at their books. How profitable were they, really? From what I've seen, and I won't name names, a lot of these corporate practices, when I've had insight into their finances, aren't actually very profitable. Private practices tend to be far more profitable. The corporate model survives mostly through outside investment and economy of scale: if you have 50 offices, you get a better deal from suppliers, labs, and so on, you're buying dental software in bulk. You get the idea.
So you weren't looking at their books, just how they ran day to day, and that isn't how you should be running your own business. People learn bad habits in those environments, carry them into private practice, and then wonder why things are going wrong. It's because that model isn't built for a small private practice to survive on.
Really, when it comes to fixing any of these things, it's fairly simple: you just have to figure out which hat the fix belongs to. If you put a crown on me and my bite is off, that's your doctor hat. If your schedule is getting booked out too far in advance because of how the office is organized, that's an executive hat issue, and you should be working with your office manager to sort it out. Whether you like it or not, you have to wear all of these hats. This is why we've done episodes before about people who rush through their clinical hours and want to bolt out the door as fast as possible, you have to build some executive time into your week. If you have an office manager, yes, they're running the practice day to day, but as the owner doctor, you still need to be looking at things on at least a weekly basis, to know what's happening and how you're tracking toward the targets you've set for yourself.
If you can take an honest, objective look at the different areas of your practice and think through the best way to set them up, sometimes it helps to ask yourself, "If someone called me in to fix their office, how would I handle this?" That question usually opens the door to the best solution. And keep in mind, it might not be an overnight fix. If you're currently doing your own hygiene, you're not going to fix that tomorrow. I've done this with clients before: we look at how many charts they have, figure out how much hygiene they're actually doing in a given week, say it comes out to about two days' worth, and then we set a target six to eight weeks out to start booking two specific days of hygiene outside the doctor's own schedule, bringing in a temp hygienist in the meantime if needed. Some of these things take a while to solve, but done right, they eventually go away, freeing you up to focus on what you should actually be doing: those three hats we talked about, sales, being a doctor, and running your business.
I hope this helps. A bit of a shorter episode this week. I've got that link to the Sales and Communication Seminars if you're interested, and if you want to know more about MGE, you can find us online at mgeonline.com, or call us at (800) 640-1140. Have a great week, and we'll see you next episode.