Joshua Frenkel, MD, MPH: As a younger ophthalmologist who’s only a handful of years out of training, I’m always trying to be more efficient in clinic. This was especially true at a point of time when I was moving to a new practice. At my previous practice, I was primarily in a surgical role. Since joining Evergreen Eye Center, it has become more of a combination of surgical and clinical.

In residency, they don’t necessarily teach you how to be efficient. You see your patients, and no one really focuses on how long it takes. You just need to get the work done.

In a private practice setting, efficiency in the clinic is crucial in an age of reductions in reimbursements and increasing overheads. So, Dr. Tester, with 20 years of experience in the clinic helping to steer a successful practice that’s grown a lot, I thought you’d be the perfect person to dispense some pearls.

Robert Tester, MD: Thanks, Josh. Yes, it’s been 20 years with Evergreen Eye Center. Efficiency is on the mind of everyone in private practice for several reasons, not the least of which is declining reimbursements. But also I think those who are drawn to ophthalmology to begin with have that competitive personality and want to do efficient work. No one wants to waste their time. So if you’re going be putting in the hours, you may as well be making them productive hours.

JF: Dr. Tester, over the years I bet you’ve found several things that work really well, and you’ve probably also found some things that don’t work very well when it comes to efficiency.

RT: I had my very first exposure to ophthalmology with the late and great Dr. Alan Crandall at the University of Utah. He is highly renowned as one of the best eye surgeons in our lifetimes. In addition, he was super efficient. In the mid-90s, he was doing about 60 cases in a day between him and his fellows. On postop day one, they had this deal with the hospital where they would block off part of the parking lot for his postops, valet park everybody and bring them in. He was doing things that were really outside of the box, and it was pretty cool to see someone working at the top of his game like that.

As I became a med student at the University of Utah, I worked with Dr. Crandall’s technicians, and we would talk about how efficient he was and try to figure out how he did it. Some would say, it’s like he has some sort of Jedi mind power where he’ll walk in the room and 60 seconds later walk out of the room with the patient who would say, “I love my doctor. He spends so much time with me.” I remember thinking through this, and it planted the seed in my mind that there are tactics here, that how you interact with the patient can leave the impression that you spend more time with them than you do.

And, on the flip side of the coin, the converse must also be true — if you’re doing the opposite things, then you can spend as much time as you want with the patient, but they’re never going to feel like it’s enough.

Once I entered private practice, the issue of efficiency became very important again. I started to talk to colleagues about it and became conscious about my dialogue in the room. And over the time we figured out some strategies to increase efficiency. For example, eye contact is so important. If you’re typing on your computer and not looking at your patient while you’re talking to them, they don’t feel like communication is happening.

That’s why a scribe becomes very important. If you’re talking to your patient and your scribe is sitting behind you logging everything that’s happening, that facilitates better face-to-face discussion.

Some of it is also the tone and cadence of your speech. I developed this mantra of “move fast and talk slow.” Say you’re 10 minutes behind schedule and trying to catch up. Even if you’re moving quickly through clinic, as soon as you sit in front of your patients and slow down the talk, that gives them the impression that you’re taking your time with them, even though you’re moving quickly and preparing the tray for the next injection, for example.

JF: Scribes are one of those things that everyone knows is helpful, but you don’t always think about why and how to actually maximize the benefit of a scribe. When I don’t have a scribe, I’m exponentially slower in the clinic.

Focusing on things like eye contact, cadence of speech and basically getting more efficiency out of your interaction with the patient so that the patient’s more satisfied, it’s really a win-win. And it’s something that is easier to forget as we get more and more computer bound. I certainly can be guilty of staring at my tablet. When I look back on my encounters with patients some may think, gosh this doctor’s not really paying attention to me. Like you said, that can really draw out your appointment because a lot of these patients just want to feel like they have your attention.

This is a luxury that we don’t always have these days, but it’s more efficient to be a little bit overstaffed than to try to be too lean. Your clinic’s going to be much more efficient, I think for that hourly wage, you’re actually going to make that money back, and much more so.

RT: Yes, I look forward to the point where we can get to that stage again. Staffing’s been the limiting factor here over the last few years ever since COVID.

About 15 years ago, I remember reading an article by Dr. Richard Lindstrom discussing the idea of the “integrated eye-care model,” having a team of subspecialized members who were each working at the peak of their training. The front desk is trained up to do exactly what they need to do, they’re handing it off to a technicians who isn’t just checking pressure and then rooming them for the doctor to do the rest of the work, but rather a technician who is also refracting, doing a good history and all of the required testing. The same can be said for surgery schedulers who can go over the lens options and lens counselors to talk to patients about options for surgery — everyone working at the peak of their training. By the time the patient gets to the doctor, we’re focusing our time on doing those tasks that only the doctor needs to be doing: making the diagnosis, doing the exam and prescribing a treatment program

While it takes an investment to train your team, you’re going to be much more efficient in the long run with that kind of model.

JF: I definitely agree with that. The key with that is to make it so that the MDs only do things that only we can do, and allow others to do everything else to maximize our efficiency of time.

RT: This also goes back to how we speak to patients. For most of us, 70-80% of the patients we see fall within five or six visit types. Being conscious about the dialogue that you use in the room with the patient for each one of those patient types, honing that dialogue, trying something new and figuring out what works and what doesn’t, that to me is really the essence of efficiency.

And it’s helpful sometimes to have others point out where we might have inefficient dialogues. One example: when seeing postops, I was always frustrated with how much time was being sucked up talking about drops. Every patient would pull the drops out of their bag, shake them and ask, “Is this going to last?” As I complained about this once to my technician, she replied, “Well, the last question you ask every patient is ‘Do you have any questions about your drops?’” So I was unknowingly programming that inefficient dialogue to happen at each visit. Going forward, I made sure that the technicians went over the drops with the patient before I got into my room and stopped asking about the drops in the room, and my day was much easier from there on out.

JF: I was just talking to one of our colleagues about coming into the room and asking the patients, “How are you doing today?” You want to be warm and personable, but by asking this simple question the conversation might go toward a lot of non-related problems. You need to keep the conversation a little bit more focused. To keep that human connection, when I’m heading out of the room, I’ll say, ”It’s really great seeing you” along with a handshake or some sort of a physical connection while obviously being respectful.

This is an example of what not to do, but sometimes I find myself asking patients if they have a question about their condition. By keeping things too open ended, they will often get off track with answers. I’ve realized I need to be more focused in my questions, so I’ve started by saying, “I see it looks like you’re having trouble with this and that,” specific things that keep it a little bit more directed.

Another example is with questions about finances. Rob, I stole this from you, that when they ask, “How much is this option for cataract surgery? Can you get me in soon?” I respond, “I focus on the surgeries, and we have really excellent coordinators who know all about that, and they know a lot better than me and will contact you within two business days.”

RT: We’re kind of sponges; we learn from our colleagues. Over the years, I’ve always tried to pick the brains of colleagues and ask them to give me their cataract spiel or their glaucoma suspect spiel for new patient. I’ve learned a lot from people who have really honed that process. I don’t like to reinvent the wheel, so if I can adopt dialogue from someone who’s doing it better, that’s going to save a lot of time.

JF: We can also find ways to use technology to improve efficiency. One recent example in our clinic has involved improvements to the patient education process, particularly about lens options. There are many platforms out there, but we’ve been using Rendia, which is a service that has a variety of educational videos you can show patients before we see them. So it starts the education process, gives them some ideas when it comes to the basics, like explaining not only the rudimentary steps of cataract survey but also detailing the difference between a “basic” lens and an “advanced” lens. This is helpful to prime the pump for the patient, getting them into the mindset that there are options above and beyond just insurance.

That’s one way to not only improve efficiency, but hopefully improve a premium lens conversions as well. It’s pretty early for us since implementing this service, but I have seen an uptick as far as patient knowledge when I start the conversation with them, which is always really helpful.

We’ve also started the process of implementing Clearwave, which is an intelligent online scheduling tool. So, if a patient schedules a cataract evaluation online, it will shuttle them into a cataract time slots within the provider’s templates, not just blindly schedule everybody for a variety of appointment types throughout the day, which also helps us to remain efficient. It also features online check-in, which should help with some of our staffing issues as our front desk staff is overloaded, while also decreasing patient wait times.

Another thing that can have a major impact on efficiency is your EMR. As someone who’s changed practices, I’ve worked with a few different EMR systems. When I got to Evergreen, we had just switched to a more desktop based EMR vs a tablet-based EMR. And our efficiency slowed down.

For example, I might be examining the patient and during the exam I need to check what the patient’s vision was at their last visit, so I go to the desktop and see. Then I check their pressure, which is doing well today, but what was it last time? I need to go back to the desktop and do three or four clicks more to look it up. Then I want to show the patient her imaging. Rather than show on my iPad, she needs to get out of her chair to see it on my desktop screen. And just all those sorts of things.

Not only was it killing my efficiency, but it hurt our staff’s efficiency and negatively impacted our morale. With a tablet-based system, they used to fill out the patient’s HPI on the tablet and ask them questions while walking them back to the testing area from the lobby. When they were tethered to a desktop, they had to wait.

So we actually switched back to a tablet-based EMR system, which has really boosted our patient flow and efficiency.

RT: EMR is always going to be a double-edged sword, right? Right now, we’re on the EMR that I hate the least of any we’ve tried. It’s very good at some things, and not so good at others. I’m not so sure we’re any quicker now than we used to be with paper charts.

But having been through four EMR changes in the last decade, I can definitely say that some are better than others and having the right EMR can make a huge difference in your daily productivity in clinic.

JF: I wasn’t practicing back then, but we have a lot more hoops we have to jump through as far as like billing and insurance and the like, which equates to all of this extra work on EMR. We do all these extra steps, and so trying to find efficiencies within that can be a challenge. There are things we have to do to get reimbursed properly, and the fewer clicks for these steps, the better. All of those extra clicks might not feel like a lot for one patient. It might be just a few minutes, but a few minutes adds up.

We talk about this a lot with turnover after surgery. Turnover that is 2 minutes shorter doesn’t sound like a big deal for one patient, but with 25 patients, that’s almost a whole hour. Imagine a clinic where you have 40 patients or more. One extra minute per patient is 40 extra minutes, which makes a huge difference and can lead to negative reviews as well.

Thank you so much, Dr. Tester, for sharing from your wealth of knowledge and experience.

RT: It was my pleasure, Dr. Frenkel. OM

JOSHUA FRENKEL, MD, MPH, is a fellowship-trained anterior segment specialist and currently practices at Evergreen Eye Center in Seattle, Wash. He specializes in cataract and refractive surgery as well as microinvasive glaucoma surgery. Email him at joshua.frenkel@gmail.com.

Robert Tester, MD, completed his medical school training at the University of Utah and residency at the Kellogg Eye Center in Ann Arbor, Mich. He is the co-president of Evergreen Eye Centers in Seattle, Wash., where he has been practicing nearly 20 years. He is a comprehensive ophthalmologist specializing in high-tech cataract surgery and medical retina. The authors reported no relevant financial disclosures.