Most vitreoretinal fellows spend their years of training focused on acquiring and honing surgical skills. However, the reality is that once we start practice, the majority of our time will be spent seeing patients in the clinical setting. Learning early how to best manage a busy clinic will save the new vitreoretinal surgeon from early burnout. Managing patient flow, testing, technician support, and the occasional irate patient—all at the same time—can be more difficult than the most challenging surgical case. We asked two efficient and effective clinicians, Kevin Blinder, MD, and Carl Regillo, MD, for their ideas and tips on how to make the vitreoretinal clinical experience satisfying for both patient and physician. -Omesh P. Gupta, MD, MBA; and Anita G. Prasad, MD

WHAT DISTINGUISHES AN EFFICIENTLY RUN CLINIC FROM AN INEFFICIENTLY RUN CLINIC?
Kevin J. Blinder, MD: In thinking about this question, I had to ask myself what do we mean by office efficiency?

Webster defines efficiency as: 1. producing or causing effects or results; and 2. producing results, etc., with the least amount of money or work. (The Pocket Webster for School & Office, Pocket Books, 1990.)

Based on these definitions, an efficient office will produce results, such as the highest level of patient care produced with the least amount of overall work, personnel, and overhead. What distinguishes an efficiently run clinic is more difficult to define. In my opinion, the theoretical equation for this determination would be the number of patients seen, the number of procedures and tests done, and the number of personnel required, divided by the duration of the patient visit. This is a complicated equation to say the least. A waiting room with standing room only vs an empty waiting room is not necessarily an indicator of the level of efficiency. All factors in the equation must be taken into account.

Carl Regillo, MD: An efficiently run clinic is able to process a relatively high number of patients in a given time frame with relatively even patient flow and low waiting times. For a clinic to run efficiently, it not only has to be adequately staffed, but the role of each staff member must be well defined, with everyone having a good understanding of how they fit into the big picture. Essentially, it involves working well as a team with each team member functioning at their highest level of proficiency and no one member of the team—especially the physician—sitting idle for any significant period of time.

HOW DO YOU MAINTAIN PATIENT SATISFACTION WHILE UNDER TIME CONSTRAINTS?
Dr. Blinder: You have to be able to read your patients well and tell which patients require more time discussing their pathology and which ones are OK with just a short explanation. In either case, it is important to have your technician do as much of the basic workup as possible and document the exam. I also have them carry forward prior diagnoses so I do not have as much writing to do. This is the second best thing to actually having scribes. My goals are to spend quality, face-to-face time with the patient so they have my full attention, and to minimize the time that my attention is on the chart. The clock is always ticking, but the trick is to make it appear to the patient that it is not and yet still maintain your level of efficiency. At the end of the visit, I ask the patient if they have any more questions, even if they just finished asking their 100th question.

Dr. Regillo: A patient should be satisfied from an encounter if all questions and issues have been adequately addressed. At no point should anyone interacting with the patient appear rushed or stressed. The patient who feels they have been "pushed through" will never be completely satisfied. In a busy clinic with greater time constraints, it is ideal if everyone involved in the encounter understands why the patient is seeing the physician and what issues must be addressed. It is crucial that the physician makes sure that ultimately all issues are addressed. Even if the clinical problem at hand is not in the domain of the specialist, it must be acknowledged as such, so that the patient knows that a specific issue was neither avoided nor forgotten. For example, if a patient is coming in for follow-up on diabetic retinopathy but also has symptoms related to blepharitis, the latter problem should be addressed in some capacity, even if it is simply to redirect the patient to his primary eye care provider.

Adequate patient education is difficult in a busy clinic setting, but is important to patient satisfaction. It is useful to have easy-to-understand patient education materials to augment what the physician conveys about specific medical problems. Both patient and family members typically appreciate added information they can take home in the form of brochures. Having staff members who are well trained in the patient education process is also useful to reiterate or add to physician counseling.

HOW DO YOU MANAGE AN IRATE PATIENT?
Dr. Blinder: Although I would like to be able to state that none of my patients fall into this category, if you practice long enough you will definitely experience the irate patient. In a busy, hectic day one must remain cognizant of the signs that help identify an irate patient.

Many times, a patient just wants to be heard and to vent a little. For example, if Mrs. Jones had 20/200 macular pucker that has improved to 20/25 postoperatively but she still has complaints of slight metamorphopsia, it is important to be empathetic and control the urge to scream out, "Look in my waiting room at Mr. Smith and his seeing eye dog!" This is the time to let Mrs. Jones speak her mind.

If a patient has a real complaint from an unforeseeable complication, it is crucial to be honest with him and tell him that you tried your best and that you are just as upset as he is with the poor postoperative result. In either case, it is important to spend as much time as the patient wishes to satisfy the patient's desire for your consultation.

I recently had a legitimate complaint of a long wait due to a misplaced chart. I gave the patient and her husband my sincere apologies, told them that there would be no charge for the visit that day, and sat with them to reassure them that this mistake would never occur again. Then I called their home that evening and again apologized for the occurrence. They concluded the conversation by telling me what a wonderful doctor I was. Other options include having the clinic manager call the patient, but in my opinion the physician making that effort goes a longer way to mend the situation.

Dr. Regillo: Empathy and understanding go a long way in handling the irate patient effectively. It will typically require extra time to listen to the issue at hand and then address it accordingly. Getting defensive or dismissing the issue must be avoided. It is best to try to resolve the problem on the spot and not let problems linger beyond the encounter.

For example, if it is a billing problem, have a representative from the billing department speak to the patient, preferably in person. If it is about waiting too long, then it may help to explain to the patient the rather unpredictable nature of patient flow in a retina practice with frequent emergencies that easily disrupt the schedule. Apologies often help and are usually appreciated. Furthermore, with a long wait situation, it may help to make it up to the patient in some way, such as having them schedule any follow-up visit in the early part of the morning to minimize the chances of waiting again.

WHAT QUALITIES AND SKILLS DO YOU LOOK FOR WHEN HIRING TECHNICIANS?
Dr. Blinder: We have two strategies that have evolved over the years for hiring technicians. The first is to hire fully qualified, trained technicians with prior experience, which may be the fastest way to get a new technician in the office and working from day 1. There are distinct disadvantages, however, with this method. First, you will need to offer this technician a higher, more competitive salary to entice him to come work for you. Second, although you are hiring experience, you are also hiring previously learned bad habits and training that may not be up to the level of excellence expected from your employees.

The second method, which I have come to prefer, is to take untrained personnel and train them internally. In this scenario, we will usually hire a secretary/front desk person. We observe their interactions with patients, physicians, and coworkers. If all the above are positive, and the employee would like to advance in the organization, we offer a technician position to the employee. If you have the luxury of not needing the technician immediately, this method has many advantages. First, usually the starting salary is not as high, although you will need to increase it later to stay competitive. Second, you are able to end up with a technician who has been trained to the level that you desire. Third, this provides a mechanism to motivate personnel to advance within the organization.

Dr. Regillo: It is ideal to be able to hire a technician that has had extensive experience with a retina practice. The next best work experience would be an individual who has experience with a general ophthalmic group or with an ophthalmic subspecialty practice. We look for people who have a kind and considerate manner along with a positive, team-oriented attitude.

HOW DO YOU OPTIMIZE TECHNICIAN EFFICIENCY?
Dr. Blinder: There are a few recommendations for optimizing technician efficiency. First, of course, is that technicians should be well trained so that they do not hinder their own efficiency with self-doubt and low self-esteem. Second, they should feel comfortable asking questions, and, to that end, we must take the time to answer their questions in a manner that is neither demeaning nor debasing. An informed and educated technician leads to higher efficiency.

Cross-training is a desirable, but often unattainable, goal of mine. An efficient technician should also be capable of handling patient check-in, scheduling follow-up appointments, and even performing basic fundus photo and optical coherence tomography (OCT) scan captures. We also ask that technicians stagger their breaks so that we do not have a large staff shortage at any one time.

Dr. Regillo: Solid training is key to technician efficiency. Once there is adequate training in a given area, some degree of cross-training should take place. Cross-training is useful in many ways. At the very least, it allows all functions to be covered during such situations as lunch breaks or if a technician is out sick. Cross-training also helps both the technician and the supervisor best assess the technician's potential and strengths. For example, one technician may perform better on a focused activity such as OCT testing, while another technician may be more effective at floating from task to task. Lastly, cross-training can be stimulating and enhance job satisfaction by providing ongoing goals and challenges.

HOW DO YOU MAINTAIN GOOD PATIENT FLOW WHEN ORDERING TESTING AND PERFORMING PROCEDURES?
Dr. Blinder: Tasks that do not require a person with a medical degree are not performed by an MD. Usually, the bottleneck to overall efficiency occurs with the physician. For example, moving patients from lane to lane is a task for a technician. When I am seeing a patient and have decided to obtain an OCT/fluorescein angiography, I call the photographers from my room and have them come take the patient to the shoot room. While I am waiting the short time for the photographer to come to the room, I am finishing up my paperwork and/or explaining the test to the patient. Once the testing is complete, the patient is brought back to the next open room for discussion of the results and treatment plan. We have viewing stations in all the physician lanes. I usually recommend proceeding with treatment that day, which greatly assists patients who may have transportation difficulties. Although this might be seen as a step that would hinder patient flow, it increases physician efficiency overall by negating the necessity of a separate treatment clinic.

Dr. Regillo: For good general flow, it is up to both technician and patient to understand the overall game plan for the encounter. Essentially, it comes down to what to do and where to go. For example, if a patient is returning to an office just for a procedure, that should be recognized upon arrival so that the patient is not incorrectly placed in an examination room. Not recognizing the purpose of the visit not only creates confusion and disrupts patient flow, but it may also contribute to medical errors. Although having an established routine is usually important, it sometimes helps to be flexible and deviate from the routine should certain areas of the clinic become clogged. For example, if it is your routine to examine a patient with wet age-related macular degeneration (AMD) on a course of antivascular endothelial growth factor therapy first and then send the patient for OCT testing, it may sometimes be better to reverse the order and send the patient for the OCT test first while the patient dilates if you are getting behind.

WHAT ARE THE KEY ELEMENTS TO MAKING A CLINIC EFFICIENT? PLEASE ADDRESS THE PROS AND CONS OF A SCRIBE AND DOUBLE/TRIPLE BOOKING PATIENTS.
Dr. Blinder: This is quite a broad question that I will attempt to answer with a few key points. The most important take-home message for developing an efficient clinic is the training of your personnel. The staff needs to know and respond to the physician's needs, wants, and desires and fulfill all expectations. This begins with the secretary who answers the phone and essentially represents your practice to the public. You must establish guidelines for triaging patient calls so that your secretarial/technical staff knows whether a patient should come into the office for an evaluation.

I have a low threshold for patient calls becoming office visits; this is our job and responsibility.

In the ideal world, I would have every employee cross-trained to function in every capacity, and I would have a scribe or alternating scribes for each patient visit. Of course, in the ideal world, we would even get paid for what we do without governmental intervention, but I do not want to go down that road. There are many advantages to having scribes, with the major disadvantage being the increased overhead.

We have many satellite offices, each with its own personality. Some offices run more efficiently than others. Some patient populations need more time for discussion than others. Some offices have a much higher no-show rate than others. All these factors play a role in how you schedule an office. I allow double, even triple booking depending on the office and the patient population. Emergency add-ons come in immediately, but the patient with increased floaters for the last month can come in at the end of the day or the next day. There are other, smaller things, such as preprinted prescription pads, that can certainly save time during a busy day. I think the ultimate in efficiency will come with the transition to electronic medical records (EMRs). Although this transition will most likely require the use of a scribe to initially input much of the information, it will improve efficiency in the long term. Currently, without EMRs, I still dictate a letter on almost every patient visit. On a busy day I save this until the end of the day so as to not disrupt the patient flow. With EMRs, the letter will be generated electronically from the note, saving the physician that extra step.

In summary, our goal in our professional careers is to maintain our level of excellence while maximizing our office efficiency. It is the balance of the two that allows us to function in our roles as retina specialists and still have time left at the end of the day.

Dr. Regillo: As previously mentioned, it is important that the clinic is adequately staffed with well-trained and proficient individuals. If the volume of patients is greater than 40 or 50 in a day, it helps to have a scribe with the physician. Also, at these numbers, proper clinical layout and space become more important for maximizing efficiency. Typically, there must be one to two screening rooms, two examination rooms, two procedure rooms, and a room for remote viewing and/or counseling.

Also important in terms of clinic efficiency is how patients are scheduled. It is useful to identify the types of patient appointments, such as consultation, postoperative visit, routine follow-up visit, follow-up with possible injection, or return visit for a procedure only (eg, laser, injection). Also, for the established patient returning for follow-up of neovascular AMD, knowing the exact type of pharmacotherapuetic that may be needed is important in order to have adequate drug supply for the day. Once the various types of appointments are identified, these appointments can be logically spread out throughout the day. This will help minimize back-ups in diagnostic and treatment areas.

Kevin J. Blinder, MD, is Clinical Associate Professor of Ophthalmology and Visual Sciences, Washington University School of Medicine ad the Barnes Retina Institute, Washington University School of Medicine in St. Louis, MO. He can be reached via e-mail at kjblinder@gmail.com.

Carl Regillo, MD, is Director of Clinical Retina Research at Wills Eye Institute and a Professor of Ophthalmology at Thomas Jefferson University in Philadelphia. Dr. Regillo is a member of the Retina Today Editorial Board. He can be reached via e-mail at cregillo@aol.com.

Omesh P. Gupta, MD, MBA, and Anita G. Prasad, MD, are second-year fellows at Wills Eye Institute. They are both members of the Retina Today Editorial Board. Dr. Gupta may be reached via e-mail at ogupta@hotmail.com; Dr. Prasad may be reached via e-mail at anita.g.prasad@hotmail.com.