PracticalDermatology

Each office and practitioner has their own approach to how they staff, and there is no right or wrong way. I started out with a ‘lean and mean’ mantra, and while I never thought I was particularly draconian, I have evolved my thinking significantly over the years.

Since I have been in practice, my opinion on the size of my nursing and front desk teams has changed significantly. While I have always run a little heavy on the nursing side, my preference toward my patient and staff happiness has led to the point where we are probably overstaffed by some practice metrics, but right-sized for my happiness and the work-life balance of my staff.

Though I am the only physician in my practice, we have two physician assistants, each working four days of 7:30 to 3:30 with a 90-minute lunch break. During those hours, we generally see about 80 to 100 patients on the clinic side, while the study side sees fewer patients. The Pas essentially act like residents, staffing most patients with me while still maintaining a lighter PA-only schedule. If any patients who are on the PA schedules wish to see me, I will see them as well. I see approximately 80% or more of the patients on any given day.

Our nursing staff is now at nine full-time individuals (all RNs) who work 3.5 days a week, generally realizing 32 to 35 hours weekly per nurse. At any given time, there will be nurses who are on maternity leave or some other form of leave, which skews the data somewhat. Two of the nurses are mostly doing nurse calls, lab results, or biologic/med approvals. Nurses act as scribes in the room, although there are some parts of the chart that my PAs and I enter in during the exam.

Procedurally, 95% or more of what my PAs and I do is assisted by a nurse. Additionally, nurses act as Mohs histotechs, doing an average of two cases daily. Nurses take out sutures and anesthetize prior to each procedure. They run certain lasers (tattoo, hair removal, and microneedling as per our state guidelines), but I do all cosmetic injections and any other lasers, which include resurfacing, pigmentation, and vascular lasers, as well as IPL.

On the cosmetic side, we have about 10 to 20 cosmetic patients per day with concerns ranging from neurotoxins and fillers to laser procedures. We employ two full-time patient coordinators who start the consults prior to my entering the room, provide pricing information, answer cosmetic patient phone calls/emails, and call existing patients to get them back in clinic. Our nurses draw up products and ready the trays for cosmetic procedures, but are generally less involved with the cosmetic patients than the patient coordinators.

As for front desk staff, we have three full-time assistants, two on check-in/check-out and one manager who assists with phone calls and billing questions. The manager, as well as our insurance person, go into rooms to go over procedure costs once we have a plan,. They also collect any payment due for procedures prior to the initiation.

We also have a clinic manager, an assistant manager, three full-time aestheticians, and a spa desk manager. The spa functions as its own entity, though the spa desk manager does help with product sales at times.

We also have a clinical trials department with its own dedicated space. The department employs four full-time nurses, which at any given time operates approximately 30 studies. To successfully run a clinical trials department is its own topic entirely, but utmost attention to detail as well as good communication and a steadfast commitment to ethics are all necessary.

We operate on the NexTech EMR system with their practice management/billing function and an overlaid NextPatient for online appointment scheduling and ratings solicitations. This works very well with the NexTech system and, as noted in a previous column, has led to huge improvements in our overall ratings as compared with every other system we used in the past. While other ratings systems got us a good rating from their proprietary and unscientific product, NextPatient works with Google ratings and has increased our rating from 3.2 to 4.7, with over 1,000 reviews.

Prior to these staffing measures we had a much higher turnover rate. At present, we have two 15-year-tenured nurses and five in the half-decade to decade range. Our PAs have worked for us for seven and 26 years, respectively. It is rare for us to have any separation other than those who must move with a spouse. This alone makes us more efficient, as we don’t have to train as often. Were a private equity shop to ever assess our practice, I am sure our staffing model would be deemed corpulent and would be among the first changes to be instituted. Not only would this instantly damage the ethos of our practice, but it would also make for a far worse patient experience. I am sure it decreases our EBITDA, but my staff is second family to myself and several of our longtime patients. It’s so much more enjoyable, and I wouldn’t have it any other way.