Prevent an awkward situation: Hygienists should be careful when doctors dismiss suspicious lesion

By Eileen Morrissey, RDH, MS

At my recent continuing education presentation, “Go ahead: Stick your tongue out at me,” I posed the following scenario to the hygienists who were present: “You are a clinical hygienist in a dental practice. You provide a traditional oral cancer screening to your recare patient, and observe an area on the lateral border of the tongue that concerns you.”

Your practice does not have an advanced, oral cancer screening technology available. You document the location, size, and description of the lesion in your chart notes. You mention to your patient that there is an area that you would like the doctor to see. You show it to the patient. You feel 100% certain that this finding justifies a referral to an oral surgeon for a potential biopsy - at the very least, a look-see by the specialist. At this point, you are stating simply to the patient that you want your GP to check it.

Your doctor comes in for the exam and you bring the lesion on the tongue to his attention. Shocker! He tells the patient: “We will watch this, and recheck it when you return in six months for your exam and cleaning. If you feel anything, or notice it changing in any way, please let us know immediately.”

What!?! I asked the hygienists at the seminar how they would handle such a situation. Three raised their hands and offered the following:

• The first stated that, once the doctor left the room, she would convey more urgency to the patient: Have it looked at by the oral surgeon sooner rather than later. She would use the phrase, “It cannot hurt to get a second opinion, and it is better to be safe than sorry.” This hygienist also added that she would not be working much longer for any doctor who would not refer for such a lesion.
• The second hygienist stated that she would use the verbiage, “In my opinion, you should have this area examined by the specialist…” I challenged her further, pretending to be the patient, who is now concerned by the hygienist’s reaction, yet conflicted by the doctor’s response. “But Dr. S said we could wait and watch it. No offense, but he is a dentist and has more education and experience than you do!” The hygienist held her ground, and reiterated once again: “In my opinion, you should have this examined by the specialist.”
• The third hygienist adamantly agreed with the other two, and added how important it is to fully document all details, including the general dentist’s decision to wait six months before checking the lesion again. She emphasized that, in her office, intraoral camera photographs would be included.

What I neglected to ask these hygienists was: Would they include their recommendations for their oral surgical referral in the chart notes when in direct opposition to what their employer had specified?

I posed this question to some of my colleagues. Two had experienced this very situation. Both made the decision to discuss further with the patients once the doctor left, and, ascertained that upon additional dialogue, that the patients did not wish to wait. One of the dental hygienists scheduled a return to the general office for another look in two weeks; the other immediately provided the referral cards for the oral surgeon. Each documented that the patients did not wish to wait hence follow-up would happen sooner. One hygienist felt so strongly about the urgency that she went so far as to say: “If this were in my mouth, I would not wait to have it looked at.” Her intent was to prompt that patient to act sooner.

I wanted a dentist’s perspective, so I asked my teaching colleague, Dr. Marshall Alter what he would do if he found out that his hygienist had “overridden his opinion” under these circumstances?

Dr. Alter’s response was, “If the hygienist is the one who tells me, I would be a little annoyed, but appreciative that my hygienist is looking out for my patient’s well-being. If I heard about it through the grapevine, I would be even more annoyed at my hygienist because he or she did not have the guts to say anything to me about it.”

Dr. Alter would prefer that his dental hygienist follow him out of the room to speak with him privately about her concern, and request that he return to scrutinize the area more carefully.

Another dentist who prefers anonymity had an altogether different response. He told me that his hygienist would be fired immediately if she undermined his findings by communicating as such with the patient. For one, he errs always on the side of caution with regard to potential pathology, and believes he has instilled that in his dental hygienists. To have his trusted doctor/patient relationship be challenged because of what his hygienist thinks she sees would not be acceptable.

One powerful suggestion from Linda Hirce, RDH, in Colorado, is that before we find ourselves in a potentially uncomfortable, scenario such as this one, we should proactively bring this article to our doctors and ask he or she how we might handle this should it arise? What an excellent idea! Onward we go; it is in our hearts’ core. RDH

EILEEN MORRISSEY, RDH, MS, is a practicing clinician, speaker, and writer. She is an adjunct dental hygiene faculty member at Rowan College at Burlington County. Eileen offers CE forums to doctors, hygienists, and their teams. Reach her at [email protected] or 609-259-8008. Visit her website at www.eileenmorrissey.com.