‘Doctor, I need a hygiene check!’

The patient in the chair is antsy and ready to leave. You should be greeting your next client. Instead, you're both marking time with small talk, waiting for the doctor to do the hygiene check. It's a recurring problem that needs a solution.

by Janice Hurley

What is a word for something that is both wonderful and a problem at the same time? I couldn't find one ... but I have heard the phrase "necessary evil" used before. Is that what the hygiene exam is? I don't think so! I think it is certainly something more positive than that. I also know that it can be stressful, frustrating, and fraught with anxiety on a regular basis.

In listening to hygienists, I know they frequently think of the hygiene exam in just those terms. Who can blame them? Why is that? Does it always have to be that bad?

I recognize the American Dental Association's assessment that it is the "standard of care" for patients to be examined by their dentists every six months. In most instances, I recommend that this exam should take place during the patient's hygiene appointment. I do not recommend that patients receive a separate appointment in the doctor's schedule unless the patient's condition warrants a more comprehensive exam. The practice of the dentist seeing patients during their hygiene appointment has numerous benefits ... but it also can cause stress and tension for everyone involved.

Who is "everyone?" We're talking about the entire dental team – the doctor, the patient, the hygienist, the assistant, and the administrative staff. Why are they all involved with this problem? It involves all staff members because the doctor is scheduled to be in two places at the same time, and the hygienist has an unforgiving schedule that doesn't have the flexibility to "wait" for that exam. The exam elevates tension for everyone.

The typical office

In the typical office, the doctor is trying to be in both exam rooms, doing what is scheduled, without making anyone wait. He dreads the looks coming from the hygienist who has to leave her room to let the doctor know the patient is ready to be checked. Most dentists would do anything to avoid conflict, but this scenario has no easy solution. Two people need him at the same time. It says so right there on the schedule!

The patient waiting for the exam often feels uncomfortable. Time may elapse between when she thought the doctor would be in for his part of the exam and her prescheduled departure time. Many patients would opt out of the "quick check" if left to their own devices. That's because they get more than their share of small talk or additional home-care instructions when it is clear that the hygienist has finished her portion of the appointment and is now waiting for the doctor.

The hygienist is watching the clock throughout the appointment. She knows when she is supposed to be finished with scaling, where she should be in scheduling the patient's next appointment, and how much time is left to polish and floss. She has control over all of these activities. If she is a talented pro who knows how to make patients feel wonderful – while still keeping them chatting – she is a godsend! And, if it were all up to her, she always would run on time!

The doctor who arrives at the end of the appointment – or well after – creates a great deal of stress for the hygienist who makes every effort to keep on schedule. The hygienist is stressed by the patient still in the chair – and the next patient who arrives on time and is waiting for her. For most offices, that could mean an uncomfortable situation occurring as frequently as 16 to 20 times a day.

The doctor's assistant is on constant standby. She is there to make it all run like clockwork on the restorative side of the practice. She has been scheduled to facilitate maximum production whether her doctor is present or not. She is forever "winging it" in terms of what should be taking place because there are so many variables involved in even the smoothest appointments. Then, add on the hygiene exam. When will the doctor leave? And of equal importance, when will he come back? Double hygiene days? Don't ask!

The administrative staff has a love-hate relationship with the hygiene exam. The hygiene exam often is the source of the doctor's production. The patient coordinator depends on a thorough exam and explanation by the doctor to fill those empty holes in the schedule. She wants the patient to clearly understand why treatment is needed and the value of completing it as soon as possible. But, she needs the doctor to do all of this in the allocated five-to-seven-minutes time. If he doesn't, she, too, watches the clock – along with the patients – and feels the stress as the office runs behind.

What do we do about it?

Start with a staff meeting dedicated to looking at this aspect of your practice. I recommend at least an hour or two so you can involve everyone in the problem-solving. Recognize that it is only a problem in terms of not having enough time to do hygiene checks without affecting the schedule. Try to write down all of the positive aspects of the hygiene exam, as well as the benefit to be gained in conducting this exam in conjunction with the patient's regularly scheduled hygiene appointment.

Here are just some of the benefits of the hygiene exam to the health of the practice.

• The hygiene exam provides information and helps us to monitor the patient's health. The exam helps the doctor diagnose decay and disease in its earliest stages. Many patients would not come in for "just a quick check," but they will come in when it is done in conjunction with their professional cleaning.
• The exam provides a forum for continued contact between the doctor and patients. Patients appreciate seeing their doctor.
• Daily production is generated through the doctor's periodic exams. The average fee is between $25-$30, and it is recorded under the doctor's production for the day.
• Hygiene exams are the strongest contributor to future dental work being scheduled. Estimates are that as much as 70 percent of all scheduled dental work was found during a patient's hygiene exam. Often, the more sophisticated treatment is reviewed and discussed at this time.

Talk about these benefits. Encourage the listing of other advantages as team members contribute their thoughts. The benefits go beyond the four that I have listed. Write down what each team member has to offer. The benefits should be bigger than the drawbacks. Everyone needs to be clear that it is very important to work together to make the system work. We know the office will be more productive overall when this system has been refined.

Some of the most productive team members I have had the pleasure to consult with are those who have worked in several areas of the practice. These team members are productive in the sense of being able to work together with their co-workers to solve problems and resolve issues. In our profession, it is not uncommon for team members to have held several different positions within the same field. This first-hand experience in understanding the challenges of another position is extremely beneficial.

Some examples of valuable experience in other dental positions might include a dentist who had worked as a hygienist, a hygienist who had been an assistant, and a Registered Dental Assistant who had previously performed the duties of a hygiene scheduler, etc. All of these situations exist in numerous offices. They make for the most empathetic team members. Empathy has been defined as the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of someone else. Empathy – true empathy – makes a great foundations on which to build a team.

Empathy is not a team-building panacea by any means, but it provides a good foundation for communicating and problem- solving. When a team member talks about the daily frustrations, at least one other staff member speaks up and says with sincerity, "I know what you mean."

In one office, the following points were agreed upon at a meeting:

1. Individual stressors in the office were acknowledged. The staff then chose to work on those areas that they had some control over.
2. "Unmet expectations" were identified as one valid definition of stress. Staff members talked about what they might expect from each other and how they impacted each other's workday. They acknowledged that running on time was a concern.
3. The other staff members gave positive reinforcement to the hygienist, who consistently ran on time and who was willing to share that the doctor arriving at the end of the appointment was causing her continuous stress.
4. The staff wrote down the factors that contributed to the doctor not arriving on time for hygiene exams, and then tried to switch those negatives into positives.

The final plan was written down and posted in the staff lounge. From that point on, the magic began! The doctor and each member of her team followed through with their part of the plan ... and it worked! The hygienist who was most stressed by the tardiness of the exams was appreciative and took the time to thank the doctor. The doctor was a wise woman who took the compliment graciously and acknowledged the efforts of everyone involved.

The difference was the doctor and her staff were willing to take two hours out of their day for a brainstorming meeting to hammer out the solution – step by step – and each team member then committed to the responsibility of making the hygiene check work the way it should.

Good story – happy ending!

Not every office achieves a happy ending. Most doctors underestimate the toll it takes on the hygienist's spirit and energy when this issue is not given its due. It directly impacts two important areas to staff members – having satisfying work and being appreciated for that effort.

Last week, I was talking with a good friend about life balance. You know, figuring out what makes you personally happy and then structuring your life so you have that balance. She is a hygienist, and an important step for her was choosing to work three days a week instead of four. She told me that the office she dropped had a nice doctor, but she was always waiting for him to do exams. Waiting for the doctor to do exams wasn't the only reason she chose that particular office or day to discontinue, but it was a factor – a strong enough factor for her to mention it to me! Although this might not have been "earth shattering" to this doctor, I was a little sad when I heard her say that. I was sad because I knew it was the type of situation that had the potential for a successful resolution.

I don't know if this doctor ever knew this was a frustration to her. Knowing her as I do, I would be surprised if he hadn't been told several times. But the question still remains – did he hear her? I don't know if he did or not. I only know what a common complaint it is among hygienists everywhere.

Recently, I had a thorough eye exam. The exam was needed because of that "getting 45 and not seeing quite as clearly anymore" situation. I went in and met with the ophthalmologist. The doctor let me know she had met me before. I hadn't a clue as to when or where. I apologized, but acknowledged that I didn't recognize her. She then proceeded to solve the small mystery for me.

I had been a consultant in one of the offices she had worked in as a temporary hygienist. She had been a hygienist for 20 years. She had gone back for a four-year postgraduate degree and was now a practicing ophthalmologist. I congratulated her with all sincerity for achieving a professional goal. At the same time, it registered in my mind that the dental profession had lost another hygienist.

Thinking about her 20 years as a hygienist, I thought about how much she knew about the challenges of hygiene and how I would have enjoyed spending more time with her, learning about her perspective. I thought about how much information she had that I wish I knew. Hands-on experience is priceless!

We never talked about the hygiene exam, but this short conversation did bring me to think about the subject. It got me thinking about all the wonderful offices I have worked with and all the individual methods the doctor and staff designed to solve this challenge of working together on coordinating efforts to get the doctor in to do the hygiene exam on time.

I thought of the time I worked with one large office that included eight operatories – two for the doctors and four for hygiene. The hygienists would put up a small, red flag outside their door when they were ready for the doctor. The idea was that if one of the doctors was moving down the hall, he or one of the dental assistants would recognize their silent call for "help." I remember this system worked the best for the older dentist, who trusted his assistants to tell him where to go. He would start to leave one room and his assistant would guide him to the next. The younger associate did not fare as well. He resisted the assistants "directing" him and the system did not work well with him as a result. I always respected the wisdom of the older doctor for doing what was best for the practice.

I have worked in offices that don't have a light system. This is a real challenge! When production and collection numbers are up, I'm quick to add this particular item to the "office wish list." But even offices with light systems can benefit from the assistants reviewing the schedule and planning optimal exam times. A "morning huddle" with a review of the day helps communication and planning, but you still find the hygienist in many of these offices roaming the halls and leaving "post-it" notes or giving pleading looks to the doctor.

For offices with light systems, a brainstorming session is well worth the time to review just how the system works. You would be surprised at how many misunderstandings there are about how it all works and what each signal means. This is particularly true for hygienists who are not full-time employees. Each office is different – different offices, different systems with different signals. It is a lot for a part-time hygienist to remember.

Some offices work hard to schedule hygiene-exam times into the doctor's schedule. They schedule extra time for the doctor after anesthesia is given. Others have the hygienist give anesthesia to the doctor's restorative patient while the doctor is doing the hygiene exam. In other words, when beneficial, the doctor and hygienist switch places.

This challenge has many resolutions. Each resolution is unique to each team. The important issue is that the problem is addressed and that some type of in-office system has been agreed upon. The system should be one you feel comfortable putting down in writing as one of your "standard operating procedures." This written documentation should provide excellent information for new or substituting staff members.

A husband and wife team hired me recently, and the husband informed me he was "an old dog, not interested in learning new tricks." However, at least he was willing to listen to my information on how challenged his hygienist was in getting him to do his portion of the hygiene exam. Well, "the old dog," who is the best communicator I have ever had the pleasure to work with, has learned one or two new tricks! Now, he does most of his hygiene exams in the same room with the hygienist. He had previously scheduled his patients once a year for a separate visit in his schedule. They both strive to have his part of the exam performed in that "window of opportunity."

Remember, the hygiene exam is just a small aspect of time management that affects every team member. It's not a necessary evil, but more like a challenging opportunity! Fax or phone to let me know how your office handles this one!

What factors contribute to the doctor not arriving on time for his or her portion of the hygiene exam? The following represents one staff's "to do" list at the end of a brainstorming session:

1. Start on time in the morning. The decision was made to arrive 20 minutes before the first patient and finish the morning huddle five minutes before the first patient was scheduled to arrive.
2. The hygiene coordinator was to list all hygiene exams in the computer, so they would be on the computer-generated schedule. This listing was to be reviewed by the assistant well before the actual appointment day arrived.
3. The assistant was to review each week's schedule, one week at a time. The day before the hygiene appointment, the decision should be made on the best time for the doctor to interrupt work being done on a restorative patient to check the hygiene patient. The goal was to try to keep on schedule in performing both restorative and hygiene procedures. The assistants were to mark hygiene exams on the schedule with a big black dot, along with a notation on the optimal time for the exam to take place (in a perfect world, of course!). To quote a well-known saying, "Plan for success and deal with the rest."
4. The hygienist was to take necessary films at the beginning of the appointment and use the light system to let the doctor know when she was ready for her to do her portion of the exam.
5. The doctor committed to performing the exam within the optimal time frame, whenever possible. The "optimal window" usually is the middle 30 minutes of the hygiene appointment time. So, for example, the optimal window for the doctor's check for a patient with an 8 a.m. appointment time would be from 8:15 a.m. to 8:45 a.m.
6. The hygienist was to be ready to hand off the patient to the doctor as soon as she arrived to expedite the transfer of pertinent information.
7. Intraoral photos were to be up on the screen for any unfinished treatment to expedite the doctor's time on the exam. (A picture is worth a thousand words!)
8. The patient coordinator was to make sure she provided adequate time in the schedule for all restorative procedures. This is even more important on days when the time to perform hygiene exams must be factored into the restorative appointment. It also is extremely important on dual hygiene days!

• Provides information and helps monitor the patient's health.
• Provides a forum for continued contact between the doctor and patient.
• Generates daily production for the doctor.
• Identifies future restorative treatment to be scheduled.

Janice E. Hurley is the president of Janice Hurley & Associates, located in Visalia, Calif. She has been a practice-management consultant for 15 years. She has been a featured speaker at dental meetings including the California Dental Association and The Holiday Dental Convention. For more information on her speaking or consulting services, call (559) 635-4843 or fax her at (559) 635-7190.