Staying on schedule

July 1, 2004
No matter what I do, I cannot stay on time! Everyday, I work into my lunch hour by a minimum of 15 minutes (usually more like 25 minutes), and I'm always the last one to leave at the end of the day.

by Dianne Glasscoe

Dear Dianne:

No matter what I do, I cannot stay on time! Everyday, I work into my lunch hour by a minimum of 15 minutes (usually more like 25 minutes), and I'm always the last one to leave at the end of the day. In an 8 a.m. to 5 p.m. day, I see an average of nine to 10 patients. I always have my first patient seated promptly at 8 a.m., but, as the morning wears on, I get more and more behind. Then, after lunch, it's the same story.

The business assistant has mentioned to me that some patients have complained. She also stated that the previous hygienist had no problem staying on schedule. That's just great, but comments like this make me feel like something is wrong with me.

I've only been out of hygiene school a year, and I'm beginning to wonder if I chose the wrong profession. My stress level is over the top, and I'm not sure how much more I can take! Can you offer any wisdom to help me deal with this problem?
Fighting a Losing Battle with the Clock

Dear Fighting:

Just reading your letter made me start to feel that old "stress" knot in my upper back that I remember so well. For me as a hygienist, running behind schedule was the most stressful thing about clinical practice.

My first impression is that you have not learned to pace yourself. This is one of the most difficult aspects of clinical practice for new graduates. Scheduling is very different in the real world when compared to how you saw patients in school. However, a year in practice seems sufficient for a suitable adjustment period.

In my first position as a hygienist fresh out of school, the schedule was arranged so that I saw no more than seven patients per day for the first month. Then I increased the number of patients gradually as my speed increased. I developed a routine and felt reasonably comfortable with nine to 10 patients per day.

Let's explore the major reasons why hygienists have problems staying on schedule.

• Waiting for the doctor

This is the number one complaint from hygienists that I receive. It is a major problem in some practices, especially in practices where the doctor is so heavily scheduled that he or she is literally running from operatory to operatory trying to stay on schedule. In one such practice where I consulted, the doctor told me that checking hygiene was the most stressful part of his day. Consider what it would be like if you had to get up from every patient and go do something else.

Adding to the stress is the fact that many hygienists will use the entire scheduled time for the patient and summon the doctor only when finished with the patient. Doing so will guarantee that you run behind. Few, if any, doctors can check hygiene immediately upon being summoned.

The good news is that, if waiting for the doctor is your major reason for running behind schedule, this is easily remedied. You need to institute an interrupted check. The sequence is:

• Greet and seat the patient
• Update medical history
• Take blood pressure reading
• Do a tour of the mouth
• Take any necessary radiographs
• Summon the doctor

This gives the doctor 20 to 30 minutes to get to your operatory for the exam. Other than a chairside emergency, I know of no valid reason for a doctor to keep a hygienist waiting longer than that.

This requires a bit of compromise for hygienist and doctor in that the hygienist will need to stop immediately when the doctor presents for the exam, and the doctor may have to examine a mouth that is not entirely clean. There will be those times when you finish exactly as the doctor walks in the operatory. In those times, I would compliment the doctor by saying, "Wow, your timing is perfect!" I have always maintained that doctors do not need to check the prophy, but rather for pathology and restorative needs. Hygienists need to be astute and draw the doctor's attention to any such needs that have been identified during the course of the appointment.

The method of summoning the doctor is important. Many offices have buzzer or light systems that may or may not be effective. Some doctors get so accustomed to hearing the beep or buzz that they actually tune it out. Furthermore, for a light system to be effective, it must be positioned where it can be easily seen.

In the absence of an automated system, I prefer that hygienists use an "unobtrusive" method for summoning the doctor. Announcing "I'm ready" or "Mrs. Smith is ready" within the hearing range of the doctor's patient can make that person feel like he or she is not getting the doctor's full attention. Also, the sticky note method is not very desirable, since sticky notes may not stick well and wind up on the floor or elsewhere.

One of my clients came up with an ingenious way to unobtrusively summon the doctor. There are two hygienists, and each one has a different colored clothespin. When hygienist "A" is ready for a hygiene check, she quietly slips the pin on the edge of the doctor's smock. When hygienist "B" is ready, she places her pin just behind the former pin. That also lets the doctor know which hygienist is first. The doctor can't remove the pins until he walks into the operatory to perform the exam. This method is tidy, cheap, and effective. Works great!

• Disorganization

Some hygienists have strong innate organizational skills. It is evident in the way they keep their cabinets neat and orderly and their operatory tidy and uncluttered. Other hygienists do not possess these same natural organizational talents and have to work to keep organized. Disorganization is evidenced by:

• Having to get up and retrieve items during patient time
• Taking excessive time to break down or set up the operatory
• Not keeping the operatory properly stocked
• Not having the appointment proceed in a routine sequence

Disorganization is very common with new graduates. In the early stages of acclimating to the "real world" of clinical hygiene, new hygienists lose time by being indecisive over which instrument to use. Every time the hygienist switches instruments, time is lost. I have observed new hygienists engage in the "pick-it-up, lay-it-down" routine because their clinical skills are not fully developed. Seasoned hygienists do not waste time by switching instruments or wiping excessively.

Maybe you need to work on your organizational skills. Be sure you get to work early enough to get things organized. I particularly like tray systems where all your disposables are retrieved and on a tray ahead of time to cut set-up time. All you have to do is reach in the cabinet and get the next tray. I've watched hygienists during set-up, opening numerous drawers to retrieve items when it would be so much easier if these items were retrieved ahead of time and set up on individual trays.

• Too much socializing

Being the "people" person that I am, I enjoy a bit of socializing with patients. Knowing a little about their lives helps you build a strong rapport with people who look forward to coming to see you. However, as with almost anything, socializing can become excessive to the point of causing clinicians to fall behind schedule. There is nothing wrong with a bit of social chatter as long as it does not cause delays. Keep the social conversation light and informal, and avoid topics that can elicit long diatribes from the patient.

Sometimes excessive socializing comes from the doctor. I've seen doctors tie up the hygiene operatory for endless minutes talking about golf, sporting events, or some such trivia, while the hygienist is anxiously waiting to clear the operatory and get ready for the next patient who has already arrived. Doctors should respect the hygienist's schedule and not tie up the hygiene operatory, taking social conversations elsewhere.

You should also be aware of your doctor's expectations regarding discussions about elective dentistry. Some doctors want you to talk about dentistry, while other doctors prefer to engage the patient only if the patient asks first. If you have an intraoral camera and determine there are restorative/cosmetic needs, you need to pace yourself to allow for those discussions sometime during the appointment.

• Over scheduling

On the surface, the average of nine to 10 patients per day does not seem excessive. However, there are variables that can influence how efficiently you can see that number. These variables include:

• A practice with a predominance of periodontal patients
• Expectations regarding new adult patients and the hygiene department
• Clinician speed.

Hygienists need to be proactive in determining the amount of time needed. Patients are variable in their preventive needs and time required. If, for example, the patient will need bitewings and periodontal probing on the next visit, time should be allotted for that. If the patient has only light calculus and little or no stain, that patient needs less time than another patient with moderate to heavy calculus and/or stain. This is common sense, but too often I see offices that have a standard time allotment for all patients, which does not work well.

Of course, with a dedicated assistant and two operatories, the hygienist can see more patients in less time because certain facets of the appointment are delegated to a qualified assistant, such as operatory tear-down/set-up, sterilization, developing/mounting radiographs, helping with charting, etc. Plus, the hygienist never has to wait on the doctor! When I did assisted hygiene, I saw 12 to 13 patients and was less tired and stressed at day's end than when I saw nine to 10 in a solo model.

In regard to working into the lunch hour and over at the end of the day, what I would suggest is that you engineer the schedule so that the last 20 minutes before lunch and at day's end is unscheduled "flex" time that allows you to catch up. This should help you get out of the office in a more timely manner.

However, none of these suggestions will work if you don't pace yourself. You need to have a keen awareness of the clock and discipline yourself to adhere to the schedule. You need to first determine what is causing you to run behind and then develop a solution. To keep practicing as you are now with maximum stress and frustration will cause physical and emotional burnout.

We live in a busy world, and people do not like to be kept waiting! To most patients, the average "allowable" wait is 10 minutes. At 15 minutes, they get annoyed, and, beyond that, patients can become agitated and downright angry. You certainly do not need to heap more stress on yourself by having to deal with an angry patient!

In a study published in the July 2003 issue of the American Journal of Public Health, it was shown that men become more upset over waiting than women. However, I distinctly remember one of my female patients leaving before treatment after having to wait for about 20 minutes. If your patient has to wait on you for any reason, please apologize when you take that patient back. It is a matter of respecting the patient's time.

The longer you practice, the better you should become at what you do. Practice builds speed and confidence. "One size fits all" solutions will not work here. Step back and try to take an objective look at the problem you've outlined.

Once you've defined the problem and determined its cause, you should be able to work out a solution. Implementing a solution will lower your stress by helping you stay on time, and most importantly, the patients and office staff will be happy.
Warm regards,

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her Web site at