Can we talk candidly?

Jan. 1, 2004
A close look at the working relationships between dental hygienists and dentists.

by Dianne D. Glasscoe, RDH, BS

Dr. Tom and Karen, RDH, have worked together for more than 20 years. They seem to have a wonderful working relationship. Karen says she can't imagine working with anyone else, and Dr. Tom expresses his appreciation for Karen's work and dedication.

In contrast, Dr. Tom has a good friend, Bill, who practices down the street. Dr. Bill, has employed nine different hygienists over a period of 11 years. What is the reason for this turnover? Was it a string of "bad luck?"

Tammy, RDH, has been fired from two different hygiene positions. Was she also unlucky, or is there an ongoing problem with her attitude about her work or her interpersonal relationships?

Ideally, the working relationship that exists between the doctor and the dental hygienist should be one of mutual respect, trust, and loyalty. However, what is ideal and what is reality are two different things.

For any workplace environment to be low stress and happy, there must be respect among co-workers. An atmosphere of mutual respect is so vital that it is the absolute foundation upon which everything else rests. In the absence of this foundation of respect, there is unhappiness, resentment, and frustration.

Dentists and dental hygienists have different educational backgrounds. In an atmosphere of respect, each recognizes the gifts and expertise of the other. The ultimate winner is the patient.

The doctor is expected to be the leader in the practice. That role involves creating and maintaining an atmosphere that is conducive to growth, harmonious working relations, and continual learning. In a good working relationship, the hygienist recognizes the doctor as the leader. The doctor sees the dental hygienist as a fellow professional who specializes in preventive care. Additionally, a good leader takes a personal interest in all of the staff members' lives outside the office.

Another key ingredient in an ideal working relationship is loyalty. Loyalty is the "first cousin" of respect. When people are loyal to each other, they focus on the positive attributes of the other and refrain from disparaging remarks that would cause pain or resentment.

Here are some accounts from hygienists with great working relationships. Cathy Seckman, RDH, a frequent author of articles in RDH, recently shared her thoughts about her wonderful working relationship with her doctor/employer, Dr. Jay Reznik.

"My boss is Dr. Jay Reznik, a pediatric dentist in his twenty-fifth year of practice. I've been there four months, and I wish I'd found him 20 years ago," Cathy said. "Our relationship is good because we communicate, we respect each other, and we complement each other.

"I respect him as a clinician, a friend, and an employer. He respects me as a friend, an employee, and a co-worker with rights and responsibilities. He pays me a compliment at least once a week, and he does the same with other employees. I think he makes a conscious effort to do that."

Michelle Jackson, RDH, of Virginia offers another account of a happy working relationship.

"I value my relationship with my employer because he respects me and believes that I do a wonderful job," Michelle said. "Whenever a patient says that they had a good cleaning, he usually says, 'Yes, Michelle is the best.' It is really nice to feel appreciated.

"He also makes sure that we know we are valued by taking us (each staff member) out for their birthday, to a show at a local theater every summer, and, in the winter, he takes us out to a very nice restaurant for a holiday meal. His wife has also pitched in and cared for my daughter so that I could work when my babysitter was not available. Another time, I was very sick but too stubborn to go home. He told me to go home and he moved the patients around immediately for me. It's nice to have someone looking out for your best interests. Dr. St. Louis is really great that way."

Shirley Cross, RDH, from Sugar Land, Texas, related that her employer, Dr. Joe French, has outfitted two operatories and hired a dedicated hygiene assistant so she could practice assisted hygiene. He also bought her loupes and headlight.

"I know that Dr. French appreciates my organizational abilities" Shirley said. "when he really wants to get something scheduled, whether it be CPR or other courses such as Arestin education, he always asks for my assistance.

"Another area that creates goodwill between Dr. French and me is the writing of our quarterly newsletter. By being a valuable asset as a worker and by taking on responsibilities for various courses and the newsletter, this frees Dr. French up to give more time for the things he needs to concentrate on for his patient's treatment and care."

Here is an account from a doctor about his good working relationship with dental hygienists. Dr. Bill Domb of Upland, Calif., offers, "After almost 30 years of practice, I'd have to say the relationships that I have developed with hygienists have been the most professionally satisfying. They have been the face of our practice and the heart. The connections they've built with our patients have been invaluable and have lasted over decades.

"Our hygienists are the main PR centers for our restorative practice as well. Their job is most clearly not just root planing, scaling, and polishing.

"They have had sharp eyes, and a number of patients are free of cancer today because their soft tissue examination caught things early. Our hygienists also have no problem letting us know where things are not looking right restoratively. They definitely do not spend all their time working the soft tissue."

Michelle Hurlbutt, RDH, one of the recent recipients of the Butler/RDH Award of Distinction, works in Dr. Domb's practice.

Another dentist said, "We love all three of our hygienists, and loved the one that we lost to cancer. I can't imagine practicing without them."

The common thread running through all these testimonials is mutual respect and appreciation. Although some respondents expressed aspects of their working relationship that were not exactly ideal, the foundation of respect was evident. Thankfully, many dentists and hygienists enjoy gratifying and congenial working relationships.

Sue Schoenfeld, RDH, lists some factors about her professionally satisfying working relationship:

• The doctor respects my opinion and lets the patient know this too.
• He allows me that time I need to treat each patient and never questions it.
• He encourages continuing education and is always eager for me to share this with him.
• He also understands and is kind in allowing time off for family, vacation, etc.
• He does not hesitate in ordering the equipment and supplies I need to perform my job.
• He is truly a "human being" and treats me as one.

Toxic working relationships

Unfortunately, not every working relationship is ideal. What are some of the factors that lead to unhealthy working relationships between dentists and dental hygienists?

• Doctor does not respect the hygienist, hygienist's schedule, and/or hygienist's abilities.

Some doctors have ego problems. They don't want to accept that hygienists are well educated and have the ability to think and problem-solve. Typically, egotistical doctors disrespect all of their staff members and many of their patients. These same doctors do not consider the hygiene schedule as important as their schedule and give little thought about causing patients or hygienists to wait for unreasonable amounts of time.

However, some hygienists bring disrespect upon themselves by various behaviors, such as consistently arriving late for work; dressing or behaving inappropriately in the office; using foul language; talking on the telephone during patient time; not helping out during downtime; not being a team player; or making unreasonable demands.

• Hygienist does not respect the doctor.

Here are some of the reasons that hygienists disrespect the doctor:

• Doctor is unethical or immoral.
• Doctor is demeaning to hygienist.
• Doctor places more emphasis on quantity over quality.
• Doctor does not follow through on promises made.

• Doctor cannot see the value of what the hygienist brings to the practice.

Some doctors do not understand the value of high quality preventive care and choose to look at everything the hygienist does as a "prophy." They prefer to do their own hygiene (rather than employ a hygienist) and place hygiene patients in the second column as "filler" appointments, never stopping to consider how much dentistry could be generated from hygiene, how much time the doctor is spending doing services that could be performed by a hygienist, and the quality of care the patient is receiving.

• Hygienist has poor work ethics and/or has an inflated view of himself/herself.

Doctors are not the only ones with big egos. Further, all hygienists are not created equally. Some hygienists have wonderful work ethics and take their jobs seriously. These hygienists are willing to do anything they can to help out their co-workers and seem to have a good concept of "team." Others have assumed a "queen bee" persona. These hygienists feel that any tasks outside their personal operatory are "not in my job description."

During downtime, queen bees will retreat to the staff lounge and conduct personal telephone calls or read a magazine, even if the sterilization area is piled high with dirty instruments. They never offer to help another staff member, but they are quick to complain when they feel someone is not pulling their share of the work load. Other staff members resent hygienists who carry "prima donna" attitudes. These attitudes are bad for the hygienist and the profession of dental hygiene in general.

• Doctor refuses to purchase instruments or other supplies needed by the hygienist.

Dental hygiene is hard work! Attempting to scale tenacious calculus deposits with worn out instruments leads to physical damage, frustration and burnout to the clinician. When hygienists are forced to work under "pseudo-poverty" conditions, it often leads to disrespect for the doctor.

Where is it all going to end?

Somewhere along the line, we lost our focus. What should our focus be? The patient, of course! What is best for our patients should be the overriding factor in all dentist/hygienist relationships. These questions deserve honest answers:

• Do our patients receive the best care possible in an environment of hostility and mistrust between care providers?

• Do our patients receive better care from lesser trained individuals?

• How can the two professions put their hostilities in the past and retrain their focus on providing high quality patient care?

A final word

A fellow speaker and writer, Dr. Greg Psaltis, says that the dental practice can be likened to a physical body, and staff members make up the parts. The business assistants are the mouth and ears of the practice, being the first to interface with patients and hearing their needs expressed. The clinical assistants are the hands and feet, performing a myriad of duties and guiding the smooth flow of patients in and out of treatment. The hygienists are the eyes, because their extensive training allows them to see and identify oral conditions that point the doctor to immediate and future dental needs the patient may have. The doctor is the soul and brain of the practice, being the leader and making treatment decisions based on advanced skill gained through education.

In short, we need each other!

If dentists and dental hygienists would work together in an atmosphere of mutual respect and recognize each possesses a particular expertise gained through quality education and practice, the relationship between dentists and hygienists would be healed.

If hygienists understood that the dental practice is a business that must be operated under certain time and monetary constraints to be profitable; and if doctors focused more on high quality care for the patient and creating an atmosphere that is nurturing to the staff members, the chasm that now exists would be closed.

If doctors praised their staff members more and if hygienists would be the ultimate team players and professionals, our patients would benefit by being the ultimate focus of our efforts.

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 Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515 or email dglasscoe@north Visit her Web site at www.professionalden

When respect is present ...

From Susan Perez, RDH:

"I feel I have an exceptionally good relationship with my boss. I started doing dentistry 30 years ago and have traveled and worked for at least 100 different dentists in my career. I have finally found a great boss and we work together very well and do the same brand of dentistry. He is a great boss and a very nice man. He has even brought a massage therapist into the office for all of us. He is a very humble person and recently went to Bolivia to do mission work — or rather, pull teeth at high altitude. One more thing: I think is pretty unique and worth sharing is that he provides health insurance, profit sharing, paid holidays and vacation, and a very reasonable salary. "

From Dr. Howard Elson:

"I am immensely grateful for what my hygienists do for our patients, me, and our practice. In a pedo practice, the responsibilities of a hygienist are a little different, I think, than in perio or general practice. While technical skill is, of course, important, social and psychological skill is even more critical. Our hygienists acclimate and ease our child patients into the flow of the office seamlessly.

"They are almost always the first contact that the child has. By the time they are done talking, talking, talking — and, of course, doing, doing, doing — they are usually eager to meet the hygienist's friend, Dr. Elson. From the tiniest infant with natal teeth, to the most sullen of teenagers to the most nervous of moms, our hygienists are terrific at making them all as comfortable and at ease about the dental experience as possible.

"At staff reviews and meetings and even in casual conversation, they will often bring up how much they appreciate the autonomy and responsibility they have, and I appreciate it too. That style is deliberate. I need my staff to be as good at what they do as I am at what I do.

"I am very grateful and appreciative of what our hygienists accomplish and couldn't practice without them."

When respect is not present ...From a doctor in California:"My story is one of a bad dentist/hygienist relationship. When I bought my practice from a retiring dentist in 1990, I hired a hygienist who had just graduated from hygiene school. She was offered 50 percent commission on cleanings and X-rays."She accepted the offer. If one of her patients failed to show up, she considered it the receptionist's duty to try to fill any holes in her schedule while she went back into the break room and read a magazine. It wouldn't matter how busy or backed up I was with patients. My assistant could have a pile of instruments needing to be sterilized, and rooms that needed to be cleaned and set up. The hygienist would just sit in the break room if her patient didn't show and say, 'I was trained and hired to do hygiene, not assisting or reception work.' Hygienists like this are very bad for the morale and work attitude of the rest of the staff."From a hygienist:"I feel like I have gone over and above what other hygienists would do for the practice. At this time, I accept the fact that I will not receive any benefits, bonuses, or even a thank-you from him as an employer."From a hygienist: "The doctor I work with never gives me a kind word and even acts like he is mad at me sometimes. I have no idea why. He is often sullen and moody and has said demeaning things to me. I haven't had a raise in two years, and I'd leave this practice if I could find another job close by. But I stick it out and work in this unhappy place because I have bills to pay."How politics encroaches on attempts to be supportive

Over the past two decades, a growing hostility has emerged between organized dentistry and organized dental hygiene. The focus of this hostility is primarily over "turf" that each profession claims. The main battlefields have been supervision of hygienists, administration of local anesthesia, and self-regulation issues. Dentists have fought vigorously in some states to prevent hygienists from administering local anesthesia, while other states have allowed this for many years. Currently, 32 states allow hygienists to give local anesthesia, and each year a couple more states come on board.

Most states have some form of indirect supervision, but there are still several states where hygienists are required to practice under direct supervision of dentists.

However, the single issue that has caused the most friction is over dentists attempting to degrade educational standards for dental hygienists in various states to allow for preceptor training. While some doctors claim alternative training programs are needed because of a shortage of available hygienists, the supply does not appear to be the overriding issue.

For example, North Carolina has 12 dental hygiene programs in place, with two more set to open in the near future. It is a fact that some (if not many) of the recent graduates have been unable to find jobs (the real shortage is a shortage of dentists). Yet, talk of establishing preceptor programs continues to rumble in the background, causing mistrust and friction between dentists and hygienists there. The real issue is not a labor shortage, but rather cheap labor.

In many states, dental boards have given duties to assistants that were typically hygiene duties, such as placing sealants and polishing. Indeed, the only duties that hygienists perform that assistants cannot perform (except in Kansas and Alabama) is scaling and probing. Hygienists have been forced to fight to protect the educational standards that are currently in place to keep the profession strong and viable. These fights are typically against organized dentistry, which has more members and more money.

These battles take an emotional toll and leave scars that linger for many years. The hostility in the dentist/hygienist relationship extends beyond simply "getting along at work."