Part 1:Clinical Complacency: Are you in a rut?

Aug. 1, 2001
How many times have you had the opportunity to have your clinical abilities evaluated since graduation? How would you truly feel about such an assessment?

by Tammy L. Carullo, RDH, PC, PS

How many times have you had the opportunity to have your clinical abilities evaluated since graduation? How would you truly feel about such an assessment? Would you take offense — view it as an inquisition? Or would you take it in stride because patient care supercedes any ego? What if a board examiner was your next patient?

How do you feel when a dentist picks up a scaler after you have just spent what seemed like a lifetime working to remove that rather tenacious calculus? If you are like many hygienists, you would probably take great offense to this action.

Before becoming defensive, answer the following question truthfully: Are you current or complacent? Which would be your response? Many dental hygienists fall into a routine that far too often leads to complacency. For a dental hygienist, seeing patients every 45 minutes, strictly adhering to such a rigid schedule, this issue can soon turn problematic. How does one avoid a rut marked by complacency in the world of dental hygiene?

First things first: We need to check our egos at the door. Before you get into an uproar, I am not referring to all hygienists — only those who the rest of the dental population would classify as prima donnas. Come on, you know who you are! I mean, let's at least be truthful about the situation. There are three main categories of dental professionals who have a direct bearing on the issue of complacency:

  • Those who take pride in what they do
  • Those who really don't care about what they do
  • Those who deem what they do as being so amazing they couldn't possibly have missed any calculus for that dentist to remove anyway!

The first category is the type of hygienist who puts the patient above and beyond all else. They take pride in their career, participate in continuing education because they want to, not because they have to. The second category tends to attend courses because of a state's licensure requirements. But they get little out of the courses, complain a lot, and don't really care if they are outdated and providing misinformation to patients. They are probably filling out Christmas cards rather than paying attention to the lecture. The third category, on the other hand, believes she should be giving the lecture, because there is no one who could possibly know more than she does.

Do I sound a bit harsh when referring to the latter two types? I am. There is no place for either ego in a dental practice. We are professionals. This type of negativity does a great disservice to the patients and the profession.

Let's delve a bit deeper into which category you would place yourself, shall we?

The first group cares about patients, wanting to provide the very best service possible. If a dentist scales after they have, it is accepted for what it is, and the fur on the back of the neck does not stand up. Two sets of eyes are always better than one.

What if the tables were reversed? Let's say you detect what you believe to be a potential decay problem upon a routine examination. When the dentist misses it, you simply and professionally offer a gentle reminder to recheck that area. It has happened to every one of us from time to time. But do you see the dentist getting upset? Well, OK, there are a few. Rarely, though, will quality-oriented dentists get upset about such attention to detail. They may be rather thankful because "to err is human."

Remember, both hygienists and dentists who take pride in what they do, put the patient first, and not allow egos to get in the way are really what this career is all about!

The dental work ethic
Work ethic is a complex subject. Not all hygienists are created equal. Some care an enormous amount, and they are kind, gentle, and nurturing. Some look at hygiene purely as a job, a means to a paycheck. The main concern with the latter mentality — above and beyond the obvious effect on both patient care and teamwork — is that of self-worth. An individual who has a good work ethic will experience less stress both in the dental office as well as during off-hours.

The second category of hygienists listed above, however, sometimes seems to have a work ethic resembling a "bull in the china shop" mentality. Go in, do your job — no matter how mediocre or how painful to the patient — get the paycheck, and then leave for the day. Seldom are they at any job for a great length of time. They tend to be rough on patients, unforgiving to staff, and deeply offended when the dentist picks up a scaler after them. But because they are the epitome of the "I don't care" attitude, they are notorious for leaving behind an unprecedented amount of unfinished work.

This is only one aspect of the negativity. Teamwork is definitely affected. Fellow teammates often are left holding the bag of endless duties that the hygienist simply doesn't deem important enough to do. Beyond all that they do to other members of the team, though, they hurt themselves the most. The second category of hygienists has a very high stress level, both in and out of the dental office. While they appear not to care, they cannot help the innate human desire to be appreciated. Unfortunately, rarely will they find the acceptance and appreciation they so desire.

But if you know someone like this, or perhaps would classify yourself as a "category two," there is hope. I always look for the positive in everyone. With proper coaching and training on the importance of a quality work ethic, a second-category hygienist can quickly become a vital, accepted, and appreciated member of the dental team.

While I do believe there is good in all, it sometimes is a bit harder and takes a bit more effort to find it in some. I don't know which to classify as worse — someone who just doesn't give a "d---" or the prima donna hygienist. Hygienists of the third category are out the door without so much as lifting a finger to help clean up (God forbid, you may break a nail!). They always have an "attitude" and take great offense to any suggestion that they are less than perfect. They criticize teammates and doctors alike. While they may take meticulous care with patients, they have a very difficult time accepting criticism on any level. Perfection is not only the goal, but the belief of a category-three hygienist.

Just a brief FYI for those of you who may fall into this category: No one is perfect! If you have deluded yourself into thinking that you are better than anyone else in the entire dental profession, you are sadly mistaken and give the rest of us a bad name. You are also doing a great disservice to your patients. Dental hygiene is about teamwork — a sense of pride because we collectively care about patients.

I don't know about the rest of you, but I welcome a dentist to pick up a scaler after me. This indicates to me that he or she has the same high-quality work ethic that I do and cares as much as I do about providing excellent service to the patient.

Isn't that what it is really all about? From a patient's perspective, I'd like to dispense with the myth that patients will think the hygienist is incompetent if the dentist scales afterward. Actually, after extensive inquiries and observations regarding this subject, patients surprisingly responded that they were thankful to be part of a practice that would care so much about the little details and be so attentive to their care.

But for the prima donna, it is the highest insult. If I am to tell the truth here, I never really understood the "prima donna" attitude. It's not like hygiene is a glamorous job; we scrape debris off of people's teeth, for goodness sake! If you are still thinking you are all that special, I challenge you to accompany your next referral to the periodontist when a flap surgery is scheduled — after you've worked your superior magic, of course. Nothing is more humbling than finding out firsthand how much debris you have really left behind. Keep in mind, folks, that humility is a virtue.

While I advocate the notion that you cannot change others, I also am not quick to write them off either. Each person possesses the ability to change; some just need a bit more of a push to convince them it is for their own good, as well as for the good of the patients. If you have a category two or three in your practice, and you haven't managed to convince her of the need for transformation, simply take the now infamous "Survivor" approach — vote her off the island!

Keeping current counts
Many dental practices are under such pressure related to insurance companies, production goals, and overhead expenses that, many times, they lose sight of the clinical needs of the patients, as well as the training needs of the professionals. Did you know that much of what you may have learned in hygiene school has changed to some degree? The information you are giving your patients may no longer be current? How often do you attend continuing-education seminars, only to leave with little more understanding than you entered with? Why is it necessary to remain on the cutting edge? After all, you are simply cleaning teeth all day! Why is it crucial to learn not only the new, but also refresh the old?

Well, to maintain the clinical edge, you need to stay clinically focused. Some of what you will learn simply will be a refresher course. Most of us need to refresh our memories. Keeping current and refreshed in the parts of dentistry that have not changed is as crucial as learning the latest innovations. A great deal of information that we learned in hygiene school is still applicable in today's world of private practice. But if you are not involved with each aspect on a daily basis, it becomes very easy to lose track and forget some of the key elements.

Take pathology, for example. It becomes easier to forget the images of every single pathological finding if not presented with them on a daily basis. Oral pathology is one area that has remained fairly constant but is one of the most overlooked as far as complacency goes.

Other areas such as periodontal therapy and sealants are changing constantly. New innovations not only will help provide a higher level of care, but will make your job easier in the process. Education in dental hygiene is not a fleeting thing, but an ongoing adventure. You need to keep up with changes and current trends in areas of restorative dentistry, periodontics, radiography, and, most importantly, hygiene care for your patients.

During the next 12 months, we have developed a series of monthly articles designed to bring you up to speed on the latest trends and cutting-edge technology. Each article will touch upon a new subject, giving you applicable information that you can use right away for the most positive and immediate results in your clinical abilities.

A day in the life
Whether you are a recent graduate, a seasoned veteran, or perhaps completely burned out, there is hope for avoiding a complacency rut. The first step is to accept responsibility for becoming complacent in the first place. Easier said than done, right? When faced with the obstacles of schedule demands, team-related issues, and practice egos, you also have to battle patients who can sometimes be less than enthusiastic about your treatment. However, you must stay focused on providing the best level of care for your patients.

The veteran hygienist — Many of you out there are true veterans, serving the field for years or decades. It is very easy for you to fall into a routine that indicates burnout is on the horizon. You have put up with a lot throughout your career. Veteran hygienists seem to be a different breed. They are far less likely to vacate their positions simply because of a bad day; they tend to be loyal, committed, and hard-working.

But, for some, continuing education really never enters the picture. There are generally two types of veteran hygienists. One is very committed to excellence, striving for perfection and loyalty, constantly attending continuing education courses, reading, learning, and expanding their knowledge and clinical abilities to serve their patients better.

The second type has fallen victim to the complacency rut. They may have had every good intention of not becoming archaic or outdated upon graduation, but reality suggests that their goals have fallen by the wayside. They are in need of a major update to bring them up to speed on all of the advancements within the field. Clinical hygiene has certainly changed since the days of only supragingival scaling, and things will continue to change and improve in the future. Hygienists who are not educated on these changes and innovations will quickly find themselves outdated and, perhaps, extinct.

The one aspect of the veteran hygienist that is often overlooked is that you possess a wealth of knowledge. Pass it along to new graduates and others within the profession. Share your experience. The opposite also holds true. While you may be able to teach newcomers a thing or two, you should open your mind to new concepts and learn all you can from others as well.

The burned-out hygienist — Some of you may be thinking, "If I see one more patient, I will pull out what little hair I have left!" In certain situations, you may be justified in feeling that way. Generally, the burned-out hygienist has adhered to a very rigorous schedule throughout his or her career. Many have never had the pleasure or convenience of using time-saving (and "hand-saving") equipment. Many are accustomed to seeing 12 to 15 patients on a daily basis, for little more than simply getting their paycheck at the end of the week, let alone anything such as bonuses, a thank you, or "great job." Don't even mention such luxuries such as a hygiene assistant.

It is so easy to become burned out in the dental hygiene profession, especially if you do not take the necessary precautions. These precautions may help you to avoid the fate of many out there who are faced with the decision to continue their destructive path or abandon their profession.

The new graduate — Here you are, fresh out of school, as current as current can be, and ready to embark on your newly found hygiene career. You are certainly not thinking that you are outdated or not educated enough. After all, you have just graduated and passed your boards. How much more current can one be?

Well, truth be told, while you are close to being as current as possible, this accomplishment is a fleeting one. You can very quickly find yourself becoming complacent. While you may have every good intention of maintaining the clinical edge, and attending as many continuing-education seminars as humanly possible, the reality of private practice soon engulfs even the best-laid plans. It is easy to settle into a routine. Before you know it, you've been out of school for 10 years without an ounce of additional training.

The other issue concerning new graduates is that, while your educators made every attempt to prepare you for your career, they seldom delved into the insurmountable task of educating you on the finer arts of getting the job done in the real world of dentistry.

Private practice is very different from the hallowed halls of a hygiene school clinic. First, you no longer have three hours per patient to accomplish your tasks. As a matter of fact, there is very little in private practice that is identical to your school experiences. Many new hygienists find themselves in very unfamiliar waters. They are truly thrown in with the lions, expected to function as though they have been doing this for years. But with a detailed plan of attack, you can maintain the edge you graduated with and overcome the complacency obstacle.

Regardless of what your level of experience is, one thing each category can have in common is frustration. You want to maintain and surpass excellence, but it is sometimes out of your control as you get sucked into the daily grind of performing your hygiene duties. But there is hope for each one of you out there. One word sums up the direction you need to take: balance. Here are some steps to accomplish this seemingly overwhelming goal.

While complacency is an unfortunate reality for a good number of hygienists out there, it does not need to be a fate set in stone. You can make the decision to become the absolute best authority on the subject of dental hygiene possible. Your patients depend on it, your profession depends on it, and, most importantly, you should depend on it. We are all only human, and, to some degree, a routine to establish continuity, not complacency, can be a very good thing.

Establishing protocol, policy, and structure are all essential qualities to being a good hygienist. But know that if you strive for excellence with the services you provide, you must do so with respect to others within your practice. Put the patient first, and everyone will come out ahead — in turn, you can avoid the pitfalls of complacency. Keep in mind, when you analyze your life and your career, there is always a little bad, a little great, and a lot of good in each of us.

10 steps for avoiding clinical complacencyEmphasize continuing education (and not just to gain licensing credits). Keeping current is paramount. Becoming outdated is a disservice to your patients, to yourself, and to the hygiene profession.Read hygiene publications. Gaining new and different perspectives on similar subjects can provide you with greater insight on how to care for your patients better.Care about your profession. Become part of your local ADHA component and get involved. When you care and take pride in what you do, the rest falls into place with relative ease. When you exude confidence and happiness about who you are, you will be happier and have less stress in your life as a whole.Do self-study courses. Case studies challenge you on various subject levels. One of the best ways to avoid complacency is to continuously challenge your level of intelligence, thinking, and rationale. Case studies provide a unique forum for learning from a wide variety of differing opinions.

Often, you will be presented with a similar situation to a particular case study, and you will be able to identify it. In the past, you may have run into a roadblock as far as treating these cases. Case studies can provide you with the one thing you may have overlooked — options. Keep in mind there is often more than one way to skin a cat!

Participate in hands-on training. It is so easy to become complacent in the area of hand instrumentation. Probing, Cavitron usage, sealant application, radiographs, or scaling/root planing are areas in which one needs to remain absolutely current. Just think of the years of hygiene when it was common practice not to scale below the gingiva compared to where we are now. Instrumentation techniques and instruments are always changing, adding new techniques to provide better care, addressing the ergonomics issue, and getting the job done better, easier, and faster. Take advantage of this world full of tremendous opportunities to learn and grow.Keep an open mind. Accept that when you think you know everything, you have only proved that you need to learn more. If you know of someone — and we all do — who feels that she truly knows it all and cannot learn anything else, this person needs to learn so much more about life than how to sharpen instruments better.

The hygiene profession is already facing battle lines of independence vs. preceptorship. We do not need dissension in the ranks. United we stand; divided we fall. There is not a single hygienist out there who does not need to take courses, read articles, learn new and innovative information, practice new techniques, and maintain a positive attitude conducive to continual growth. Our profession not only depends on it, we thrive on it.

Expand into new areas. If you do not know the latest information about periodontal care for your patients, or obtain information about digital radiography, or get involved with caring for cancer patients, where will you be in 10 years, and what type of care will you be providing? There is never an excuse good enough to provide substandard levels of care — never!Change with the times. Dental hygiene is forever growing, changing, and expanding its horizons. Aside from the clinical component of hygiene, you must also be aware of your surroundings. Know the legal issues of the profession. Understand the legislative pulse in your state and your community. Educate yourself about the detrimental effects of preceptorship and the equally daunting task of independence. Learn about the importance of being a team player and developing a co-therapist relationship between dentistry and dental hygiene.Walk a day in another's shoes. If you work in a general practice, offer to do a day of pro bono work in a specialty practice, simply for the experience. The best way to learn in life is to do. The strides in areas of oral surgery, cosmetic dentistry, and plastic/periodontal surgery is astounding. But if you don't pursue a path of upward growth, how will you know if you are complacent and outdated or maintaining the cutting edge of your profession?What the dentist does — Learn all you can about operative options and why they have a direct link to what you can do for your patients. You may think that you have enough to contend with in learning what's new in hygiene and perio, let alone keeping up-to-date on issues that really don't concern you. The dentist is responsible for the operative side of the coin, right? Wrong! You play a very integral role not only in the operative side of dentistry, but in case acceptance, practice acceptance, and overall patient care.

To put it bluntly, it's part of your job, but more importantly part of a solid work ethic. You should know as much as possible in all areas of dental care so you can widen the scope of education that you bring to your patients. An informed patient is generally a healthy and compliant patient.

Precautions for avoiding burnoutChange your situation or scenery. Long gone are the days when you are obligated to stay at one job long-term. The dictator who is inflexible, rigid, and even feared should be one of the past. Many dentists are finally figuring out that there is more profitability and satisfaction in providing high-quality care as opposed to production-line hygiene. There is a wider variety of choices for hygienists than ever before.

You are not chained to the circumstances of a negative work environment. You should find a position and practice where mutual respect is a given and where your contributions to the practice team are appreciated.

Run for the hills from "crack the whip" practices. Keep in mind that only you have the power to change your situation. If things are truly that bad, and there are no indications that you can work through your issues within your current situation, perhaps it is time to move on.

Be assertive. Voicing your concerns that you are nearing or have surpassed the burnout edge may be your only hope in avoiding total annihilation. However, I must caution you on being too assertive. There is a difference between being assertive or self-confident and being disrespectful and insubordinate. Sometimes, someone who is simply trying to be heard is described as being too pushy or aggressive. Proceed with caution; remember that even a small voice will be heard over no voice at all.Know and accept your responsibilities and limitations. Educate yourself on current trends and techniques in dental hygiene. It is the responsibility of every dental professional to maintain the clinical cutting edge. Complacency is not acceptable. Patients deserve the very best — the most current care possible. Aside from improving the level of care for your patients, many new innovations and techniques make your life as a dental hygienist easier. If you do not feel sufficiently trained to provide some care options, such as soft-tissue management, a wide variety of training options are available to you.Accept that change can be a good thing. If you are nearing burnout, change may be just what you need. If the scenery and situation in your practice are good, perhaps changing your routine and the types of services provided will help to avoid burnout.

Tammy L. Carullo, RDH, PC, PS, is CEO of Practice by Design, Inc. She is a practice-management consultant and continuing-education instructor. She may be contacted by e-mail at [email protected] or phone (717) 867-5325. For more information about her company, visit her Web site at